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

We decided that the Plan does not have to waive the copayment foran ultrasound examination provided on August 20, 2020.You asked the Plan to waive the copayment forultrasound. You say that you were told your copayment would be $35.The Plan denied your request. The Plan says the copayment amount 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 $125 copayment for ultrasound examination. You have been asked to pay the allowed amount of $117.35, which is less than the $125 copayment for ultrasound. Ultrasound 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 foran ultrasound examination provided on August 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab work and a specialist office visit provided by participating providers on August 18, 2020, to August 25, 2020.You asked the Planto waive the copayment for lab work and a specialist office visit. You say that you should not have to pay for this twice. The Plan denied your request. The Plan says the correct copayments have 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 $20 copayment for outpatient diagnostic tests/in-network/labs and a $50 copayment for physician/practitioner services/specialist. You have been asked to pay a $20 copayment for lab work and a $50 copayment for a specialist office visit. The total amount you are being asked to pay is $70 ($20+ $50 = $70). Lab work falls within the outpatient diagnostic tests/in-network/labs benefit category and a specialist office visit falls within the physician/practitioner services/specialist benefit category. This means that you have been asked to pay thecorrect 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 lab work and a specialist office visit provided by participating providers on August 18, 2020, to August 25, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on February 20, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services are available in-network.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 payfor 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 forthe medical services provided to the enrollee by an out-of-network provider on February 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an OON provider.

You asked the Plan to pay for prolonged inpatient or observation services and nursing facility care. You say that the services provided were reasonable and medically necessary.The Plan denied your request. The Plan says rules for payment have not been met.

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 by an OON provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveunderpads and diapers.You asked the Plan to pre-approveincontinence supplies. You say that your doctor wrote a prescription several months ago and it should have been approved by your insurance plan if the doctor requested it.The Plan denied your request. The Plan says the item in question is not covered under your benefit planunder any normal circumstances.The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items.Therefore, we decided that the Plan does not have to pre-approveunderpads and diapers.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible forthe diagnostic test provided on July 29, 2020.You asked the Plan to waive the deductible forthe diagnostic test. You say that the test did not so you should not have a charge.The Plan denied your request. The Plan says you were charged this deductible correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $500 deductible for covered medical services. The item or service you asked the Plan to waive the deductible for falls within the benefit category of covered medical services deductible. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible forcovered medical services. This cost sharing is a contractual obligation that had not been met at the time the diagnostic test was received on July 29, 2020.Therefore, we decided that the Plan does not have to waive the deductible forthe diagnostic test provided on July 29, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray interpretation provided on August 26, 2020.
You asked the Plan to pay for the chest x-ray interpretation. You say that there were multiple services on this date of service. The Plan denied your request. The Plan says this claim was already paid.
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 a second claim for CPT code 71045 is not supported in the medical record. Specifically, there is only one record for this physician in the file. A claim for this physician was paid on September 10, 2020. Based on this information, we decided that Medicare rules for coverage of the second chest x-ray interpretation have not been met. Therefore, we decided that the Plan does not have to pay for another chest x-ray interpretation provided on August 26, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvePalonosetron for the enrollee.You asked the Planto pre-approvethe drug. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found Trastuzumab is associated with a minimalemetogenic risk and paclitaxel with a low emetogenic risk. Palonsetron is FDA approved for moderate and highly emetogenic risk. There is no off-label indications and use in a minimal to low risk patient is not indicated. The service is not reasonable or medically necessary.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 drug have not been met.Therefore, we decided that the Plandoes not haveto pre-approvePalonosetron for the enrollee
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance services.You asked the Plan to waive the copayment forthe ambulance services. You say that this claim was processed as out of network. This claim should have been processed as in network. Please reprocess.The Plan denied your request. The Plan says you were charged this cost sharing 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 $270 copayment for each ambulance trip. You had 1 ambulancetrip(s). The Plan charged you $270 for these services. 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 forthe ambulance services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora vaccine (Tetanus) provided on August 21, 2020.You asked the Plan to pay forthis service. You say that this vaccine should be covered by the Plan.The Plan denied your request. The Plan says this vaccine is not covered under Medicare Part B.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide this service. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to this service.Therefore, we decided that the Plan does not have to pay fora vaccine (Tetanus) provided on August 21, 2020.Benefits for this servicemay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for pin retentions (D2951 x 2) received.

You asked the Plan to pay for pin retentions. You say that the dentist had to place pins in the tooth to retain the filling.The Plan denied your request. The Plan says the requested service is not covered under your 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 pin retentions (D2951 x 2) received.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care you received from
March 27, 2020, to April 1, 2020.
You asked the Plan to waive the copayment for the inpatient hospital care. You say that you shouldn't have to
pay additional copayments because you returned to the hospital within 12 hours of your discharge. The Plan
denied your request. The Plan says you were charged this copayment 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 $400
copayment per day for days 1-4 for inpatient hospital care.
You have been asked to pay a $400 copayment per day for days 1-4 for the inpatient hospital care. This
copayment applies regardless of the reason for your admission. 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 you received from March 27, 2020, to April 1, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve computed tomography (CT) services.
You asked the Plan to pre-approve the CT scan. You say that the osteochondroma was stable and therefore an MRI is not needed at this time. You say that the osteochondroma is quite large and is in an unusual location. You say that, due to the small soft tissue component, it is recommended that the enrollee be monitored at 2-year intervals with CT scanning. The Plan denied your request. The Plan says that the requested CT scan is not medically reasonable or necessary.
The Plan must follow Medicare rules. Medicare rules say that CT 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 the CT scan. Our reviewer says that the criteria for coverage have been met. Our physician reviewer found the enrollee has a longstanding osteochondroma lesion of the rib that has been stable. The enrollee has pain and an abnormality. Due to the change in exam and imaging study, our physician reviewer feels that the requested CT scan is indicated. The requested CT scan is not a screening, but rather a diagnostic test based on imaging and symptomatology. 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 CT scan have been met. Therefore, we decided that the Plan has to pre-approve computed tomography (CT) services.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Dexcom G6 continuous glucose monitor (CGM) and supplies for the enrollee.You asked the Plan to pre-approvea CGM and supplies. You say that this is medically necessary for the enrollee.The Plan denied your request. The Plan says that the enrollee does not meet criteria for coverage.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, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM and supplies have not been met.Therefore, we decided that the Plan does not have to pre-approvea Dexcom G6 continuous glucose monitor (CGM) and supplies for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on September 1, 2020.You asked the Plan to pay forthe 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 withthe 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 forthe medical services provided to the enrollee by an out-of-network provider on September 1, 2020
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the services provided to the enrollee on June 17, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that this provider cannot bill for these services.
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. The code in question is a payable code for physician services. There is no evidence that the provider does not meet the definition of an NP and she has a valid NPI number. No evidence has been provided to show that the services were provided outside the scope of the NP's State license. The Plan has not provided any evidence to support that this provider cannot be paid for the services at issue. Therefore, we decided that the Plan has to pay for the services provided to the enrollee on June 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to a long term acute care hospital (LTACH) for the enrollee.You asked the Planto pre-approvethe LTACH services. You say that this is medically necessary.The Plandenied your request. The Plansaysthe enrollee can stay at the current level until ready todischarge to a lower level of care.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.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-approvethe LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee appears to be gradually improving but requires additional short term acute care services which can safely be performed at the current facility. The enrollee does not require any services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Therefore, this request for LTACHservices will be considered not medically necessary. Ongoing treatment at the current facility is appropriate until the enrollee is able to be safely transferred to a lower level of care.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 LTACH services have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadmission to a long term acute care hospital (LTACH) for the enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible forthe office visit providedon June 30, 2020.You asked the Plan to waive the deductible forthe office visit. You say that the plan benefits state a $20 copayment for a PCP and specialist visit.The Plan denied your request. The Plan says the deductible applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that your deductible is $400. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost for most of your covered services. The item or service you asked the Plan to waive the deductible for falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $400 deductible applies to office visits. This cost sharing is a contractual obligation that had not been metat the time the office visit was received on June 30, 2020.Therefore, we decided that the Plan does not have to waive the deductible forthe office visit provided on June 30, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forDME provided from April 26, 2019, to August 26, 2019.You asked the Plan to waive the coinsurance forDME. You say that you disagree with the charges and cannot afford them.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 10% coinsurance for DME and related supplies. You received DME on April 26, 2019. The allowed amount is $2,899.50 and 10% of that is $289.50. You received DME on May 26, 2019. The allowed amount is $2,899.50 and 10% of that is $289.50.You received DME on June 26, 2019. The allowed amount is $2,899.50 and 10% of that is $289.50.You received DME on July26, 2019. The allowed amount is $2,899.50 and 10% of that is $289.50.You received DME on August 26, 2019. The allowed amount is $2,899.50 and 10% of that is $289.50.The total amount you owe is: $289.50 (coinsurance) x 5 (dates of service) = $1,449.75. 
You have been asked to pay the totalcoinsuranceamount of $1,449.75for DME. DME falls within the DME and related supplies benefit category. This means that you have been asked to pay thecorrect amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the coinsurance forDME provided from April 26, 2019, to August 26, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadditional routine transportation.You asked the Plan to pre-approveadditional routine transportation. You say that the service is medically necessary.The Plan denied your request. The Plan says the member hasexhausted their maximum benefit allowed.Medicare does not cover transportin a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 12 trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the member has exhausted the Plan maximum benefit for coverage of routine transportation.Therefore, we decided that the Plan does not have to pre-approveadditional routine transportation.