Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve epoetin alfa (Retacrit).

You asked the Plan to pre-approve epoetin alfa. You say that the medication is medically necessary. The Plan denied your request. The Plan says that the provider has failed to provide documentation that the member meets the specified criteria.

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. We find that there were no medical records provided to support the denial of the requested drug. Without medical records to review, we cannot determine that the criteria has not been met. Therefore, we decided that the Plan has to pre-approve epoetin alfa (Retacrit).

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on December 17, 2020.
You asked the Plan to pay for the 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 as billed.
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on December 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forinpatient rehabilitation care provided on November 6, 2020, through November 12, 2020.You asked the Plan to waive the copayment forinpatient rehabilitation care. You say that the service should be considered as skilled nursing facility care, and therefore, covered by the Plan.The Plan denied your request. The Plan says the cost share was applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $325 copayment each day one through six for inpatient hospital care. The enrollee has been asked to pay a $325 copayment each day one through six for inpatient rehabilitation care. This service falls within the inpatient hospital care benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forinpatient rehabilitation care provided on November 6, 2020, through November 12, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for gastroenterology services provided on October 28, 2020.

You asked the Plan to pay for the gastroenterology services. You say that the services in dispute were provided during the enrollee's observation admission. You say that the Plan's policy does not require prior authorization to be obtained for observation admissions. You say that the documentation provided shows that the facility listed the services as an observation stay and the services in dispute should be paid in full. The Plan denied your request. The Plan says that the provider should have verified the enrollee's eligibility, health benefits, and obtained authorization prior to the enrollee's visit and before providing services to the enrollee.

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 rules also say that a Medicare Plan is financially responsible for emergency services, regardless of whether the services are obtained within or outside of their network.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan did not provide documentation to show the services in dispute were not provided during an observation stay, nor did they provide any evidence that the facility claim was denied. The appellant provided documentation stating that the enrollee was admitted due to abdominal pain and had gastroenterology services as part of the work up for their emergent medical condition. Observational care is for an emergency medical condition which needs evaluation to determine if the enrollee can be stabilized or if an inpatient stay is needed. Therefore, we decided that the Plan has to pay for gastroenterology services provided on October 28, 2020.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurancefor the home ventilator (E0466) provided on February 19, 2021.You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's denial of payment.The Plan denied your request. The Plan says the coinsurance has been applied correctly to the durable medical equipmentprovided.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-covered durable medical equipmentand related supplies. You have been asked to pay $189.94 ($949.71 x 20% coinsurance) for the durable medical equipment provided. 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, wedecided that the Plan does not have to waive the coinsurancefor the home ventilator (E0466) provided on February 19, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pre-approve emergency room services for treatment of a periapical abscess without sinus, provided on January 25, 2021.

You asked the Plan to pre-approve the emergency room services. You say that the records provided support that the services in dispute were medically necessary. The Plan denied your request. The Plan says the services provided are not a covered 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 requested items or services are not among those covered under this benefit. The emergency room services in dispute primarily involved the care and treatment of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are considered dental services that are not covered. Therefore, we decided that the Plan does not have to pre-approve emergency room services for treatment of a periapical abscess without sinus, provided on January 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the extended patient service without direct patient contact
(99358) provided on January 31, 2021, by an OON provider.
You asked the Plan to pay for the extended patient service without direct patient contact. You say that you
would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says prior
authorization was not obtained for these services rendered by an OON provider.
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 extended patient service without direct patient
contact (99358) provided on January 31, 2021, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate for the additional periapical x-ray (D0230) provided on February 10, 2021.
You asked the Plan to pay the in network rate for the additional periapical x-ray. You say that you called the Plan for verification that your dentist was in network. You say that the Plan confirmed that the dentist was in network. You also say that you received a bill for these services. The Plan denied your request. The Plan says 1 periapical x-ray is covered per calendar year. The Plan also says that the frequency limit has been exceeded.
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 and periapical x-ray is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a periapical x-ray that you received on this date of service. Therefore, we decided that the Plan does not have to pay the in network rate for the additional periapical x-ray (D0230) provided on February 10, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments foroutpatient rehabilitation services provided from July 23, 2020, to September 28, 2020.You asked the Plan to waive the copayments foroutpatient rehabilitation services. You say that gyms were closed due to COVID-19 so you had to receive rehabilitation and feel that you should not be responsible for the charges.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 copayment for outpatient rehabilitation services. You received outpatient rehabilitation services from July 23, 2020, to September 28, 2020, for a total of 23 visits. Therefore, you are responsible to pay a $15 copayment per each visit. The total amount you owe is: $15 (copayment) x 15 (outpatient rehabilitation services) = $345. You have been asked to pay the total copayment amount of $345 for outpatient rehabilitation services. Outpatient rehabilitation services fall within the outpatient rehabilitation 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 copayments foroutpatient rehabilitation services provided from July 23, 2020, to September 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the oncology (urothelial), gene expression profiling (0012M) rendered by the out of network (OON) provider on October 21, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered 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 had network providers available who could have provided the service at issue in this appeal.
The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the oncology (urothelial), gene expression profiling (0012M) rendered by the out of network (OON) provider on October 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) rendered by the out of network (OON) provider on January 7, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered 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 had network providers available who could have provided the service at issue in this appeal.
The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99214) rendered by the out of network (OON) provider on January 7, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay fordrug testing (G0483) provided on September 16, 2020, by an out of network (OON) provider.You asked the Plan to pay fordrug testing. You say that the services were medically necessary.The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services rendered by an out-of-network provider.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. The records provided for review do not show that the services at issue were urgent or emergent. The records provided for review also show that the referring provider was out-of-network. 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 fordrug testing (G0483) provided on September 16, 2020, by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for chiropractic services provided on March 18, 2021.

You asked the Plan to waive the co-payment for chiropractic services. You say that the services are necessary to keep you mobile and you request that you no longer owe a co-payment. 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 co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 co-payment for chiropractic services.

You have been asked to pay a $20 co-payment for chiropractic services. Chiropractic services fall within the chiropractic 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 co-payment for chiropractic services provided on March 18, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance transportation (A0426, A0425) received December 28, 2020.You asked the Plan to waive the copayment forthe ambulance transportation. You say that you were not consulted by the hospital about being transferred by ambulance to another hospital.The Plan denied your request. The Plan says the correct cost share applied to the claim.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $240 copaymentfor Ambulance Services. You have been asked to pay a $220 copayment for the ambulance transportation. The ambulance transportation falls within the Ambulance Services benefit category. You have been asked to pay an amount that is less than or equal to the required copayment of $240. 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 forthe ambulance transportation (A0426, A0425) received December 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on January 14,
2021.
You asked the Plan to waive the copayment for a specialist visit. You say that you did not want the Plan you
were signed up for and should not be responsible for the charges. The Plan denied your request. The Plan says
the claims were processed correctly, and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $0 or
$25 copayment for each specialist visit.
You had a specialist visit on January 14, 2021. The record shows that you were not eligible for Medicaid
assistance at the time the services were received. Therefore, you are responsible to pay the $25 copayment.
You have been asked to pay a $25 copayment for a specialist visit. A specialist's 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 a specialist visit provided on January 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forchiropractic care provided by a participating provideron February 26, 2021.You asked the Plan to waive the copayment forchiropractic care. You say that you do not agree with this copayment.The Plan denied your request. The Plan says the correct copayment 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 $15 copayment for chiropractic services/in-network. You have been asked to pay a $15 copayment for chiropractic care. The correct copayment has been applied to the services that were provided. Chiropractic care falls within the chiropractic services/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 copayment forchiropractic care provided by a participating provider on February 26, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharefor the hospital outpatient clinic visit (G0463), debridement services (11042, 11045), nail trimming (G0127), and the unna boot strapping (29580) provided from September 29, 2020, through November 24, 2020.You asked the Plan to waive the cost share. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says the cost share has been applied correctly to the services provided.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee'scontract with the Plan clearly says that hemust pay a $40 copayment for each specialist visit. Additionally, enrollees must pay a 20% coinsurance for durable medical equipment. The enrollee has been asked to pay $184.98 which includes a $40 copayment x 4 days=$160for the specialist visits provided and the Plan allowed amount of $124.91x 20% coinsurance=$24.98 for the durable medical equipmentprovided. This means that the enrollee has been asked to pay the correct amount based on hiscontract with the Plan. This cost sharing is a contractual obligation the enrolleeagreed to pay when heenrolled in the Plan.Therefore, we decided that the Plan does not have to waive the cost sharefor the hospital outpatient clinic visit (G0463), debridement services(11042, 11045), nail trimming (G0127), and the unna boot strapping (29580) providedfrom September 29, 2020, through November 24, 2020.