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

We decided that the Plan does not have to waive the copayment for the ER visit provided on January 31, 2020.
You asked the Plan to waive the copayment for the ER visit. You say that you shouldn't have to pay when nothing was done for you. 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 $90 copayment for emergency care. You have been asked to pay a $90 copayment for the ER visit. The ER visit falls within the "Emergency care" benefit category. The records show that you were treated in the ER. 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 ER visit provided on January 31, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe physical therapy visits provided from December 10, 2019 to December 31, 2019.You asked the Plan to waive the copayments forthe physical therapy visits. You sent your bills in for review. The Plan denied your request. The Plan says you have been charged 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 a $40 copayment for Medicare-covered physical therapy and speech therapy. You have been asked to pay a total of $180 copayment for the physical therapy visits. The physical therapy visits fall within the "Outpatient rehabilitation services" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments forthe physical therapy visits provided from December 10, 2019 to December 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wheelchair accessory, power seat elevation system, any type (E2300).You asked the Plan to pre-approve the item. You say that the power elevating seat is used and needed for transfers as you are a tall man.The Plan denied your request. The Plan says this item is not covered under Medicare or the Health Plan.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 wheelchair accessory, power seat elevation system, any type (E2300)
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided by a participating facility on March 3, 2020.You asked the Plan to waive the copayment fora diagnostic colonoscopy. You say that this was preventative and should be covered 100%. The Plan denied your request. The Plan says the correct copayment has been applied.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $125 copayment for outpatient surgery. You have been asked to pay a $125 copayment for a diagnostic colonoscopy. Evidence was provided that showed polyps were removed. The rules say that, if during the course of the screening colonoscopy, a lesion or growth is detected which results in a biopsy or removal of the growth, the appropriate diagnostic procedure classified as a colonoscopy with biopsy or removal should be billed. A diagnostic colonoscopy falls within the 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 copayment for a diagnostic colonoscopy provided by a participating facility on March 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital discharge day management services provided to the enrollee on November 9, 2019.You asked the Plan to pay for the services. You say that this should be paid for.The Plan denied your request. The Plan says the enrollee was enrolled in a federal hospice program during the time services were rendered.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 hospital discharge day management services provided to the enrollee on November 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora meningococcal vaccine (90734) and a Haemophilus influenzaetype b vaccine (90648) provided on February 6, 2020.You asked the Plan to pay for meningococcal and Haemophilus influenzae type b vaccines. You say that these were ordered to prepare you for surgery.The Plan denied your request. The Plan says coverage of these vaccines is the responsibility of your Part D prescription drug plan.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide meningococcal and Haemophilus influenzae type b vaccines. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to meningococcal and Haemophilus influenzae type b vaccines.Therefore, we decided that the Plan does not have to pay fora meningococcal vaccine (90734) and a Haemophilus influenzae type b vaccine (90648) provided on February 6, 2020.Benefits for meningococcal and Haemophilus influenzae type b vaccines 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI provided on January 15, 2020.You asked the Plan to waive the copayment for an MRI. You say that you feel that the MRI should be included in a previous emergency room visit copayment.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 $100 copayment for advanced imaging services. You have been asked to pay a $100 copayment for an MRI. An MRI falls within the outpatient diagnostic tests and therapeutic services and 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 copayment for an MRI provided on January 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on April 15, 2019 and September 9, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented. 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 physician's 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 physician's services provided on April 15, 2019 and September 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit and EKG provided on November 21, 2019.
You asked the Plan to waive the copayment for the office visit and EKG. You say that you went for your yearly checkup and there was no copayment. You say that your EKG should cost less. The Plan denied your request. The Plan says the copayments 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 $15 copayment for each covered Primary Care Provider (PCP) office visit and a $60 copayment for each covered diagnostic procedure or test at a network doctor's office. You have been asked to pay a total of $37.31 for the office visit and EKG.
The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The EKG falls within the "Outpatient diagnostic tests and therapeutic services and 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 copayment for the office visit and EKG provided on November 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and x-ray of teeth provided on August 14,
2019 by an out of network provider.
You asked the Plan to pay for the dental services. You say that you had been seeing this provider for follow up
visits to an emergency in 2017. You say that the visits had always been covered. You say that you were not
aware that the provider was no longer in network. The Plan denied your request. The Plan says the provider in
this case is not a network provider. The Plan also says dental services that you receive out of network are not
covered.
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 dental services are not covered
under this benefit when you receive them out of network. The Evidence of Coverage clearly states care
rendered by a provider that is not part of our supplemental dental network is not covered. Therefore, we
decided that the Plan does not have to pay for the office visit and x-ray of teeth provided on August 14, 2019
by an out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided on September 11 - September 13, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the records provided support the services in dispute. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan say that the enrollee's medical records did not support the medical necessity required to approve an inpatient level of care. The Plan says that the enrollee could have been evaluated and treated in the observation level of care.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the records provided do not show that, at the time of the inpatient admission, care at the observation level was not appropriate. The enrollee could have received care at the observation level with the option to move the enrollee to inpatient status when, and if, it became clear that the enrollee's hospital stay would span two midnights or more. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided on September 11 - September 13, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forambulance service with no transportation provided on October 17, 2019.You asked the Plan to pay forambulance with no transport. You say that you refused to be transported to the emergency room because of your personal preference.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this service is not covered by Medicare.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on October 17, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forambulance service with no transportation provided on October 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder-elbow-wrist-hand orthosis provided on December 26, 2019.You asked the Plan to pay for the shoulder-elbow-wrist-hand orthosis (L3960). You say that the orthosis was medically necessary. The Plan denied your request. The Plan says medical records were requested but not received.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. There are no medical records to support medical necessity, therefore the billed codes cannot be supported. Based on this information, we decided that Medicare rules for coverage of the shoulder-elbow-wrist-hand orthosis (L3960) have not been met. Therefore, we decided that the Plan does not have to pay for the shoulder-elbow-wrist-hand orthosis provided on December 26, 2019.
Appeal type: Outpatient Therapies
Decision: Partially Favorable

We decided that the Plan has to pre-approve 4 additional speech therapy visits. We decided that the Plan does not have to pre-approve 6 additional speech therapy visits.
You asked the Plan to pre-approve 10 additional speech therapy visits. You say that the services are necessary. The Plan denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria have not been met.
We decided that the Plan has to pre-approve 4 additional speech therapy visits. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Part C Plan was correct in denying the request to pre-approve 4 additional speech therapy visits. Our reviewer says that the requested service is considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the enrollee continues to be treated for residual deficits after recent stroke. Progress notes indicate improvement in deficits including memory. An additional four speech therapy treatments are indicated for development of a maintenance exercise program.
Therefore, we decided that the Plan has to pre-approve 4 additional speech therapy visits. We also decided that the Plan does not have to pre-approve 6 additional speech therapy visits. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found the additional speech therapy is not medically necessary.
Therefore, we decided that the Plan does not have to pre-approve 6 additional speech therapy visits.
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 home health services rendered from November 5, 2019 to December 23, 2019.
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 claims were not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that home health claims must be billed with one of three Q codes. We looked at the file and Medicare rules. The claims were not billed with one of the required Q codes. 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 home health services rendered from November 5, 2019 to December 23, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to have the copayment forthe post-cataract laser eye surgery provided on March 21, 2019.You asked the Plan to have the copayment forthe post-cataract laser eye surgery. You say that you do think this was surgery and you should not be charged a $250 copayment The Plan denied your request. The Plan says you have been charged 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 a $250 copayment for each covered surgery or observation room service in an outpatient hospital. You have been asked to pay a $250 copayment for the post-cataract laser eye surgery. The post-cataract laser eye surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows that the post-cataract laser eye surgery is considered a surgical procedure.This means that you have been asked to pay the correctamount 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 have the copayment forthe post-cataract laser eye surgery provided on March 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services and injections provided on February 26, 2019 to March 4, 2019 by an out of network (OON) provider.You asked the Plan to pay forphysician services and injections. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the member was not referred by a Plan participating provider.Medicare rules say that plans can require enrollees to get care fromnetwork 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 has network providers available who can provide 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 forphysician services and injections provided on February 26, 2019 to March 4, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe initial 15 minutes of general anesthesia (D9222) and the additional 15 minutes of general anesthesia (D9233) provided on October 22, 2019 by an out of network dentist.You asked the Plan to pay forthe general anesthesia. You say that due to a severe oral gag reflex, oral surgeons are unable to work using local pain killers.The Plan denied your request. The Plan says general anesthesia is not listed as a covered service.Medicaregenerally 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, general anesthesia is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe initial 15 minutes of general anesthesia (D9222) and the additional 15 minutes of general anesthesia (D9233) provided on October 22, 2019 by an out of network dentist.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fortrain of four testing (95999) provided on October 14, 2019.You asked the Plan to pay fortrain of four testing. You say that this was medically necessary.The Plan denied your request. The Plan says payment ofthis service is bundled into other services.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code 95999 is not supported in the medical record. Specifically, the use of unlisted CPT code 95999 to report train of four testing is not supported. According to CPT coding rules, train of four testing is not a separately reportable procedure and is included in the other interoperative neuromonitoring procedures. Based on this information, we decided that Medicare rules for coverage of train of four testing have not been met.Therefore, we decided that the Plan does not have to pay fortrain of four testing (95999) provided on October 14, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodontal maintenance provided on December 17, 2019.You asked the Plan to pay for the periodontal maintenance. You say that you need to continue with periodontal maintenance to maintain your gum health.The Plan denied your request. The Plan says this service is not covered under the Plan.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 forthe periodontal maintenance provided on December 17, 2019.