Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit provided on December
24, 2020.

You asked the Plan to waive the copayment for the urgent care visit. You say that that before even getting your
vitals taken or seeing a nurse or doctor, you decided to leave, and your copayment was refunded. The Plan
denied your request. The Plan says you have been asked to pay 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 $45
copayment per visit for covered services to an in- or out-of-network medical facility or urgent care center.

You have been asked to pay a $45 copayment for the urgent care visit. The urgent care visit falls within the
"Urgently needed services" benefit category. The medical record shows services were rendered such as a
review of systems and verbal and written discharge instructions were provided. 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 urgent care visit provided on December 24, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport you received on November 9, 2020.
You asked the Plan to waive the copayment for the ambulance transport. You say that you thought that because this ambulance trip was needed due to COVID-19 that there would be no copayment. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that only Coronavirus testing, vaccines, and inpatient and hospital observation services are covered at 100% due to COVID-19 and that the copayment for ambulance services still 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $200 copayment per trip for ambulance services. You have been asked to pay a $200 copayment per trip for the ambulance This means that you have been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation you agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance transport you received on November 9, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve trigger point injections.

You asked the Plan to pre-approve trigger point injections. You say that the requested trigger point injections are medically necessary. The Plan denied your request. The Plan says that the requested trigger point injections are not medically necessary.


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. In this case, we sent a request to the Plan to provide medical records for review in order to determine if Medicare criteria have been met for the requested trigger point injection. The Plan made no response and records were not provided for review. We are unable to make a determination based on Medicare criteria without the necessary documentation. Therefore, we decided that the Plan has to pre-approve trigger point injections.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the limited oral evaluation (D0140) provided on September 21, 2020.
You asked the Plan to reimburse you for the dental service. You say that this oral exam was necessary. You say that you had 2 teeth that broke off. You say that an oral surgeon needed to evaluate how to proceed with extractions and the state of your health before proceeding with the extractions. The Plan denied your request. The Plan says 1 limited oral evaluation is covered per plan year. The Plan says the frequency limit has been exceeded.
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 and limited oral evaluation is listed as a covered service, the frequency limit has been exceeded. The record shows that the Plan paid for a limited oral evaluation that you received on September 8, 2020. Therefore, we decided that the Plan does not have to reimburse you for the limited oral evaluation (D0140) provided on September 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic treatment provided from July 14, 2020, through September 14, 2020.

You asked the Plan to pay for the chiropractic treatment. The Plan denied your request. The Plan says that the Plan requires the member to obtain covered services, except for emergency care and out-of-area urgent care, from Plan providers.

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 chiropractic treatment. 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 chiropractic treatment provided from July 14, 2020, through September 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse the in network rate for the limited oral evaluation (D0140), the surgical extractions (D7210 x 2), the panoramic x-ray (D0330), and the incision and drainage of an abscess (D0001) provided on September 17, 2020.

You asked the Plan to reimburse the in network rate for the dental services. You say that your dentist referred you to the dentist in this case. You say that you did not know that the provider in this case was out of network. You say that your face was very swollen, and you were in a lot of pain. You say that this was an emergency. You also say that you cannot afford to pay this kind of expense. The Plan denied your request. The Plan says limited oral evaluation is not listed as a covered service. The Plan says surgical extractions are not listed as covered service. The Plan says panoramic x-ray is not listed as a covered service. The Plan also says that incision and drainage of an abscess is not listed as a covered service.

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 reimburse the in network rate for the limited oral evaluation (D0140), the surgical extractions (D7210 x 2), the panoramic x-ray (D0330), and the incision and drainage of an abscess (D0001) provided on September 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on March 5, 2020.
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 an office visit provided on March 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic radiology services provided on October 13, 2020.

You asked the Plan to pay for the diagnostic radiology services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.

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 diagnostic radiology 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 diagnostic radiology services provided on
October 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0480) provided by an out of network (OON) provider.

You asked the Plan to pay for OON drug testing. You say that this service was provided in good faith. The Plan denied your request. The Plan says this 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 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 drug testing (G0480) provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a Medtronic guardian sensor (continuous glucose monitor or CGM) (A9276).
You asked the Plan to preapprove the CGM. You say that the claim should be paid. The Plan denied your request. The Plan says this particular CGM is not covered.
The Plan must follow Medicare rules. Medicare will cover therapeutic continuous glucose monitors brand Freestyle Libre or Dexcom G5 or G6. They will be approved if your doctor requests them with Codes K0554 and K0553. The Medtronic guardian sensor (A9276) is not covered by Medicare. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to preapprove a Medtronic guardian sensor (continuous glucose monitor or CGM) (A9276).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Freestyle Libre therapeutic continuous glucose monitor.

You asked the Plan to pre-approve the therapeutic continuous glucose monitor.. You say that the item is medically necessary. The Plan denied your request. The Plan says the continuous glucose monitor is not medically reasonable and necessary.

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 use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the therapeutic continuous glucose monitor. have not been met. Therefore, we decided that the Plan does not have to pre-approve the Freestyle Libre therapeutic continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided from September 25, 2020, to October 9, 2020.

You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you disagree with the charges because you were told that you would owe a lesser amount. 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 20% coinsurance for Medicare Part B prescription drugs. 

You received Medicare Part B drugs on September 25, 2020. The total allowed amount is $376.71 and 20% of that is $75.34. 

You received Medicare Part B drugs on October 2, 2020. The total allowed amount is $376.71 and 20% of that is $75.34. 

You received Medicare Part B drugs on October 9, 2020. The total allowed amount is $376.71 and 20% of that is $75.34. 

The total amount you owe is: $226.02. 

You have been asked to pay the total coinsurance amount of $226.02 for Medicare Part B drugs. Medicare Part B drugs fall within the Medicare Part B prescription drugs 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 coinsurance for Medicare Part B drugs provided from September 25, 2020, to October 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve test materials and equipment for home INR monitoring to be provided by the out-of-network provider.

You asked the Plan to pre-approve the test materials and equipment for home INR monitoring. The Plan denied your request. The Plan says the member must get care from network providers. The plan will not cover care from a provider who does not work with the health plan unless one of the following situations applies: emergency or urgently needed care from an out-of-network provider, If the member needs care that our plan covers and our network providers cannot provide it to the member they can get the care from an out-of-network provider, kidney dialysis services when the member is outside the plan's service area for a short time and when the member first joins the plan they can keep getting services and seeing the doctors and other providers they go to now for at least 90 days from their enrollment start date.

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 items at issue in this appeal. We found no exception that would require the Plan to pre-approve these items. Therefore, we decided that the Plan does not have to pre-approve test materials and equipment for home INR monitoring to be provided by the out-of-network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81479) provided on February 18, 2020.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not authorized and there was no referral from a network provider for this testing.

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 service 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 lab services (81479) provided on February 18, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve esomeprazole magnesium, 40 mg capsule.

You asked the Plan to pre-approve the self-administered drug. You say that you have been taking this medication for many years. You also say that you need this medicine. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare Part B.

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 esomeprazole magnesium, 40 mg capsule.

Benefits for the self-administered drug 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation, complete series of intraoral x-rays, and scaling in presence of generalized moderate or severe gingival inflammation provided on November 25, 2020, and December 4, 2020 by an OON provider.

You asked the Plan to pay for the comprehensive oral evaluation, complete series of intraoral x-rays, and scaling. You say that you would like these services to be covered. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that services performed by an OON provider are not covered because your healthcare plan does not have OON benefits.

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, you are responsible for 100% of the cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation, complete series of intraoral x-rays, and scaling in presence of generalized moderate or severe gingival inflammation provided on November 25, 2020, and December 4, 2020 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam CT capture and interpretation (D0364) and incomplete endodontic therapy (D3332).

You asked the Plan to pay for the cone beam CT capture and interpretation and incomplete endodontic therapy. You say that you believe these services should be covered. The Plan denied your request. The Plan says these services are not covered benefits under your 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 for the cone beam CT capture and interpretation (D0364) and incomplete endodontic therapy (D3332).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary. The Plan denied your request. The Plan says the enrollee's needs can be met at a different level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee may require skilled physical therapy and occupational therapy but based on the medical records provided the enrollee does not require treatment in an intensive rehabilitation therapy program. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.