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

 
We decided that the Plan does not have to waive the copayment for the outpatient office visit (99213) 
additional supplies, materials, and clinical staff time over and above those usually included in an office visit or 
other non-facility service (99072) provided October 28, 2020. 
 
You asked the Plan to waive the copayment for the office visit. You say that you waited 2 hours to see this 
doctor. As you were going out the door the receptionist stopped you and said you were no longer a patient. You 
paid your copay of $32 and you would like it back. The Plan denied your request. The Plan says this claim was 
processed 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 $32 for 
each visit for each specialty physician office.  
 
You have been asked to pay $32 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 (99213) additional supplies, materials, and clinical staff time over and above those 
usually included in an office visit or other non-facility service (99072) provided October 28, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for laboratory services provided from August 
24, 2020, to October 5, 2020. 
 
You asked the Plan to waive the copayments for laboratory services. You say that you feel that the provider 
should not be considered a freestanding laboratory. The Plan denied your request. The Plan says the claims 
were processed correctly and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for lab services provided at a freestanding laboratory. 
 
The record shows that you received laboratory services at a freestanding facility from August 24, 2020, to 
October 5, 2020. Therefore, you are responsible to pay the total allowed amount of $61.24, which is less than 
the total copayment amount.   
 
You have been asked to pay the total allowed amount of $61.24 for laboratory services. Laboratory services fall 
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 copayments for laboratory services provided from August 24, 2020, to October 5, 
2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diabetic testing lancets, 450 per thirty days. 
 
You asked the Plan to pre-approve the lancets. You say that the additional lancets are medically necessary. The 
Plan denied your request. The Plan says rules for coverage are not met. 
 
The Plan follows Medicare rules. Medicare rules say that more than 300 lancets every three months are only 
covered when 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 lancets. Our reviewer says that the 
additional lancets are not medically necessary. Our physician reviewer found the plan has approved enough 
lancets to test ten times daily. The record provides no reason why the enrollee would need to test more than ten 
times a day. 
 
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 lancets have not been met. Therefore, we decided that the Plan does not 
have to pre-approve diabetic testing lancets, 450 per thirty days.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a lumbar sympathetic block for the enrollee. 
 
You asked the Plan to pre-approve the block. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is considered necessary for treatment of complex regional pain syndrome. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the block. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found phantom limb pain may be alleviated by a sympathetic block. The procedure is medically reasonable and 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the block have been met. Therefore, we decided that the Plan has to pre-approve 
a lumbar sympathetic block for the enrollee.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on October 5, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that the services provided were medically necessary. 
The Plan denied your request. The Plan says the services were not urgent, emergent, or prior 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided 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 for the medical services provided on October 5, 2020 by an out of network (OON) 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

Wedecided that the Plan does not have to pay forthe first intraoral periapical x-ray (D0220) provided on August 21, 2020.You asked the Plan to pay forthe first intraoral periapical x-ray. You say that you asked your dentist to get a pre-approval for the services you received. You also say that you would not have had this procedure done if you had been told what the costs would be.The Plan denied your request. The Plan says this service is not a covered benefit under your dental 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 Medicarecoverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe first intraoral periapical x-ray (D0220) provided on August 21, 2020.Your complaint about being misled by the Planis not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services rendered on June 13, 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 claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for these services was not filed until October 22, 2020. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the services rendered on June 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device provided from June 26, 
2020, to July 23, 2020. 
 
You asked the Plan to pay for a pneumatic compression device (E0675). You say that this device was used to 
help prevent blood clots/swelling during and after the operation. The Plan denied your request. The Plan says 
items used for preventative service or function are excluded from coverage under the Medicare DME benefit. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0675) is a preventive service. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided 
that the Plan does not have to pay for a pneumatic compression device provided from June 26, 2020, to July 23, 
2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing services (G0483) provided on February 17, 2020, by an out-of-network (OON) provider.You asked the Plan to pay forOON drug testing services. You say that this was medically necessary.The Plan denied your request. The Plan says this was 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 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 forthese items/services.Therefore, we decided that the Plan does not have to pay forthe drug testing services (G0483) provided on February 17, 2020, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe duplex scan of lower extremity arteries or arterial bypass grafts (93926) provided November 2, 2020 to November 9, 2020.You asked the Plan to waive the copayment forthe duplex scan. You say that these charges are excessive and should be considered a follow up to a procedure that was performed on 10/8/2020.The Plan denied your request. The Plan says these claims were processed 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 $55 copayment for each standard x-ray and ultrasound. You have been asked to pay $55 copayment for the duplex scan. The duplex 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 paywhen you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe duplex scan of lower extremity arteries or arterial bypass grafts (93926) provided November 2, 2020 to November 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvehome health skilled nursing services for the enrollee.You asked the Planto pre-approvethe services. You say that additional visits are needed.The Plandenied your request. The Plansaysthis is not medically necessary.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 services. Our reviewer says that the requested visits are not medically reasonable or necessary. Our physician reviewer found in this case, the documentation doesn't support that the enrollee requires skilled nursing services or skilled rehab services to provide treatment that is medically necessary. The enrollee does not require skilled nursing to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. The enrollee has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The additional skilled nursing home healthcare visits 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 the services have not been met.Therefore, we decided that the Plandoes not haveto pre-approvehome health skilled nursing services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copay forthe urgent care services provided on September 12, 2020.You asked the Plan to waive the copay forthe services provided. You say that you were advised to go to the hospital.The Plan denied your request. The Plan says the claim processed 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 $65 copay per visit for urgently needed services. You have been asked to pay a $65 copay for the services provided. The services fallwithin the urgently needed services benefit category. Thismeans 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 copay forthe urgent care services provided on September 12, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a SNF admission.
You asked the Plan to pre-approve the SNF admission. The Plan denied your request. The Plan says your request does not meet Medicare guidelines because you are receiving adequate and necessary intensive rehabilitation in the Inpatient Rehabilitation Facility. The Plan also says that movement to a SNF 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 the SNF admission. Our reviewer says that you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Although you have skilled therapy needs, these needs are not on a daily basis. Based on this information, we decided that Medicare rules for coverage of the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve a SNF admission.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services provided on October 1, 2020, by an out-of-network (OON) provider.You asked the Plan to pay forphysician services. You say that you did not know the provider you were using was out-of-network. You say that going forward you will use an in-network provider.The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the rendering physician is out-of-network.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 forphysician services provided on October 1, 2020, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection provided by a participating provider on August 14, 2020.
You asked the Plan to waive the coinsurance for an injection. You say that you do not agree with this coinsurance. The Plan denied your request. The Plan says the correct coinsurance has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare Part B prescription drugs/in-network. You have been asked to pay a 20% coinsurance of the allowed amount for an injection. The total allowed amount is $2,972.56. The total amount you are being asked to pay is $594.52 ($2,972.56 x 20% = $594.52). An injection falls within the Medicare Part B prescription drugs/in-network 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 an injection provided by a participating provider on August 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for initial hospital care provided on June 15, 2019.

You asked the Plan to pay for the initial hospital care. You say that the claim should be reprocessed and paid. The Plan denied your request. The Plan says the claim was not filed timely.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for the initial hospital care was not filed until September 18, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for initial hospital care provided on June 15, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount forhearing aids purchased on August 14, 2020.You asked the Plan to pay an additional amount forhearing aids. You say that you were told hearing aids would be covered when purchased from an out-of-network provider.The Plan denied your request. The Plan says the denial of payment for these hearing aids is correct, because the Plan only covers an allowance of $700 per hearing aid device per ear every 3 years which has been exhausted. The Plan also says that they have approved payment of $700 per each ear ($1,400 total), so this denial is only for the amount above the allowance for hearing aids.Medicaredoes not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only up to an allowance of $700per hearing aid device per ear every 3 years. We looked at the file, Medicare rules, and the Plan's rules. The Plan has reimbursed you up to the allowance amount for each hearing aid. You are responsible for any amount you paid above the allowance. Therefore, we decided that the Plan does not have to pay an additional amount forhearing aids purchased on August 14, 2020
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an EKG provided by an out of network (OON) provider.

You asked the Plan to pay for an EKG. You say that you have no idea what patient you will see. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the facility or physician.

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 an EKG provided 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 PPE provided on October 6, 2020.
You asked the Plan to pay for the PPE. You say that this should be a requirement during the pandemic, and you believe it was denied in error. The Plan denied your request. The Plan says your plan does not provide benefits for this service.
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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the PPE provided on October 6, 2020.