Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response, treatment no transport provided by the Ambulance Company on July 20, 2019.
You asked the Plan to pay for the ambulance response, treatment no transport. You say that you bit into a lemon rind and was unable to breathe. By the time the paramedics arrived you were able to breathe again. You should not have been charged for these services. The Plan denied your request. The Plan says this service is not covered under Medicare or the plan.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on July 20, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response, treatment no transport provided by the Ambulance Company on July 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 14 office visits with the physician.
You asked the Plan to pre-approve the 14 out-of-network office visits. You say that your cancer is very rare and lethal. You say that the only research for cholangiocarcinoma is done elsewhere in the United States, and in Europe. You say that research for this diagnosis is not done within the plans network and there is no expertise in your state. You say that you have been getting regular chemotherapy for the last 5 months, but that there is no way forward to prolong your life. You say that you need a consult with an oncologist who is informed of ongoing research and clinical trials. The Plan denied your request. The Plan says the provider is not in the enrollee's network. The Plan says that the records provided do not show that the enrollee's medical needs cannot be met in-network.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the 14 out-of-network office visits. Our reviewer says that the criteria for coverage of out-of-network care have not been met. Our physician reviewer found the Plan is medically justified on the basis that it is offering adequate care to meet the enrollee's medical needs through referral to an in-network oncologist. There is nothing unique about the enrollee's condition that would make it medically necessary for her to see the requested out-of-network provider. Our physician reviewer found that, while the diagnosis of cholangiocarcinoma is not common, it is not so rare that an in-network provider is unable to supply treatment. The Plan has shown that they have in-network providers who meet the Standards of Care required for treatment of the enrollee's condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the 14 out-of-network office visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 14 office visits with the physician.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve finger joint fusion (arthrodesis) (26860).You asked the Plan to pre-approvefinger joint fusion. You say that this is necessary because medication is not working.The Plan denied your request. The Plan says that you have not had sufficient conservative therapy.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review thecase file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve finger joint fusion. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found current evidence based medical literature supports arthrosis of the interphalangeal joints of the hand for pain, deformity and/or stiffness as a salvage procedure. Given the length of time since the injury and failure of apparent long-term activity modification and medications, surgical intervention is reasonably indicated to restore function. Therefore, this request for fusion of the finger is medically reasonable and necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of finger joint fusion have been met.Therefore, we decided that the Plan has to pre-approvefinger joint fusion (arthrodesis) (26860)
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the train of four testing provided to the enrollee on May 31, 2019.
You asked the Plan to pay for the train of four testing. You say that intra-operative monitoring during surgery reduces the risk of postoperative deficits. The Plan denied your request. The Plan says the service is considered a bundled procedure, and payment is included in the payment for the already approved neuromonitoring.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that Train of Four Testing does not fit the criteria set by CMS and Insurance Carriers. There is no separate code for Train of Four Monitoring. Therefore, it would be inappropriate to separately bill the Neuromuscular Junction Testing for Train of Four Monitoring. Based on this information, we decided that Medicare rules for coverage of the train of four testing have not been met. Therefore, we decided that the Plan does not have to pay for the train of four testing provided to the enrollee on May 31, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe CT scan provided on December 9, 2019.You asked the Plan to waive the copayment forthe CT scan. You say that the copayment is almost 40% of the bill. You say that the cost is excessive.The Plan denied your request. The Plan says the copayment applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 copayment for CT, MRI, MRA and SPECT scans. You have been asked to pay a $200 copayment for the CT scan. The CT scan falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay whenyou enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe CT scan provided on December 9, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forlaboratory services provided on November 7, 2019.You asked thePlan to waive the copayment forlaboratory services. You say that this should be part of your annual physical.The Plan denied your request. The Plan says the copayment applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $20 for Medicare-covered laboratory tests.You have been asked to pay a $20 copayment for laboratory services. Laboratory services fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. Outpatient diagnostic tests are considered a separate service. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment forlaboratory services provided on November 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for pulmonary rehabilitation therapy provided from June 3, 2019 to June 28, 2019.
You asked the Plan to waive the copayments for pulmonary rehabilitation therapy. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment for pulmonary rehabilitation services. You received pulmonary rehabilitation therapy from June 3, 2019 to June 28, 2019 for a total of 10 visits. Therefore, you are responsible to pay a $20 copayment per each service. The total amount you owe is: $200.00. You have been asked to pay the total copayment amount of $200.00 for pulmonary rehabilitation therapy. Pulmonary rehabilitation therapy falls within the pulmonary rehabilitation services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for pulmonary rehabilitation therapy provided from June 3, 2019 to June 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on August 13, 2019 by an out of network (OON) provider.You asked the Plan to pay foroffice visit. You say that this service was medically necessary.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and prior authorization was not obtained.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe medical services provided on August 13, 2019 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe chest x-ray (71046) provided on September 16, 2019.You asked the Plan to pay forthe chest x-ray. You say that you have never neededpreauthorization before.The Plan denied your request. The Plan says the provider was out-of-network and the services were not preauthorized.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these /services.Therefore, we decided that the Plan does not have to pay forthe chest x-ray (71046) provided on September 16, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychiatry services provided on October 11, 2019 by an out of network (OON) provider.
You asked the Plan to pay for psychiatry services. You say that you were unaware that you were considered out-of-network. The Plan denied your request. The Plan says no prior authorization was obtained for these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for psychiatry services provided on October 11, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve shoulder arthroscopy surgery.You asked the Plan to pre-approveshoulder arthroscopy surgery. You say that you are appealing.The Plan denied your request. The Plan says that the denial of authorization for this service is correct, because this surgery is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review thecase file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve shoulder arthroscopy surgery. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has persistent left shoulder pain and dysfunction. Clinical examination findings have been consistent with imaging evidence of a full thickness retracted supraspinatus tear, partial thickness infraspinatus and subscapularis tears, and tear and retraction of the long head of the bicep tendon. Detailed evidence of a recent, comprehensive, non-operative treatment trial and failure has been submitted. Current evidence-based medical literature supports biceps tenodesis to address the enrollee's condition. The inclusion of biceps tenodesis at the discretion of the operating surgeon at the time of rotator cuff repair surgery is reasonable.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of shoulder arthroscopy surgery have been met.Therefore, we decided that the Plan has to pre-approveshoulder arthroscopy surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe Mohs procedure provided on December 11, 2019.You asked the Plan to waive the copayment forthe Mohs procedure. You say that you were informed you don't have a copayment.The Plan denied your request. The Plan says the copayment applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment per visit for Medicare-covered specialty care services. Covered services include medically-necessary medical care or surgery services furnished in a physician's office. You have been asked to pay a $40 copayment for the Mohs procedure. The Mohs procedure falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe Mohs procedure provided on December 11, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ER visit at the facility from August 26, 2019 to September 3, 2019.
You asked the Plan to waive the copayment for an ER visit. You say that you request help with the $120 charge. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $120 copayment for emergency care. You have been asked to pay a $120 copayment for an ER visit. An ER visit falls within the emergency care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an ER visit at the facility from August 26, 2019 to September 3, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids provided on July 29, 2019.You asked the Plan to reimburse you for the hearing aids. You say that while you were out of state, your hearing aid stopped working and you had a difficult time hearing so you purchased new hearing aids from a local hearing center. The Plan denied your request. The Plan says you must use a Plan network provider or vendor.Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when provided by the Plan's provider or vendor.We looked at the file and the Plan's rules. The provider at issue in this appeal is not a Plan provider or vendor. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids provided on July 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveendovenous ablation therapy.You asked the Plan to pre-approvethe requested services. The Plan denied your request. The Plan says the clinical documentation does not meet the criteria for the requested service.The Plan follows Medicare rules. Medicare rules say that treatment of varicose veins and venous stasis is only covered under certain medical indications.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician reviewer found that you have documented morbid obesity, and a history of osteoarthritis and hip replacements. Your body mass index is not documented to be under 35. Other criteria not met include documentation that you are having functional limitation due to your veins. The majority of the areas of reflux in the greater saphenous veins are not over 500 milliseconds as required for coverage, furthering the possibility that you are not having functional limitation due to your veins. The documentation also states you are not having problems with your legs. Therefore, the requested services are not medically reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approveendovenous ablation therapy.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound provided on October 18, 2019.
You asked the Plan to waive the copayment for the ultrasound. You say that you were informed you do not owe $20. You say that you aren't responsible for the copayment. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment for outpatient diagnostic tests provided by an in-network specialty physician. You have been asked to pay a $20 copayment for the ultrasound. The ultrasound falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show that a diagnostic ultrasound was performed. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ultrasound provided on October 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a partial denture (99070) provided on August 9,
2019.
You asked the Plan to reimburse you for the dental service. You say that you paid $325 for a partial denture.
You say that you were given a statement in order to receive reimbursement for the service. You also say that
you never expected to be refused reimbursement. The Plan denied your request. The Plan says dentures are not
covered under any condition.
Medicare generally does not cover dental services. The Plan follows the same rule.
The services you are asking the Plan to reimburse you for involve the care, treatment, filling, removal or
replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not
covered or paid for by Medicare. Therefore, we decided that the Plan does not have to reimburse you for a
partial denture (99070) provided on August 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve all white glass crowns for teeth 22 and 27 (D2740).You asked the Plan to pre-approvethe crowns. You say that the records provided should support the necessity of the services in dispute.The Plan denied your request. The Plan says this request is not covered under the plan benefits.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess ofMedicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approveall white glass crowns for teeth 22 and 27 (D2740).