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

We decided that the Plan does not have to waive the copay for the emergency room services provided on February 21, 2021, and February 22, 2021.

You asked the Plan to waive the copay for the services provided. You say that your first visit was not satisfactory. The Plan denied your request. The Plan says the copay was based on 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 $50 copay for each Medicare-covered emergency room visit. 

You have been asked to pay a $50 copay for each date of service. The copay is not determined by the quality of care or the outcome of services provided. The services fall 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 copay for the emergency room services provided on February 21, 2021, and February 22, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for an injection (20610, 77002) provided on September 10, 2020.

You asked the Plan to pay for an injection. You say that you do not have other insurance. The Plan denied your
request. The Plan says that this claim must be submitted to your primary insurance.

The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for
services until the claim for those services has gone to the primary insurer. However, plans are still required to
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a
bill for reimbursement to the primary insurer.

Although the record shows that you have another type of insurance, the Plan has not met its obligation with
regards to coordination of benefits. There is no documentation in the record that the Plan has sent this claim to
your primary insurance or directed the provider to bill your primary insurance. The Plan is required to
coordinate benefits with your primary insurer. Therefore, we decided that the Plan has to pay for an injection
(20610, 77002) provided on September 10, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an injection of anesthetic into the spine (64483) provided on August 25, 2020, to September 8, 2020.

You asked the Plan to waive the copayment for an injection. You say that you disagree with the charges. 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 $250 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.

You have been asked to pay a $250 copayment for an injection. The EOC confirms $250 is the required copayment for each outpatient hospital service including certain drugs and biologicals that you cannot give yourself. The records show that you were charged a copayment for an injection on each visit. Injections fall within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 injection of anesthetic into the spine (64483) provided on August 25, 2020, to September 8, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room services rendered on February 4, 2021.

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. The rules say that claims must be billed with the most precise diagnosis code. 

We looked at the file and Medicare rules. The file shows that the services were not billed with a valid primary diagnosis code. 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 emergency room services rendered on February 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of a neurostimulator system (Remede system) for treatment of sleep apnea.

You asked the Plan to pre-approve Remede system. You say that the enrollee failed conventional treatment and is not suitable for continuous positive airway pressure or adaptive servo ventilation. The Plan denied your request. The Plan says this service 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 Remede system. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the initial treatments for the enrollee's condition are nocturnal oxygen and continuous positive airway pressure (CPAP), which have not been tried. The enrollee should have a facility-based CPAP titration and CPAP treatment trial with supplemental oxygen as indicated. Transvenous phrenic nerve stimulation has been evaluated in a controlled trial, but it has not been compared to treatment with oxygen and CPAP. It is not indicated as a first line treatment for this condition.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Remede system have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of a neurostimulator system (Remede system) for treatment of sleep apnea.
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
January 21, 2021.

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 services provided by an out-of-network provider on January
21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), a panoramic radiographic image (D0330), an intraoral periapical radiographic image (D0220), and extractions (D7140 x8, D7210 x2) provided from March 8, 2021, through March 11, 2021.
You asked the Plan to pay for a comprehensive oral evaluation (D0150), a panoramic radiographic image, an intraoral periapical radiographic image, and extractions. You say that you thought the services were covered. The Plan denied your request. The Plan says you are not covered for these services when seen by an out-of-network provider.
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 comprehensive oral evaluation, a panoramic radiographic image, an intraoral periapical radiographic image, and extractions have not been met. Specifically, services were provided by an out-of-network provider without prior authorization. The Plan has contracted providers available to provide these services. 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 a comprehensive oral evaluation (D0150), a panoramic radiographic image (D0330), an intraoral periapical radiographic image (D0220), and extractions (D7140 x8, D7210 x2) provided from March 8, 2021, through March 11, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve corneal topography to be provided by an out-of-network
provider.
You asked the Plan to pre-approve corneal topography with an out of network ophthalmologist. You say that
you are going blind in your left eye and need a referral. The Plan denied your request. The Plan says they were
not able to obtain the required physician's order and supporting medical information from your primary care
physician.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to 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 services at issue in this appeal. There is no referral from your primary care
physician. We found no exception that would require the Plan to pre-approve these services. Therefore, we
decided that the Plan does not have to pre-approve corneal topography to be provided by an out-of-network
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor.

You asked the Plan to pre-approve a therapeutic continuous glucose monitor. You say that the requested device is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for a therapeutic continuous glucose monitor have not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day and does not use insulin with at least three daily injections.

Based on this information, we decided that Medicare rules for coverage of a therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for non-emergency ambulance services (A0428), and ground mileage (A0425) provided on November 6, 2020.
You asked the Plan to waive the copayment for non-emergency ambulance services, and ground mileage. You say that you did not call for the ambulance and you should not have to pay. 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 $350 copayment for ambulance services. You have been asked to pay a $276.66 copayment for non-emergency ambulance services, and ground mileage. The services at issue fall within the ambulance services benefit category.
Since the Allowed Amount for this service is less than the required copayment of $350, you have been asked to pay only $276.66. 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 non-emergency ambulance services (A0428), and ground mileage (A0425) provided on November 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing test provided on November 18, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the hearing exam. You say that this was a cost-effective solution for you to get free hearing aids. The Plan denied your request. The Plan says you did not use a plan provider for this hearing test, so this service is not covered.

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 hearing test provided on November 18, 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 copayment for the podiatry services you had on March 24, 2021.

You asked the Plan to waive the copayment for the podiatry services. You say that you have never had a copay for this service in the past. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan agrees that there is no copayment for routine diabetic foot care services. However, the medical records show that in addition to routine diabetic foot care, you also received an evaluation of your hammertoe deformity, which is not related to diabetic foot disease. That is why a specialist visit copayment applies.

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 $40 copayment for specialist visits.

You have been asked to pay a $40 copayment for the podiatry services. The podiatry services falls within the specialist visits benefit category. This is because you received non-routine evaluation of your hammertoes in addition to routine diabetic foot care. 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 podiatry services you had on March 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the eye exam and external ocular photography rendered on January 5, 2021.

You asked the Plan to waive the copayments for these services. You say that you were not told there would be a second copayment. 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 $40 copayment for Medicare-covered benefits, including diagnosis and treatment for diseases and conditions of the eye and a $50 copayment for all other Medicare-covered outpatient diagnostic tests.

Review of the file shows that you received an eye exam on January 5, 2021. You have been asked to pay a $40 copayment for these services. These services fall within the Medicare-covered benefits, including diagnosis and treatment for diseases and conditions of the eye, 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 ocular photography on January 5, 2021. Per the contract with the Plan, there is a $50 copayment for all other Medicare-covered outpatient diagnostic tests. However, the Medicare allowed amount for these services was $25. Given that the allowed amount was less than the $25 copayment, you have been asked to pay $25 for these services.

The total amount you have been asked to pay for these services is $65. 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 eye exam and external ocular photography rendered on January 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory service (81525) rendered by the out of network (OON) provider on January 5, 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 laboratory service (81525)
rendered by the out of network (OON) provider on January 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an orthosis (L0650) provided September 17, 2020.

You asked the Plan to pay for the orthosis. You say that the orthosis was medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.

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 relevant medical record which support medical necessity for the supplies provided in this case. There is no documentation of the order provider discussing the need for this item. 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 an orthosis (L0650) provided September 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, bitewing x-rays, and prophylaxis provided on February 15, 2021.
You asked the Plan to pay for the periodic oral evaluation, bitewing x-rays, and prophylaxis. You say that you received a cleaning and x-rays, and no diagnosis was made. The Plan denied your request. The Plan says these services are not covered under the medical plan.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. The record shows that you were not enrolled in one of the Optional Supplemental Benefit plans on this date of service. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, bitewing x-rays, and prophylaxis provided on February 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve right prosthetic leg components (multi-axial ankle with swing phase, code L5968 and flex-walk system, code L5981).
You asked the Plan to pre-approve prosthetic leg components. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of authorization for these components is correct, because the documentation does not support that you are a K3 ambulator and you require a cane for ambulation.
The Plan follows Medicare rules. Medicare rules state that prosthetic leg components may be covered when certain clinical 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 prosthetic leg components. Our reviewer says that you do not meet the Medicare criteria for these prosthetic leg components. Our physician reviewer found these components exceed your medical need. Your documented comorbidities of unsteady balance and use of an assistive device do not support that you are a K3 ambulatory and do not meet the Medicare criteria for medical necessity. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of prosthetic leg components have not been met. Therefore, we decided that the Plan does not have to pre-approve right prosthetic leg components (multi-axial ankle with swing phase, code L5968 and flex-walk system, code L5981).