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

We decided that the Plan does not have to waive the copayment for a breast biopsy procedure provided on August 26, 2020.
You asked the Plan to waive the copayment for outpatient surgery. You say that this procedure was not performed in a hospital. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 $150 copayment for outpatient surgery at an outpatient hospital facility. This provider is considered to be an outpatient hospital facility; therefore, the outpatient hospital surgery copayment applies to this claim. You have been asked to pay $150 copayment for outpatient surgery. Outpatient surgery 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 breast biopsy procedure provided on August 26, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sodium ferric gluconate complex in sucrose injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee has not been on oral iron, and there is no documentation why the enrollee cannot take oral iron.
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 pre-approve the injection. Our reviewer says that the requested injection is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided indicating that the enrollee has not been on oral iron and there is no documentation as to why the enrollee cannot take oral iron. The review has determined that the requested injection is not medically reasonable or 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve sodium ferric gluconate complex in sucrose injection for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical eye visit by an out of network (OON) provider.
You asked the Plan to pay for the medical eye visit. You say that the provider listed the health plan as an in-network insurance provider. The Plan denied your request. The Plan says no prior authorization was 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 had network providers available who could have provided 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 a medical eye visit by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on October 14,
2020, and October 15, 2020.
You asked the Plan to pay for the subsequent nursing facility care. 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
subsequent nursing facility care. 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 for subsequent nursing facility care provided on
October 14, 2020 and October 15, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan.
You asked the Plan to waive the copayment for these services. You say that the provider's office advised you that the services would be free. The Plan denied your request. The Plan says the copayment cannot be waived.
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 $325 copayment per day for other Medicare-covered diagnostic radiology services that are not ultrasounds.
The services at issue are a CT scan. If you choose to receive these services, you will be asked to pay a $325 copayment for these services. These services fall within the other Medicare-covered diagnostic radiology services that are not ultrasounds 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. The Plan cannot be held liable for possible misinformation given by a provider's office regarding your contractual copayments. Therefore, we decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on November 20, 2020.
You asked the Plan to pay for the comprehensive oral evaluation. You say that you feel that this service should be covered. The Plan denied your request. The Plan says this service exceeds the frequency limitation in your benefit plan.
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 of Medicare coverage, comprehensive oral evaluation (D0150) is limited to one procedure every three plan years. The record shows that you received a comprehensive oral evaluation (D0150) on July 30, 2018 and your comprehensive oral evaluation (D0150) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on November 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair glide.
You asked the Plan to pre-approve a stair glide. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a stair glide.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the power scooter provided on July 29, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the scooter. You say that you need to be reimbursed. The Plan denied your request. The Plan says there was no authorization on file.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available to provide the scooter at issue. The Plan did not pre-approve the item at issue. We found no exception that would require the Plan to pay for this scooter. Therefore, we decided that the Plan does not have to pay for the power scooter provided on July 29, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the biofeedback therapy provided on August 13, 2020.
You asked the Plan to pay for the biofeedback therapy. The Plan denied your request. The Plan says this coverage criteria are not met.
The Plan follows Medicare rules. Medicare rules say that biofeedback is covered for the treatment of stress and/or urge incontinence in cognitively intact patients who have failed a documented trial of pelvic muscle exercise (PME) training. 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 biofeedback therapy. Our reviewer says that the requested biofeedback therapy is not medically reasonable and necessary. Our physician reviewer found that there is no documentation of a failed trial of pelvic muscle exercise (PME) training. Therefore, the biofeedback therapy is not medically reasonable and necessary according to the coverage criteria established in the NCD. 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 biofeedback therapy have not been met. Therefore, we decided that the Plan does not have to pay for the biofeedback therapy provided on August 13, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on September 28, 2020.
You asked the Plan to pay for the ambulance services (A0429-QL). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the claim was not billed according to Medicare billing guidelines.
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 looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ambulance services (A0429-QL) have not been met. Specifically, code A0429 is not the appropriate code for billing Medicare when the enrollee is pronounced dead after the ambulance is called. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on September 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says this is considered experimental and investigational.
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 pre-approve the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy of the device. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the interim caries arresting medicament application or waive the coinsurance for the fillings.
You asked the Plan to pay for the interim caries arresting medicament application. You say that these services were necessary to keep your teeth healthy. The Plan denied your request. The Plan says this service is not covered by your supplemental benefit.
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 of Medicare coverage, the interim caries arresting medicament application is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the interim caries arresting medicament application.
You asked the Plan to waive the coinsurance for the fillings. You say that the requested services were necessary to keep your teeth healthy. The Plan denied your request. The Plan says the correct cost share applied to the claims.
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 55% coinsurance for dental services. You have been asked to pay a 55% coinsurance for the fillings (55% of $139 = $76.45; 55% of $131 = $72.05), for a total of $148.50. The fillings fall within the dental 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 coinsurance for the fillings, posterior and anterior.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve right knee nerve ablation.

You asked the Plan to pre-approve destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed (64624) right knee. You say that the enrollee needs this procedure. The Plan denied your request. The Plan says long term studies have not yet proven that this procedure is safe and effective or superior to standard treatments for chronic knee pain.

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 pre-approve destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed (64624) right knee. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is an experimental/ investigational procedure that is the subject of ongoing clinical trials. Therefore, the request is considered not medically reasonable or 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 destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed (64624) right knee. have not been met. Therefore, we decided that the Plan does not have to pre-approve right knee nerve ablation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on November 17, 2020.
You asked the Plan to pay for the office visit. You say that you paid your copayment, but the Plan refused to pay for the exam. The Plan denied your request. The Plan says this provider is not a network provider with the Plan.
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 had network providers available who could have provided 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 the office visit provided by an out-of-network provider on November 17, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a sacroplasty (0200T) provided October 9, 2020.
You asked the Plan to pay for the sacroplasty. You say that the procedure is medically necessary. The Plan denied your request. The Plan says the requested service is considered investigational and is not covered.
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 the sacroplasty. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found Sacroplasty remains experimental for insufficiency fractures of the sacrum, more research is needed to show safety and efficacy of sacroplasty for sacral fractures. 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 sacroplasty have not been met. Therefore, we decided that the Plan does not have to pay for a sacroplasty (0200T) provided October 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August 11, 2020.
You asked the Plan to pay for the physician's services. 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 physician's services. 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 for physician's services provided on August 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug test (80307) provided on November 15, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the drug test. You say that you would like reconsideration because issuers must ensure that enrollees may obtain covered medical and behavioral health services from the Indian health care provider at no greater cost than if the service were obtained from network providers and facilities. The Plan denied your request. The Plan says these services were not urgent, emergent or approved in advance.
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 had network providers available who could have provided 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 the drug test (80307) provided on November 15, 2019 by an out of network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room visit, and electrocardiogram provided on September 13, 2020.
You asked the Plan to pay for the emergency services. You say that the enrollee required hospitalization. You also say that a revocation of election to hospice was signed on September 13, 2020. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the member's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Although the enrollee disenrolled from hospice on the date of service, claims are covered by original Medicare until the first day of the following month in which hospice was revoked. Therefore, we decided that the Plan does not have to pay for the emergency room visit, and electrocardiogram provided on September 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient office visit (99203) scanning computerized ophthalmic diagnostic imaging (92134) provided November 18, 2020.
You asked the Plan to waive the copayment for the office visit. You say that on 2 occasions you were told by a plan representative that this provider was in-network. The provider also charged a copay of $60 and was surprised at this charge as the plan does not state that you are responsible for a $60 copay. The Plan denied your request. The Plan says the claim processed correctly, and the correct copayment was applied per the Evidence of Coverage.
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 $30 copayment for specialist's office visits for Physician/Practitioner services, including doctor's office visits. You have been asked to pay $30 copayment for specialist's office visits for the office visit. The office visit 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 for the outpatient office visit (99203) scanning computerized ophthalmic diagnostic imaging (92134) provided November 18, 2020.