Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on September 25, 2020.
You asked the Plan to waive the copayment for ambulance services. You say that you were not informed that you would owe a copayment for the services. 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 $200 copayment for ambulance services. You have been asked to pay a $200 copayment for ambulance services. Ambulance services fall within the 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 on September 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the pacemaker services provided on December 13, 2020 by an out of network (OON) provider.
You asked the Plan to pay for these services. You say that the charges are a financial hardship. The Plan denied your request. The Plan says the services were 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 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 pacemaker services provided on December 13, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided September
15, 2020, to September 23, 2020.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you would like this claim
reprocessed. The Plan denied your request. The Plan says the copayment has processed correctly, and no
reimbursement is due.
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 $295
copayment each day for days 1-5 of Medicare-covered hospital care and a $0 copayment for additional
Medicare-covered days for inpatient hospital care.
You have been asked to pay a total cost share of $1475 for the inpatient hospital care (5 max days x $295 copayment). This care 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 inpatient hospital care provided September 15, 2020, to September 23, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Atacand.
You asked the Plan to pre-approve Atacand. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Atacand.
Benefits for Atacand may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy provided by an out-of-network provider on December 7, 2020.
You asked the Plan to pay for the psychotherapy. You say that the service was provided with no adequate time to obtain authorization. You say that the records reflect the medical necessity for the service and the claim should be reprocessed for payment. The Plan denied your request. The Plan says authorization for out of network services was not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for psychotherapy provided by an out-of-network provider on December 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care (99308) and debridement (11042) provided on November 11, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the nursing facility care and debridement. You say that you would like reconsideration because medically necessary services were provided on request of the Medical Director/Primary Care Physician. The Plan denied your request. The Plan says there are many in-network providers able to provide the services that the member requires.

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 nursing facility care (99308) and debridement (11042) provided on November 11, 2020 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 limited oral evaluation (D0140) and the panoramic radiographic image (D0330) provided on December 3, 2020.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says you have exceeded the allowable frequency limit for these services.

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.

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of these services have not been met. Specifically, a limited oral evaluation is covered once per plan year. You previously received this service on May 20, 2020. Additionally, a panoramic x-ray is covered by the Plan once every three years. You previously received this service on April 2, 2019. Therefore, you have exhausted the allowable benefit for these services provided. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) and the panoramic radiographic image (D0330) provided on December 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular stimulator provided September 5, 2020.
You asked the Plan to pay for the neuromuscular stimulator. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the documentation submitted is missing required documents.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.
The record does not contain a valid proof of delivery for the supplies provided in this case. Review of the file shows that the proof of delivery did not include an itemize order form or invoice to indicate the specific supplies; therefore, the billed supply code cannot be verified. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the neuromuscular stimulator provided September 5, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost for the injections of tendon sheath, ligament, or muscle membrane (20550) provided November 12, 2020, to December 8, 2020.
You asked the Plan to waive the cost for the injections of tendon sheath, ligament, or muscle membrane. You say that you believe you are being overcharged. The Plan denied your request. The Plan says these claims have processed correctly and no reimbursement is due.
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 $245 copayment for Medicare-covered outpatient surgery. You have been asked to pay a total cost share of $243.14, less than the required $245 copayment, for each date of service of the injections of tendon sheath, ligament, or muscle membrane. These services fall within the
Medicare-covered outpatient surgery 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 cost for the injections of tendon sheath, ligament, or muscle membrane (20550) provided November 12, 2020, to December 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a practitioner visit provided on January 11, 2021 by an out of network (OON) provider.

You asked the Plan to pay for practitioner visit. You say that your provider depends upon the facility staff to verify eligibility and obtain the proper authorization. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the plan and authorization was not obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan 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 a practitioner visit provided on January 11, 2021 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office services and laboratory testing provided on October 29, 2020 by an out of network (OON) provider.

You asked the Plan to pay for office services and lab tests. You say that the provider told you it would be okay to see this doctor. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and authorization was not obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan 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 office services and laboratory testing provided on October 29, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office services provided on June 22, 2020 by an out of network (OON) provider.

You asked the Plan to pay for office services. You say that according to your records an office visit does not require authorization. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and authorization was not obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan 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 office services provided on June 22, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for scaling in the presence of gingival inflammation (D4346) provided on December 11, 2020.
You asked the Plan to pay for scaling in the presence of gingival inflammation. You say that you told your provider to only perform covered services, so this service should be covered. The Plan denied your request. The Plan says this service is not covered by Medicare or by the Plan's supplemental dental 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. Therefore, we decided that the Plan does not have to pay for scaling in the presence of gingival inflammation (D4346) provided on December 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for wound dressing (A6196) provided on February 4, 2021.
You asked the Plan to pay for wound dressing. You say that this is separately reimbursable. The Plan denied your request. The Plan says this cannot be paid separately.
The Plan must follow Medicare rules. Medicare rules say that a status code of P indicates a bundled or excluded code. If the item or service is covered as incident to a physician service and is provided on the same day as a physician service, payment for it is bundled into the payment for the physician service to which it is incident.
We looked at the file and Medicare rules. Code A6196 has a status code of P. Payment for this code is bundled into the payment for the physician service to which it is incident. Based on this information, we decided that Medicare rules for coverage of wound dressing have not been met. Therefore, we decided that the Plan does not have to pay for wound dressing (A6196) provided on February 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture treatment (97810, 97811) provided on October 9, 2020.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services are not payable as the acupuncture treatment was not provided by a licensed physician.

The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case.

We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the acupuncture services have not been met. Specifically, the Plan contract states that the person providing the acupuncture must be a physician licensed to perform the service. The services in this case were provided by a licensed acupuncturist, not a physician. Therefore, we decided that the Plan does not have to pay for the acupuncture treatment (97810, 97811) provided on October 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for a filling (D2150), and protective restoration (D2940) provided on January 12, 2021.
You asked the Plan to pay an additional amount for a filling, and protective restoration. You say that you want the Plan to pay the entire amount for the services at issue. The Plan denied your request. The Plan says the claims for these services were processed correctly with the applicable out-of-network allowable amount paid.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of a filling, and protective restoration have not been met. Specifically, the allowed amount of these services for an out-of-network provider were paid by the plan. Any amount beyond the allowed amount is your contractual responsibility. Therefore, we decided that the Plan does not have to pay an additional amount for a filling (D2150), and protective restoration (D2940) provided on January 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on June 19, 2020.

You asked the Plan to pay for the lumbar-sacral orthosis (L0650). You say that the orthosis was medically necessary. The Plan denied your request. The Plan says the information in the enrollee's medical record does not adequately support the medical necessity for the orthosis.

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 pay for the lumbar-sacral orthosis (L0650). Our reviewer says that the orthosis is not medically reasonable or necessary. Our physician reviewer found the available documentation in the case file does not support that the requested lumbar-sacral orthosis was medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. An appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for a lumbar-sacral orthosis have been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is insufficient documentation of an appropriate evaluation of the enrollee and insufficient documentation of a credible physical examination of the back. 

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 lumbar-sacral orthosis (L0650) have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on June 19, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) services provided April 1, 2020 to April 18, 2020.
You asked the Plan to waive the copayment for the SNF services. You say that you feel you should not be responsible for almost $1400 balance when the facility did nothing to help your mother's recovery, instead prolonged it. The Plan denied your request. The Plan says the 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 $0 copayment per day for days 1-20 and $178 copayment per day for days 21-100. You have been asked to pay $1,389.75 ($178x7 = $1,246+$143.75 = $1,389.75) for the SNF services. Because you had met your maximum out of pocket the last SNF day was prorated to $143.75. The SNF services falls within the Skilled nursing facility (SNF) 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 skilled nursing facility (SNF) services provided April 1, 2020 to April 18, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the positron emission tomography (PET) scan rendered on November 19, 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 diagnosis is not supported.

The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee underwent left upper lobectomy for lung cancer. The record indicates she had one previous post-treatment scan. The billed diagnosis code of C34.92 is not a proper code for this test. The PET scan is not supported.

We looked at this physician's review, the file, and Medicare rules. 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 positron emission tomography (PET) scan rendered on November 19, 2020.