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

We decided that the Plan has to waive the copayment for the physician services provided on September 29,
2019.
You asked the Plan to waive the copayment for the physician services. You say that you would like the Plan to
reconsider your request. The Plan denied your request. The Plan says that the correct copayment has applied
per your contract with the Plan.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. Specifically, it is the plan's responsibility to show that its decision to deny
coverage is correct. Records from a plan provider are considered to be within the control of the plan. In cases
where the plan has not supplied records from a plan provider that are critical to its decision, we may properly
find that the denial is not medically appropriate or justifiable. Enrollees should not be penalized for a plan's
failure to obtain records that are within the plan's control. The date of service, September 29, 2019 falls on a
Sunday and the enrollee is stating they were not seen by any provider on this date. As the Plan did not provide
any medical records proving that the enrollee received the disputed service, we are unable to determine if the
correct cost share has applied. Therefore, we decided that the Plan has to waive the copayment for the
physician services provided on September 29, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on October 28, 2019
You asked the Plan to pay for the laboratory services provided on October 28, 2019. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 laboratory 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 laboratory services provided on October 28, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services provided on August 28, 2019.You asked the Plan to pay forthe laboratory services.You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed priorto services taking place.Therefore, we decided that the Plan does not have to pay forthe laboratory services provided on August 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe wound care treatments provided from October 21, 2019 to November 25, 2019.You asked the Plan to waive the copayments forthe wound care treatments. You say that you had the same services in 2018 and did not have to pay anything. 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 a $200 copayment for each Medicare-covered visit to an ambulatory surgical center or outpatient hospital facility. For each date of service, you have been asked to pay the allowed amount of the claim because these amounts are less than the $200 copayment for woundcare visits in an outpatient hospital.You have been asked to pay a $127.17 copayment for the each of the wound care treatments. The wound care treatments fall 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 copayments forthe wound care treatments provided from October 21, 2019 to November 25, 2019.Our decision is only about the 2019 services. If you have any questions about prior years billing, please contact the plan directly.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory services provided on
December 12, 2019.
You asked the Plan to waive the copayment for the laboratory services. You say that you feel you should not be
responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied
your request. The Plan says you received laboratory services on the date of service at issue in this appeal. The
Plan states the correct copayment has applied per your contract with the Plan.
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 $10
copayment for outpatient laboratory services.
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received outpatient
laboratory services on December 12, 2019. You have been asked to pay a $2.49 copayment for the laboratory
services, which is less than the contracted amount. The laboratory services fall within the Outpatient diagnostic
tests 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 laboratory services provided
on December 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on May 9, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the clinic visit. You say that you would like reconsideration because this service was medically necessary. The Plan denied your request. The Plan says it is the responsibility of the provider to confirm participation and member eligibility before services are rendered.
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 the medical services provided on May 9, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar medial branch block for the enrollee.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the enrollee requires a radiofrequency procedure, and not a diagnostic block.
The Plan follows Medicare rules. Medicare rules say that facet joint injections are 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 the enrollee has chronic axial low back pain. He then underwent bilateral radiofrequency ablation (RFA) and achieved 100% pain relief at those levels. However, he has pain at higher lumbar levels. The request is for repeat diagnostic blocks rather than repeat RFA. There is no indication for repeat diagnostic blocks. The request should be for repeat RFA. The request for diagnostic blocks 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar medial branch block for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay fordental oral exam (D0120) provided on November 4, 2019.You asked the Plan to pay forthe dental services. You say that you were unaware that emergency exams count towards exam frequency limitations.The Plan denied your request. The Plan says you were not eligible for this exam.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.You exhausted your benefit because you had oral exams performed on May 1, 2019 and August 29, 2019.Therefore, we decided that the Plan does not have to pay fordental oral exam (D0120) provided on November 4, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe subsequent nursing facility care (99308) rendered by the out of network (OON) provider on October 29, 2019.You asked the Plan to pay forthese services. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says the services were provided by an out of network provider, without 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 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 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 forthe subsequent nursing facility care (99308) renderedby the out of network (OON) provider on October 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for bilateral wrist hand orthoses (L3916) provided to the enrollee on November 4, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the medical records do not support this service.
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 orthoses. Our reviewer says that the enrollee does not meet criteria for the orthoses ordered. Our physician reviewer found the documentation in the case file does not support that the requested wrist/hand orthoses were medically reasonable and necessary for the enrollee in this case. There is no documentation of examination of the enrollee's wrists, nor the need for wrist/hand orthoses. The documentation does not support that the wrist/hand orthoses were medically reasonable and necessary in this case, as there is no documentation of a physical examination of the wrists. The documentation in the medical records does not support the diagnoses of Primary osteoarthritis of the right and left hands listed on the Physician's Order. 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 orthoses have not been met. Therefore, we decided that the Plan does not have to pay for bilateral wrist hand orthoses (L3916) provided to the enrollee on November 4, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral for the member to see the doctor.
You asked the Plan to pre-approve the referral to an out-of-network neuropsychologist. You say that the services are medically necessary. The Plan denied your request. The Plan says there are network providers who can provide the services at issue.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an out-of-network referral for the member to see the doctor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses and sleeves provided to the enrollee on November 8, 2019.You asked the Plan to pay for the orthoses and sleeves. You say that these items were medically necessary.The Plan denied your request. The Plan says that this was amisrepresentation of services.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 orthoses and sleeves. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. There is no documentation of recent injury to, or recent surgical procedure on, either of the enrollee's knees, and there is no objective documentation of joint laxity. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these items.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 orthoses and sleeves have not been met.Therefore, we decided that the Plan does not have to pay forthe knee orthoses and sleeves provided to the enrollee on November 8, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approvehome health aide services.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules todetermine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has difficulty performing activities of daily living. There is no indication that he is homebound; therefore, the criteria for coverage of home health services are not met. The requested aide services are not medically 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approvehome health aide services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0652).You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee requires the device.The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have notbeen met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to preapprove a pneumatic compression device (E0652).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided,on November 19, 2019.You asked the Plan to waive the copayment for the office visit. You say that you do not agree with the copayment because you were only seen for five minutes with no resolution to your elbow problem. 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 a $10 copayment for each covered visit or consultation in an outpatient location with your PCP or other primary care physician. You have been asked to pay a $10 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The medical record shows you were assessed and a plan was determined during your office visit.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 office visit provided on November 19, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility services provided on September 10, 2019 to September 30, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the skilled nursing facility services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.
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 the skilled nursing facility services provided on September 10, 2019 to September 30, 2019 by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on November 18, 2019.
You asked the Plan to waive the copayment for the emergency room visit. You say that you only waited in the lobby and no services were performed. You say you should not be responsible for the copayment. 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 a $90 copayment per visit for emergency care. You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. The medical record shows vitals were taken and triage was completed.
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 emergency room visit provided on November 18, 2019.