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

We decided that the Plan does not have to waive the copayment for an ER visit provided from June 15, 2018 to June 18, 2018.You asked the Plan to waive the copayment for an ER visit. You say that you disagree with the charges.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 $50 copayment for emergency care. You had an ER visit from June 15, 2018 to June 18, 2018. The medical records show that you did not receive inpatient hospital services following the ER visit. Therefore, you are responsible to pay the $50 copayment. You have been asked to pay a $50 copayment for an ER visit. An ER visit falls within the emergency care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment for an ER visit provided from June 15, 2018 to June 18, 2018.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay fora buccal swab genetic test provided to the enrollee on September 10, 2019.You asked the Planto pay forthe test. You say that this is medically necessary.The Plandenied your request. The Plansaysif there is no documentation the evaluation/testing was in relation to specific symptoms or treatment, the test isconsidered a screening service and denied as notcovered under Medicare.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the test. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found no provider records have been submitted for review. Therefore, there is no evidence to support that the provided service was medically necessary and reasonable to diagnose, treat or otherwise manage the enrollee's condition(s).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 test have not been met.Therefore, we decided that the Plandoes not haveto pay fora buccal swab genetic test provided to the enrollee on September 10, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the SNF services provided from April 24, 2019 to April 30, 2019.
You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 SNF 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 skilled nursing SNF services provided from April 24, 2019 to April 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe wrist hand orthosis (L3916) provided December 18, 2019.You asked the Plan to pay forthe orthosis. You say that the records provided should support the necessity of the service in dispute.The Plan denied your request. The Plan says no medical records were provided to corroborate the services and confirm Medicare coverage has been met.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. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met.Therefore, we decided that the Plan does not have to pay forthe wrist hand orthosis (L3916) provided December 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on July 29, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 July 29, 2019.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve an upper extremity prosthesis (L7499).
You asked the Plan to pre-approve an upper extremity prosthesis. You say that this item is medically necessary
and will help with activities of daily living. The Plan denied your request. The Plan says that the documentation
submitted does not support medical necessity.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve an upper extremity prosthesis. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found The enrollee has a loss of function affecting prehension as described above.
She is also suffering psychosocial impairment due to the loss of cosmesis. The treatment plan included partial
finger passive silicone prostheses. The requested partial passive finger silicone prostheses are medically
reasonable and 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 an upper extremity prosthesis have been met. Therefore, we decided that the
Plan has to pre-approve an upper extremity prosthesis (L7499).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services you provided on February 8, 2019.You asked the Plan to pay for the physician's services. 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 servicesat 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 physician'sservices you provided on February 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 20, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the medical services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.
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 January 20, 2020 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) rendered by the out of network (OON) provider on December 17, 2019.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan 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 subsequent nursing facility care (99308) rendered by the out of network (OON) provider on December 17, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a porcelain crown (D2750)
You asked the Plan to pay for the crown. You say that the crown was medically necessary. The Plan denied your request. The Plan says the service at issue is not a covered 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 a porcelain crown (D2750)
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the mental health services provided on January 8, 2020.
You asked the Plan to waive the copayment for the mental health services. You say that you feel the cost share amount is incorrect and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received mental health services provided by a Psychiatrist on the date of service at issue in this appeal. The Plan says the correct copayment has applied per your contract with the Plan.
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 $30 copayment for Outpatient mental health care. We looked at the file, the Plan contract and Medicare rules. The file shows you received mental health care provided by a Psychiatrist on January 8, 2020. You have been asked to pay a $30 copayment for the mental health services. The mental health services fall within the Outpatient mental health 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 the mental health services provided on January 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea shower chair.You asked the Plan to pre-approvea shower chair. You say that you need the requested shower chair to prevent yourself from falling while you are in the shower.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approvea shower chair.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home infusion therapy rendered from September 25,2019 to October 2, 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 the services are not covered.The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies.We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe home infusion therapy rendered from September 25, 2019 to October 2, 2019.Benefits for these servicesmay be available under Medicare Part D.Contactthe 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 a domiciliary, rest home visit provided on June 27, 2019.You asked the Plan to pay for the domiciliary, rest home visit. ThePlan denied your request. The Plan says out of area services are limited to urgent or emergent services.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 a domiciliary, rest home visit provided on June 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner servicesyouprovidedon October 18, 2019.You asked the Plan to pay for the nurse practitioner services. 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 servicesat 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 nurse practitioner services you provided on October 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam therapy.
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.twitt
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the use of proton beam therapy is not recommended for the treatment of prostate cancer outside of a clinical trial. There is no clear evidence that proton beam therapy offers any clinical advantage over other forms of radiation therapy for prostate cancer. The services would exceed your needs and are not 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve proton beam therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) provided to the enrollee on October 22, 2019.You asked the Plan to pay for the orthosis. You say that the durable medical equipment is medically necessary.The Plan denied your request. The Plan says the medical records do not support this service.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met. Healthcare Common Procedure Coding System (HCPCS) code L0650 (1 Unit) remains not supported.The documentation submitted did not include a detailed physician order. Of note, there are multiple Healthcare Common Procedure Coding System (HCPCS) codes for LSO back braces. Without a detailed description of the product ordered the validity and accuracy of the claim line cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information.Therefore, we decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) provided to the enrollee on October 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aid provided on October 16, 2019 by an out of
network (OON) provider.
You asked the Plan to pay for the hearing aid. You say that these services were medically necessary. The Plan
denied your request. The Plan says that only urgent/emergent services are covered when services are delivered
out of 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 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 hearing aid provided on October 16, 2019 by
an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forEKG provided on November 12, 2019.You asked the Plan to waive the copayment forthe EKG. You say that you believe the EKG should be covered under the Cardiovascular disease testing benefit. You say that the November 12, 2019 visit was a follow up for the hemoglobin, A1C, and thyroid tests. 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 per day for Medicare-covered tests. You will only pay one copayment per day even if multiple tests are performed. You have been asked to pay a $20 copayment for the EKG. The EKG falls within the "Outpatient diagnostic tests and therapeutic services and supplies" category. The record shows that an EKG is considered an outpatient diagnostic test. 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 EKG provided on November 12, 2019.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to hold you harmless for the laboratory testing provided on October 15, 2019.You asked the Plan to pay for the laboratory testing. You say that you cannot afford this testing.The Plan denied your request. The Plan says that the services received are not a covered benefit.Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules.You were provided the laboratory testing by provider. provider is a contract provider. The file does not show that the plan provided notice that the laboratory testing would not be covered. Under Medicare rules, this means the laboratory testing is considered approved by the plan. Therefore, we decided that the Plan has to hold you harmless for the laboratory testing provided on October 15, 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.