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

We decided that the Plan does not have to pay for psychotherapy services (90832) provided on July 31, 2020, by an out of network provider.

You asked the Plan to pay for psychotherapy services. You say that psychotherapy services were provided to the enrollee in good faith. The Plan denied your request. The Plan says rules for out of network care have not been met.

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 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 psychotherapy services (90832) provided on July 31, 2020, by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213) provided on January 22, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the office visit. You say that you did not know that you needed or how to get prior authorization. You say you have received some payments from this insurance company before. The Plan denied your request. The Plan says out-of-network services are only covered under limited circumstances. The provider in question is not part of this plan's network. Prior authorization was not obtained, and these services were not urgent or emergent. Payment cannot be made.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the office visit (99213) provided on January 22, 2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided to the enrollee on January 22, 2021.

You asked the Plan to waive the copayment for the services. You say that the provider overreacted. The Plan denied your request. The Plan says the copayment was applied correctly according to your benefits and the services rendered.

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 copayment for Medicare-covered ambulance services. 

You have been asked to pay a $240 copayment for the services. The services fall within the Medicare-covered ambulance 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 copayment for ambulance services provided to the enrollee on January 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the root canal (D3320) for tooth # 21 provided on December 22, 2020.
You asked the Plan to pay for the dental service. You say that this service should be covered by your policy per the booklet and Minnesota Law. The Plan denied your request. The Plan says the root canal is not listed as a covered 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 root canal (D3320) for tooth # 21 provided on December 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic connection (E2311), expandable controller (E2377), self-leveling cup (K0108), and expandable controller harness (E2313).
You asked the Plan to pre-approve an electronic connection, expandable controller, self-leveling cup, and expandable controller harness. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that covers certain wheelchair accessories when specific criteria are met. 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 an electronic connection, expandable controller, self-leveling cup, and expandable controller harness. Our reviewer says that the services are not medically necessary. Our physician reviewer found the documentation does not reveal that you require other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.) You do not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices),other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. Your strength and function in the upper extremities with the ability to independently bathe and groom supports that you can control any power options through their own individual switches. The K0108 self-leveling cup is not primarily medical in nature and therefore does not meet Medicare criteria for medical necessity per Social Security Act, Section 1862 (a)1(A) and the 42 CFR 411.15(k).We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an electronic connection, expandable controller, self-leveling cup, and expandable controller harness have not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic connection (E2311), expandable controller (E2377), self-leveling cup (K0108), and expandable controller harness (E2313).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services rendered on November 20, 2020.

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 billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct Place of Service (POS) code.

We looked at the file and Medicare rules. The file shows that the claim was incorrectly billed with POS code 22 for the outpatient setting. The enrollee was under inpatient status and the claim should have been billed with POS code 21. 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 pay for the anesthesia services rendered on November 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on December 4, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the 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 services provided by an out-of-network provider on December 4, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided on
January 16, 2021, to January 17, 2021.
You asked the Plan to waive the copayment for an emergency room visit. You say that you visited the
emergency room. You also say you were admitted and then discharged the next day under inpatient care. The
Plan denied your request. The Plan says the copayment 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 a $120
copayment for emergency room services. Your contract with the Plan also clearly says that even if you stay in
the hospital overnight, you might still be considered outpatient, or in this case emergency outpatient.
You have been asked to pay a $120 copayment for emergency room visit. The record shows that the provider
billed for an emergency service, not an inpatient visit. An emergency room visit falls within the emergency
care 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 emergency room visit
provided on January 16, 2021, to January 17, 2021.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve WATS 3D Biopsy, morphometric analysis (88361) provided December 5, 2019.

You asked the Plan to pre-approve WATS 3D Biopsy. You say that testing was ordered for the enrollee after the ordering physician made a professional determination of medical necessity for the detection and surveillance of Berrett's esophagus and associated dysplasia. The Plan denied your request. The Plan says that the request does not meet Medicare medically necessary criteria.

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 WATS 3D Biopsy. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found ASGE guidelines recognizing the low quality of available evidence in favor of widespread application of the technique, suggest only conditionally that WATS-3D be reserved for cases of known or suspected Barrett's esophagus. The enrollee's available record supports the high likelihood of Barrett's esophagus based on history and tissue appearance, and thus does meet the criteria of ASGE guidance relative to medically necessary use of WATS-3D in this case.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of WATS 3D Biopsy have been met. Therefore, we decided that the Plan has to pre-approve WATS 3D Biopsy, morphometric analysis (88361) provided December 5, 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 waive the coinsurance for lumbar-sacral orthosis provided on December 17, 2020.
You asked the Plan to waive the coinsurance for a lumbar-sacral orthosis. You say that you told the nurse, that if you had a cost share for the lumbar-sacral orthosis, not to order the item. The Plan denied your request. The Plan says the coinsurance 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 a 20% coinsurance for DME and related supplies.
The allowed amount of the claim is $1,371.22, resulting in a coinsurance obligation of $274.24. You have been asked to pay a 20% coinsurance for each DME item. A lumbar-sacral orthosis falls within the DME and related 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 coinsurance for a lumbar-sacral orthosis (L0650) provided on December 17, 2020. 
Your complaint about potentially receiving misinformation from the nurse is 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the duplex scans rendered on January 8,
2021, and January 22, 2021.

You asked the Plan to waive the copayments for these services. You say that you disagree with the charges.
The Plan denied your request. The Plan says the copayments were 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). Your contract with the Plan clearly says that you must pay a $110
copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in a
physician's office or at a freestanding facility.

Review of the file shows that you received a bilateral duplex scan of the extremity veins on January 8, 2021.
You have been asked to pay a $110 copayment for these services. These services fall within the Medicare-covered
radiological diagnostic services, not including x-rays, performed in a physician's office or at a
freestanding facility benefit category. This means that you have been asked to pay the correct amount based on
your contract with the Plan.

The file shows that you received a unilateral duplex scan of the extremity veins on January 22, 2021. Per the
contract with the Plan, there is a $110 copayment for Medicare-covered radiological diagnostic services, not
including x-rays, performed in a physician's office or at a freestanding facility. However, the Medicare allowed
amount for these services was $102.32. Given that the allowed amount was less than the $110 copayment, you
have been asked to pay $102.32 for these services.

The total amount you have been asked to pay for these services is $212.32. 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 the duplex scans rendered on January 8, 2021, and January 22, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe breast ultrasound rendered on June 11, 2020.You asked the Plan to waive the copayment forthese services. You say that you disagree with the charges.The Plan denied your request. The Plan says the copayment 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). Your contract with the Plan clearly says that you must pay a $150 copayment for all other diagnostic tests. Review of the file shows that you received a breast ultrasound on June 11, 2020. Per the contract with the Plan, there is a $150 copayment for all other diagnostic tests. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. However, the Medicare allowed amount for these services was $73.62. Given that the allowed amount was less than the $150 copayment, you have been asked to pay $73.62 for these services Therefore, we decided that the Plan does not have to waive the copayment forthe breast ultrasound rendered on June 11, 2020
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient services provided by an out-of-network provider from July 9, 2020, to July 18, 2020.

You asked the Plan to pay for the 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 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 inpatient services provided by an out-of-network provider from July 9, 2020, to July 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an automatic pill dispenser.
You asked the Plan to pre-approve an automatic pill dispenser. You say that the item is necessary. The Plan denied your request. The Plan says the requested item is not primarily medical in nature. Therefore, coverage criteria have not been met.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve an automatic pill dispenser.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an implantable loop recorder (33285).
You asked the Plan to pre-approve an implantable loop recorder (33285). You say that the requested
implantable loop recorder (33285) is medically necessary. The Plan denied your request. The Plan says the
enrollee does not meet criteria for the requested implantable loop recorder (33285).
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve an implantable loop recorder (33285).
Our reviewer says that the enrollee does not meet criteria for the requested implantable loop recorder (33285).
Our physician reviewer found in this case; the enrollee had a stroke in 2005. A ZIO monitor demonstrated
atrial tachycardia. The last 14-day event monitor in March 2021 showed six episodes of supraventricular
tachycardia thought to be atrial in origin. The enrollee has not had syncope. The enrollee has a documented
arrhythmia. The elements of the coverage rule are not satisfied. The requested service is not recommended.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of an implantable loop recorder (33285) have not been met. Therefore, we decided
that the Plan does not have to pre-approve an implantable loop recorder (33285).
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 6, 2020.
You asked the Plan to waive the copayment for the office visit. You say that you received a letter stating all out-of-pocket costs were eliminated and the Plan should pay all costs. The Plan denied your request. The Plan says the copayment 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). Your contract with the Plan clearly says that you must pay a $35 copayment for provider and professional services at an in-network specialist's office.
You have been asked to pay a $35 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The Plan says that only costs for in-network primary care visits, outpatient behavioral health visits and telehealth visits were being waived. 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 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
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 IRF care. Our reviewer says that the
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the
enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an
interdisciplinary approach to rehabilitation care. The enrollee was admitted for surgery for a meningioma.
Medical conditions are stable. There are no complex nursing or rehabilitation needs.
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational
therapy, in an intensive rehabilitation therapy program. The enrollee does require physical and occupational
therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services
can be provided in a different level of care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.