Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on January 21, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not authorized.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 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 medical services provided to the enrollee by an out-of-network provider on January 21, 2020
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an epidural injection
You asked the Plan to waive the copayment for outpatient surgery. You say that the pain pump connections from this procedure came out, so you did not get relief. 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 $250 copayment for in-network outpatient surgery at an outpatient hospital facility. You have been asked to pay $250 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 an epidural injection
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a high utilization amount of OneTouch Ultra Blue test strips.
You asked the Plan to pre-approve the non-preferred brand of test strips. You say that you should not be forced to use a brand of meter that doesn't do what the requested brand does. The Plan denied your request. The Plan says there is no medical reason documented that you are medically unable to use the Plan preferred test strips.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. There is no physician documentation that the non-preferred brand is necessary to avoid an adverse medical outcome. Based on this information, we decided that Medicare rules for coverage of the non-preferred brand of test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve a high utilization amount of OneTouch Ultra Blue test strips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on December 13,2019 by an out of network (OON) provider.You asked the Plan to pay for skilled nursing services. 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.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 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 skilled nursing services provided on December 13, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the mammogram (77067) provided on November 26, 2019 by provider.You asked the Plan to pay for the mammogram. You say that the service was medically necessary.The Plan denied your request. The Plan says there were network providers available that could 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 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 mammogram (77067) provided on November 26, 2019 by provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for extracapsular cataract removal provided from October 1, 2019 to October 15, 2019.
You asked the Plan to waive the coinsurance for extracapsular cataract removal. 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 20% coinsurance for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. You received extracapsular cataract removal on October 1, 2019. The total allowed amount is $2,623.33 and 20% of that is $524.67. You received extracapsular cataract removal on October 15, 2019. The total allowed amount is $2,498.06 and 20% of that is $499.61. The total amount you owe is: $1,024.28. You have been asked to pay the total coinsurance amount of $1,024.28 for extracapsular cataract removal. Extracapsular cataract removal falls within the outpatient surgery and other medical 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 coinsurance for extracapsular cataract removal provided from October 1, 2019 to October 15, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not haveto pre-approve a dental consultation (D9310) and surgical extraction (D7210) to be provided by an oral surgeon.You asked the Plan to pre-approvethe dental services. You say that you are appealing because you have a rotten tooth that has crackedin half and needs to be extracted.The Plan denied your request. The Plan says dental services are not covered when provided by an oral surgeon.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceedsMedicare coverage. For that reason, the Plan's coverage rules apply in this case. The health plan contract specifically says that services must be performed by a participating general dentist.Though the Plan offers a dental benefit in excess of Medicarecoverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvea dental consultation (D9310) and surgical extraction (D7210) to be provided by an oral surgeon.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for orthotics (HCPCS L0650) provided to the enrollee on November 13,
2019.
You asked the Plan to pay for the brace. You say that the claim was denied in error stating that you did not
supply the delivery ticket for processing. The Plan denied your request. The Plan says that HCPCS L0650
remains not supported, as the documentation submitted did not include an itemized shipping/billing invoice to
indicate the specific billed supplies.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate code.
In this case, the CPT Code Manual definition of code L0650 is " Lumbar-sacral orthosis (LSO), sagittalcoronal
control, with rigid anterior and posterior frame/panel(s), posterior extends from sacrococcygeal
junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panel(s), produces intracavitary
pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps,
pendulous abdomen design, prefabricated, off-the-shelf."
We find that HCPCS code L0650 is supported in the medical record. The plan did not substantiate their denial
of this code. Specifically, the provider sent in proof that the brace was delivered, and showed that this
information was faxed to the plan. Based on this information, we decided that Medicare rules for coverage of
the brace have been met. Therefore, we decided that the Plan has to pay for orthotics (HCPCS L0650) provided
to the enrollee on November 13, 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 the medical services provided on August 27, 2019 by an out of network (OON) provider.You asked the Plan to pay for surgical service. You say that pre-authorization was not requested.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 the enrollee self-directed for service.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 August 27, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis provided on December 9, 2019.
You asked the Plan to pay for the prophylaxis. You say that a representative from the provider's office told you that you were covered and there would be no charge for your upcoming appointment. The Plan denied your request. The Plan says the copay was applied correctly per your 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 of Medicare coverage, you are required to pay a $10 copay for one cleaning each year. Therefore, we decided that the Plan does not have to pay for the prophylaxis provided on December 9, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forhome health care services provided from January 6, 2019 to April 27, 2019.You asked the Plan to pay forhome health care services. You say that this should be covered.The Plan denied your request. The Plan says these services were provided by a provider who does not participate in Medicare.The Plan mustfollow Medicare rules. Medicare rules say that home health services are covered only when the home health agency that is providing the services to the beneficiary has in effect a valid agreement to participate in the Medicare programWe looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health care services have not been met. The provider you received these services from does not participate in the Medicare program.Therefore, we decidedthat the Plan does not have to pay forhome health care services provided from January 6, 2019 to April 27, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora CT scan provided on November 14, 2019.You asked the Plan to waive the copayment fora CT scan. You say that you disagree with the fact that the Plan is only paying $5.87.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 $180 copayment for advanced imaging services provided in a specialist's office, outpatient hospital or a freestanding radiological facility. You have been asked to pay a $180 copayment for a CT scan. A 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 when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment fora CT scan 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 care provided from October 21, 2019 to October 30, 2019.
You asked the Plan to waive the copayment for inpatient care. You say that you were not aware of this copayment. The Plan denied your request. The Plan says this claim processed correctly with the copayment listed in the EOC.
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 $375 copayment per day for days 1 through 4 of inpatient hospital care. You have been asked to pay a $1,500 copayment for nine days of inpatient care ($375 x 4 days = $1500 + $0 for additional days). 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 care provided from October 21, 2019 to October 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that you are disabled and have a bad knee, lower back pain, and arthritis. You say these conditions make it hard for you to bend or stand for long periods of time. You stated that you are unable to wash your feet and need the requested shower chair to do so. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair 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 shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the ReWalk Personal 6.0 System.
You asked the Plan to pre-approve the customizable exoskeleton for home use. You say that the ReWalk System is medically necessary to restore the enrollee's walking abilities. The Plan denied your request. The Plan says experimental or investigational services are not covered.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The DME MAC Joint Publication says recently several products described as powered exoskeletons have been developed. These items are reported to support mobility for spinal cord injured beneficiaries who are unable to ambulate. We looked at the file and Medicare rules. The ReWalk-P (Personal) wearable lower-limb robotic exoskeleton is considered experimental, investigational and unproven for use in lower limb paraplegia after spinal cord injury due to insufficient evidence in the peer reviewed medical literature. Therefore, we decided that the Plan does not have to pre-approve the ReWalk Personal 6.0 System.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient skilled nursing facility (SNF) care services.
You asked the Plan to pre-approve continued SNF care. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says continued inpatient skilled nursing facility care is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 continued SNF care. Our reviewer says that continued inpatient skilled nursing facility care is not medically necessary. Our physician reviewer found that the enrollee does not require skilled nursing or skilled therapy services on a daily basis. Additionally, the enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient skilled nursing facility (SNF) care services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested varicose vein treatment.You asked the Plan to pre-approve the varicose vein treatment. The Plan denied your request. The Plan says that the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from 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 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the requested varicose vein treatment.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography (CT) scan services.
You asked the Plan to pre-approve the CT scan. You say that the records provided support the need for the requested CT scan. The Plan denied your request. The Plan says a repeat high-resolution CT is not medically necessary for the enrollee at this time.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. 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 CT scan. Our reviewer says that the documentation does not support that a CT scan of the chest is currently medically necessary or reasonable. Our physician reviewer found the enrollee is noted to have interstitial lung disease. There is no documentation of a recent change or increase in signs or symptoms. Prior imaging has not revealed pulmonary nodules. 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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT) scan services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on December 2, 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 documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on December 2, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested varicose vein treatment.
You asked the Plan to pre-approve the varicose vein treatment. The Plan denied your request. The Plan says the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from 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 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the requested varicose vein treatment.