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

We decided that the Plan does not have to waive the coinsurance for outpatient mental health services provided on February 7, 2020 and to pay for out of network services provided on January 25, 2021.

You asked the Plan to waive the coinsurance charged to the enrollee on February 7, 2020 and to pay for services provided to the enrollee on January 25, 2021.

You say that this claim should be paid by the Plan. The Plan denied your request. The Plan says the enrollee
did not have prior authorization for out of network care. The enrollee had outpatient mental health visits on
February 07, 2020 and January 25, 2021, from non-par providers. The Plan states that for date of service,
February 7, 2020 this claim paid this service at the plan level benefit, applying a 20% contractual coinsurance
according to the 2020 Evidence of Coverage. For date of service, January 25, 2021, the Plan received an
additional claim from a non-par provider. The Plan states they upheld the appeal request as enrollee's are
responsible for cost share related to services rendered. The Plan notes there was also a claim for date of service
August 7, 2020 which was overturned as plan directed care.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care. The contract with the Plan clearly shows a coinsurance
expectation for outpatient mental health care and a prior authorization requirement.

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 service at issue.
We found no exception that would require the Plan to waive the coinsurance for services rendered in 2020
and/or pay for the services rendered out of network without prior authorization. Therefore, we decided that the
Plan does not have to waive the coinsurance for February 7, 2020 or pay for out of network services provided
on January 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B drug provided on February 24, 2021.

You asked the Plan to waive the coinsurance for the Part B drug. You say that you have never paid a coinsurance for this same injection. You say this is not a chemotherapy injection. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% of the cost for Part B drugs.

You have been asked to pay $143.69 which is 20% of the allowed amount for the Part B drug. The allowed amount is $718.45. ($718.45 x 20% = $143.69). The Part B drug falls within the "Medicare Part B prescription drugs" benefit category. The record shows you were received a bortezomib injection which is considered a Part B drug.

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 the Part B drug provided on February 24, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the ustekinumab injection provided on April 1, 2021.

You asked the Plan to waive the coinsurance for the ustekinumab injection. You say that you were told by the doctor that this was prior authorized, and it would be a specialist copayment. You say that going forward you will be receiving the medication for $9 and you are frustrated with the cost. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for Medicare covered Part B drugs and other Medicare covered items from an in-network provider.

You have been asked to pay $1,180.75, which is 20% of the allowed amount for the ustekinumab injection. The allowed amount is $5,903.77 (20% x $5,903.77 = $1,180.75). The ustekinumab injection falls within the "Medicare Part B prescription drugs" 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 the ustekinumab injection provided on April 1, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray provided on October 26, 2020.
You asked the Plan to pay for the chest x-ray. You say that the service provided on this date of service was rendered appropriately in response to the enrollee's medical condition. You also say that you would like this claim to be reprocessed. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the chest x-ray provided on October 26, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion procedure.

You asked the Plan to pre-approve the Vertiflex Superion procedure. You say that this request is medically necessary. The Plan denied your request. The Plan says the Vertiflex device is considered experimental/investigational.

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 the Vertiflex Superion procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy of the device. 

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 Vertiflex Superion procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided by an opted-out provider on March 15, 2021.

You asked the Plan to pay for office visit. You say that payment of non-network providers is part of your Plan and as long as the doctor is licensed in the United States it is the responsibility of the Plan to reimburse you the Medicare amount. You also say that whether the doctor participates in Medicare or not should be irrelevant to the process. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider has opted out of Medicare and is not payable.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. 

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for an office visit provided by an opted-out provider on March 15, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to waive the copayment for a collection of a blood specimen from an implantable
venous access device (36591) performed on February 6, 2020.

You asked the Plan to waive the copayment for a collection of a blood specimen from an implantable venous
access device. You say that you have never before had to pay a copayment for blood draws. The Plan denied
your request. The Plan says that the correct copayment was applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that enrollees must pay a $0 copayment for laboratory tests.

The Plan says you must pay a $110.73 copayment for a collection of a blood specimen from an implantable
venous access device. Based on the Plan contract, however, you cannot be asked to pay more than a $0
copayment for a collection of a blood specimen from an implantable venous access device. Therefore, we
decided that the Plan has to waive the copayment for a collection of a blood specimen from an implantable
venous access device (36591) performed on February 6, 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing care in the home provided by a RN (S9123) provided from January 15, 2021, to January 29, 2021.
You asked the Plan to pay for the nursing care in the home. You say that you request that the bill for the visits be paid promptly, in line with the policy provisions. The Plan denied your request. The Plan says the treating provider is not certified with Medicare and is out-of-network with the Plan.
The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered Medicare items or services, a provider or supplier must be enrolled in the Medicare program. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the nursing care in the home have not been met. This provider is not part of the Medicare program and is not payable. Therefore, we decided that the Plan does not have to pay for the nursing care in the home provided by a RN (S9123) provided from January 15, 2021, to January 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on February 5, 2021.

You asked the Plan to pay for the panoramic x-ray. You say that your previous panoramic x-ray was not good enough for your current provider to use. You also say that you cannot pay out of pocket for this service. The Plan denied your request. The Plan says this service exceeds the maximum count allowed per period.

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, panoramic x-ray (D0330) and is limited to one procedure every three plan years. The record shows that you received a panoramic x-ray (D0330) on June 10, 2020 and your panoramic x-ray (D0330) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on February 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay from February 26 through March 2, 2021.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you would like this visit to be considered a continuation of care from your previous visit. The Plan denied your request. The Plan says this was a separate visit and therefore 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 $100 copayment per visit for Inpatient Hospital Care.
You have been asked to pay a $100 copayment per visit for the inpatient hospital stay. The inpatient hospital stay falls within the Inpatient Hospital 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 the inpatient hospital stay from February 26 through March 2, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the service is medically necessary. The Plan denied
your request. The Plan says the service 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 in the Medicare rules section 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 SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found you do not require skilled nursing or skilled
therapy services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have not been met. Specifically, the enrollee's care needs at this point
are custodial and, as a practical matter, can be provided at a lower level of care. This means SNF care is not
medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve skilled
nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the OmniSeq Insight Panel Test for the enrollee.

You asked the Plan to pre-approve the test. You say that this testing is indicated for patients with advanced stage, solid tumor cancers who intend to purse treatment for their cancer diagnosis. The Plan denied your request. The Plan says this testing exceeds the recommended NCCN guidelines and is not considered medically necessary by Medicare.

The Plan must follow Medicare rules. The rules say that genetic testing is not covered if it is unlikely to impact therapeutic decision-making in the clinical management of the patient. 

The requested test is coded with CPT 81455. Medicare does not consider testing coded with CPT 81455 to be medically necessary and likely to impact medical management. Based on this information, we decided that Medicare rules for coverage of the test have not been met. Therefore, we decided that the Plan does not have to pre-approve the OmniSeq Insight Panel Test for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy-duty power operated vehicle (K0801).

You asked the Plan to pre-approve a heavy-duty power operated vehicle. You say that this request is medically necessary as it is your sole mode of transportation. The Plan denied your request. The Plan says the criteria for a heavy-duty power operated vehicle have not been met.

The Plan must follow Medicare rules. Medicare rules say that a heavy-duty power operated vehicle is covered for enrollee's that weigh between 285 - 450 pounds. 

We looked at the file and Medicare rules. In this case, the records indicate that your weight is currently less than 285 pounds. Based on this information, we decided that Medicare rules for coverage of a heavy-duty power operated vehicle have not been met. Therefore, we decided that the Plan does not have to pre-approve a heavy-duty power operated vehicle (K0801).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on June 10, 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 June 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on February 1, 2021 by an out-of-network provider.

You asked the Plan to pay for the office visit. You say that the enrollee needed to be seen so the Plan should pay this claim. The Plan denied your request. The Plan says you did not request prior authorization for the out-of-network services.

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 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 the service. Therefore, we decided that the Plan does not have to pay for the office visit provided on February 1, 2021 by an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says custodial care is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found your main diagnosis is debility and is medically stable. There are no daily skilled nursing needs. Daily skilled therapy services are not required on an inpatient basis in the SNF. 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and x-ray provided on May 5, 2021.

You asked the Plan to pay for the services provided. You say that you were not advised the services were not covered. The Plan denied your request. The Plan says the services are not covered at the chiropractor's office.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the services at issue are not manual manipulation of the spine. The services, when provided by a chiropractor, are not a covered benefit. Therefore, we decided that the Plan does not have to pay for the office visit and x-ray provided on May 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network physician.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says physician's services must be provided by network providers.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network physician.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on April 7, 2021.

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 on April 7, 2021.