Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy provided on December 12, 2019 by an out of network (OON) provider.
You asked the Plan to pay for psychotherapy. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the member's primary care physician did not recommend 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 psychotherapy provided on December 12, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a cystourethroscopy provided on February
24, 2020.
You asked the Plan to waive the copayment for a cystourethroscopy. You say that you disagree with the
overcharge. 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 $240
copayment for surgery in an ambulatory surgical center.
You have been asked to pay a $240 copayment for a cystourethroscopy. A cystourethroscopy falls within the
outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers
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 a cystourethroscopy provided on
February 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora domiciliary, rest home visit provided from December 30, 2019 to February 6, 2020.You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization. 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 did not pre-approve the services 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 fora domiciliary, rest home visit provided from December 30, 2019 to February 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the dialysis treatments provided on August 2, 2019 to August 31, 2019.You asked the Plan to waive the coinsurance for the dialysis treatments. You say that you believe you have met your 2019 maximum out-of-pocket amount. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 20% coinsurance for Medicare-covered benefits for outpatient dialysis treatments. You have been asked to pay a total of $632 which is 20% of the allowed amounts for the dialysis treatments. The total allowed amount is $3,160. ($3,160 x 20% = $632). The dialysis treatments fall within the "Services to Treat Kidney Disease" benefit category. The record shows you had not met your maximum out-of-pocket amount at the time of services. 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 coinsurance for the dialysis treatments provided on August 2, 2019 to August 31, 2019.Please note that the Explanation of Benefits (EOB) issued to you for this claim contains inaccurate information regarding the allowed amount of the claim. Please contact the health plan to receive a corrected Explanation of Benefits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for arthrocentesis (20611) provided on January 20, 2020.
You asked the Plan to waive the copayment for the arthrocentesis. You say that you would like reconsideration because no services were rendered on this date of service. The Plan denied your request. The Plan says the records indicate that you were treated on this date of service so you are responsible for a $35 copayment.
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 $35 copayment for treatment by a specialist. You have been asked to pay a $35 copayment for the arthrocentesis. The arthrocentesis falls within the treatment by a specialist 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 arthrocentesis (20611) provided on January 20, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing visits.
You asked the Plan to pre-approve the skilled nursing visits. You say that you are appealing to prevent exacerbation of CHF and continued need to maintain edema control to prevent skin breakdown from weeping of legs and to keep out of the hospital. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for skilled nursing services.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 skilled nursing visits. Our reviewer says that skilled nursing visits are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee received oral medications and had stable vital signs. She was treated for chronic LE pain with effect. She used oxygen via nasal cannula. The records do not show a decline in functional or medical status or care plan to warrant skilled nursing visits. Skilled nursing visits are not required to effectively provide treatment, care, and/or services which are medically necessary for the enrollee. 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 skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve the skilled nursing visits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Myriad myRisk genetic testing rendered on July 25, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 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 pay for these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee has a diagnosis of metastatic ductal invasive breast cancer. There is a family history of bladder cancer and leukemia. Integrated BRACAnaylsis with Myriad myRisk Hereditary Cancer panel testing was ordered. The documentation is insufficient to demonstrate that the Myriad myRisk genetic testing was medically reasonable and necessary for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the Myriad myRisk genetic testing rendered on July 25, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.
You asked the Plan to pre-approve additional routine transportation trips. You say that you require these trips to get to physical therapy. The Plan denied your request. The Plan says that your benefit is exhausted.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of fifty (50) trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the bank fees you incurred on November 3, 2019.
You asked the Plan to reimburse you for the bank fees. You say that the services you received were indicated,
reasonable, and should be covered. The Plan denied your request. The Plan says bank financial fees are not a
medically necessary service.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
The file shows that you received services in an emergency room. You were charged a $50 copay for the
provided services. We looked at the file, and Medicare rules. The bank fees are not primarily medical in nature.
Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we
decided that the Plan does not have to reimburse you for the bank fees you incurred on November 3, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on November 18, 2019 and November 25, 2019.You asked the Plan to waive the copayment for ambulance services. You say that the services were medically necessary and 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 $350 copayment for ambulance services. You received ambulance services on November 18, 2019. Therefore, you are responsible to pay the $350 copayment. You received ambulance services on November 25, 2019. Therefore, you are responsible to pay the allowed amount of $245.67. The total amount you owe is: $595.67.You have been asked to pay the total copayment amount of $595.67 for ambulance services. Ambulance services fall within the ambulance 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 copayment for ambulance services provided on November 18, 2019 and November 25, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for an ambulance transport (A0428, A0425) provided October 18, 2019.
You asked the Plan to pay for the ambulance transport. You say that the ambulance transport was medically necessary. The Plan denied your request. The Plan says coverage criteria was not met.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 pay for the ambulance transport. Our reviewer says that ambulance transportation was not medically necessary Our physician reviewer found the enrollee did not require the expertise of trained personnel or the equipment available only on an ambulance in order to effectuate a safe transport. Transportation could have been provided by other means (Ex. stretcher van, wheelchair van) without endangering 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 ambulance transport have not been met. Therefore, we decided that the Plan does not have to pay for an ambulance transport (A0428, A0425) provided October 18, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the MRI provided on February 15, 2020.
You asked the Plan to waive the copayment for the MRI. You say that the MRI was unreadable and unusable.
You say that you should be refunded 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 $180
copayment for advanced imaging services at an in-network PCP's office, specialist's office and freestanding
radiological facility.
You have been asked to pay $173.30, which is less than the standard $180 copayment for the MRI. The MRI
falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records
show that the MRI 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 MRI provided on
February 15, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy provided on December 16, 2019.
You asked the Plan to waive the copayment for the colonoscopy. You say that the member was encouraged to have a colonoscopy because there is a $0 copayment. You say that this was a diagnostic exam not an elective surgery. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $250 copayment per visit for Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient facility. The enrollee has been asked to pay a $250 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that the colonoscopy was ordered for diagnostic purposes and polyps were removed which is considered a surgical procedure. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the colonoscopy provided on December 16, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for one unit of destruction by neurolytic agent (64624) provided on February 12, 2020.
You asked the Plan to pay for the unit of destruction by neurolytic agent. You say that you would like reconsideration because the records support the number of units billed. The Plan denied your request. The Plan says the units billed are greater than the Medicare MUE, MAI of 2.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. In this case, the MUE for CPT code 64624 is 2. You billed 3 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the unit of destruction by neurolytic agent have not been met. Therefore, we decided that the Plan does not have to pay for one unit of destruction by neurolytic agent (64624) provided on February 12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on August 28, 2018.You asked the Plan to pay for the genetic testing. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services rendered are not a covered benefit.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The genetic testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay for the genetic testing provided on August 28, 2018.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hydrocodone-Acetaminophen for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Hydrocodone-Acetaminophen for the enrollee.
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan and nuclear imaging of bones provided on November 14, 2019.
You asked the Plan to waive the copayment for a CT scan and nuclear imaging of bones. You say that you were told that you would only owe one $150 copayment. 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 $150 copayment for diagnostic radiology services. You received a CT scan on November 14, 2019. Therefore, you are responsible to pay the $150 copayment. You received nuclear imaging of bones on November 14, 2019. This is considered as a different test than a CT scan. Therefore, the $150 copayment applies. The total amount you owe is: $300. You have been asked to pay the total copayment amount of $300 for a CT scan and nuclear imaging of bones. A CT scan and nuclear imaging of bones 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 when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a CT scan and nuclear imaging of bones provided on November 14, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from January 27, 2020 through January 30, 2020.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that you were admitted on January 27, 2020 and discharged on January 30, 2020. You were asked to pay a $350 copayment per day from January 27, 2020 through January 29, 2020, days 1-3 of your inpatient hospital care. You were discharged on January 30, 2020 and there was no copayment charge for the day of discharge. Per your contract there is a $350 copayment per day required for days 1-5. 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 inpatient hospital care from January 27, 2020 through January 30, 2020.