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

We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan. You asked the Plan to pre-approve these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not medically necessary. 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 pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of Gleason 9 prostate cancer. A computed tomography (CT) scan showed a thickened esophagus and one metastases. The requested PET is not covered for initial staging of prostate cancer and is not reasonable or medically necessary at this time. 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 pre-approve a positron emission tomography (PET) scan.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room services provided to the enrollee on July 17, 2019. You asked the Plan to pay for the emergency room services. You say that the services are unrelated to hospice care. The Plan denied your request. The Plan says during the election, Original Medicare also covers attending physician services and all care unrelated to the terminal illness. 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 emergency room services provided to the enrollee on July 17, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the mammogram or the ultrasound provided on November 21, 2019.
You asked the Plan to waive the copayments for the mammogram and the ultrasound. You say that this was your preventive mammogram and it should be covered. 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 each basic imaging service (e.g., general x-rays or ultrasound). You have been asked to pay a $40 copayment for the mammogram and a $40 copayment for the ultrasound. The mammogram and the ultrasound fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The medical record shows the mammogram and ultrasound were performed due to a right palpable abnormity, which makes the services diagnostic in nature.
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 for the mammogram or the ultrasound provided on November 21, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical pathology services (88305) provided on August 22, 2019 by an out of network (OON) provider.
You asked the Plan to pay for surgical pathology services. You say that this service was medically necessary. The Plan denied your request. The Plan says this service was 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 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 for the surgical pathology services (88305) provided on August 22, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 3, 2019 by an
out of network (OON) provider.
You asked the Plan to pay for office visit. You say that you provided services to the enrollee in good faith with
the expectation of payment. 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 prior 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 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 for the medical services provided on December 3,
2019 by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER visit provided on November 6, 2019.
You asked the Plan to waive the copayment for the ER visit. You say that you shouldn't have to pay. 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 $120 copayment for emergency care. You have been asked to pay a $120 copayment for the ER visit. The ER visit falls within the "Emergency care" benefit category. The records show that you were treated in the emergency room. 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 November 6, 2019.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for CPT codes 36558, 76937, and 77001 billed for date of service November 7, 2019. ou asked the Plan to pay for CPT codes 36558, 76937, and 77001. You say that the medical records support the services rendered. The Plan denied your request. The Plan says that an approved authorization exists, but the services performed do not match what was approved on the authorization. The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan has not given a valid rationale for denial of CPT code 36558. The documentation provided shows that the enrollee was approved for treatment for end stage renal disease. This documentation showing the pre-authorization issued does not specify any codes. Dialysis catheter insertion is done for the treatment of end stage renal disease, so the code billed matches the diagnosis referenced in the pre-authorization issued. Because CPT code 36558 is payable based on the information provided, the denial reason for CPT codes 76937 and 77001 is not valid, as there is a payable primary procedure code for the same date of service. Therefore, we decided that the Plan has to pay for CPT codes 36558, 76937, and 77001 billed for date of service November 7, 2019. If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments for the outpatient clinic visits provided on August 21, 2019 and November 22, 2019.
You asked the Plan to reduce the copayments for the clinic visits. You say that you were seen for your annual wellness visit in August and you should not have the clinic charge. You say you should have only been charged a $10 copayment for the November visit. 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 $20 copayment for all other Medicare-covered in-network outpatient hospital services. You have been asked to pay a $20 copayment for the clinic visits. The clinic visits fall within "Outpatient hospital services" benefit category. The record shows other conditions such as hypertension and prescription adjustments were discussed in addition to the wellness visit on August 21, 2019. The record also shows the visit on November 22, 2019 was received in an outpatient clinic.
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 reduce the copayments for outpatient clinic visits provided on August 21, 2019 and November 22, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xifaxan. You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says self-administered drugs are not covered. 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 Xifaxan. Benefits for these services 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 13, 2019 to August 10, 2019 by an out of network (OON) provider. You asked the Plan to pay for physician visits. You say that this provider is the sole psychiatrist brought into the facility to treat patients, and he cannot refuse treatment. 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 prior 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 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 for the medical services provided on July 13, 2019 to August 10, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider from November 18, 2019, to November 22, 2019.
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 has network providers available who can provide 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 medical services provided to you by an out-of-network provider from November 18, 2019, to November 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an influenza vaccine (90662) and administration (90471) provided on October 2, 2019 by an out of network (OON) provider. You asked the Plan to pay for an influenza vaccine and administration. You say that you needed this vaccine from an out-of-network provider because you were traveling. The Plan denied your request. The Plan says these 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 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 for an influenza vaccine (90662) and administration (90471) provided on October 2, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided by the Medical Center on October 7, 2019.
You asked the Plan to waive the copayment for laboratory services. You say that the laboratory services should be included as part of a wellness visit. 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 $10 copayment for laboratory tests. You received laboratory services on October 7, 2019. Laboratory services are not included in an annual wellness visit. Therefore, you are responsible to pay the $10 copayment. You have been asked to pay a $10 copayment for laboratory services. Laboratory services fall 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 laboratory services provided by the Medical Center on October 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lumbar-sacral orthosis provided on November 19, 2019.You asked the Plan to pay forthe lumbar-sacral orthosis (L0650). You say that the orthosis was medically necessary.The Plan denied your request. The Plan says the enrollee received a lumbar-sacral orthosis from a different provider on March 7, 2018 and it is still under reasonable useful lifetime.The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.The enrollee's current orthosis is still within the 5-year RUL and the documentation submitted does not show that the orthosis is irreparably worn, irreparably damaged, or that the enrollee had a change in medical condition to warrant the lumbar-sacral orthosis at issue.Therefore, we decided that the Plan does not have to pay forthe lumbar-sacral orthosis provided on November 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient clinic visit provided on December 17, 2019. You asked the Plan to waive the copayment for the clinic visit. You say that you already paid a $30 copayment and you are disputing the charge for the use of the facility. 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 $20 copayment for all other Medicare-covered in-network outpatient hospital services. You have been asked to pay a $20 copayment for the clinic visit. The clinic visit falls within the "Outpatient hospital 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 the outpatient clinic visit provided on December 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services rendered to the enrollee on September 3, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 95999 is not supported.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 95999 is unlisted neurological or neuromuscular diagnostic procedure.We find that CPT code 95999 is not supported in the medical record. Specifically, the records show that train of four testing was provided and there is a more appropriate codefor these services. 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 forthe services rendered to the enrollee on September 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services provided on October 11, 2019 by an out of network (OON) provider.You asked the Plan to pay forphysician services. 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 self-referred.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-approvedcare.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 provided on October 11, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for scanning computerized ophthalmic diagnostic imaging (92134) provided November 19, 2019. You asked the Plan to waive the copayment for the vision services. You say that you asked for an eye exam only and the provider did this test without your consent and should be responsible for their mistake. The Plan denied your request. The Plan says this claim processed correctly and the correct copayment has been applied. The rules say that a Cost plan must disclose in writing all benefits available under the Plan. The health plan contract says that enrollees must pay $30 copayment for Medicare covered diagnostic exams.You have been asked to pay $30 copayment for the vision services. The vision services fall within the Vision 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 scanning computerized ophthalmic diagnostic imaging (92134) provided November 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a vision test provided on September 12, 2019. You asked the Plan to waive the copayment for a vision test. You say that you disagree with the charges because the technician was not supervised. 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 $35 copayment for each eye exam. You have been asked to pay a $35 copayment for a vision test. A vision test falls within the vision 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 fora vision test provided on September 12, 2019.