Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network mental health services provided to the enrollee from December 3, 2019 to December 20, 2019.You asked the Plan to pay for out of network services. You say that this claim should be paid.The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network services.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The contract with the Plan also says outpatient mental health care may require prior authorization. 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 these 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 out of network mental health services provided to the enrollee from December 3, 2019 to December 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the retreatment of previous root canal therapy (D3348) provided on January 28, 2020.You asked the Plan to pay for retreatment of previous root canal therapy. You say that you found that your root canal was infected when you went to the dentist. You also say that the only way to remedy the infection was to have the root canal retreated.The Plan denied your request. The Plan says this service is not covered under your contract under any normal circumstances.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 retreatment of previous root canal therapy (D3348) provided on January 28, 2020
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an Echocardiogram (93306) provided November 11, 2019.You asked the Plan to waive the copayment for the Echocardiogram. You say that the copayment should be $30.The Plan denied your request. The Plan says because the services were provided in the outpatient hospital setting, the correct copayment was 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 $100 copayment for outpatient hospital services. You have been asked to pay a $100 copayment for the Echocardiogram. the Echocardiogram 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 an Echocardiogram (93306) provided November 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis, periodic oral evaluation, bitewings, resin-based composite -four or more surfaces, and resin-based composite -three surfaces provided on January 23, 2019 and January 31, 2019 by an OON provider.You asked the Plan to pay for the prophylaxis, periodic oral evaluation, bitewings, and resin-based composites. You say that the provider's receptionist contacted your plan prior to your appointment and understood that you would still be covered although this provider was out-of-network. You also say that you are appealing based on the misinformation provided to the receptionist.The Plan denied your request. The Plan says the treating provider is OON. The Plan also says that services from non-contracted providers are excluded.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 covered when they are received OON. The records show that you did not contact the Plan yourself to verify your dental benefits or to inquire about the provider's network status. The records also show that the receptionist was told multiple times that you only have in-network benefits, and no misinformation was given.Therefore, we decided that the Plan does not have to pay for the prophylaxis, periodic oral evaluation, bitewings, resin-based composite -four or more surfaces, and resin-based composite -three surfaces provided on January 23, 2019 and January 31, 2019 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on January 15, 2020.You asked the Plan to pay for the prophylaxis. The Plan denied your request. The Plan says this service exceeds the frequency limitation in the benefit 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, prophylaxis (D1110) are limited to 1 visit every 6 months, up to 2 visits every calendar year. The record shows that you received a prophylaxis on September 23, 2019, and your prophylaxis benefit was then exhausted for the time period.Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110) provided on January 15, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER visit provided on December 29, 2019.You asked the Plan to waive the copayment for the ER visit. You say that this was a medical emergency that wasn't handled appropriately.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 $60 copayment for each Medicare-covered emergency room visit.You have been asked to pay a $60 copayment for the ER visit. The ER visit falls within the "Emergency care" benefit category. The records show that you were treated during the ER visit. 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 December 29, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the unlisted ambulance services, supplies (A0999) provided September 22, 2019.You asked the Plan to pay for the unlisted ambulance service. You say that this claim was incorrectly denied as not a covered service.The Plan denied your request. The Plan says payment for these items is included in the transportation fee.The Plan must follow Medicare rules. Medicare rules say that payment for these items is included in the transportation fee. Medicare does not allow for separate billing of these services and supplies. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the unlisted ambulance service have not been met.Therefore, we decided that the Plan does not have to pay for the unlisted ambulance services, supplies (A0999) provided September 22, 2019
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for Ambulance (als or bls) oxygen and oxygen supplies (A0422) provided June 11, 2019You asked the Plan to pay for the ambulance supplies. You say that you are requesting that the plan reprocess the claim for the correct allowed rate.The Plan denied your request. The Plan says payment for these items is included in the transportation fee.The Plan must follow Medicare rules. Medicare rules say that payment for these items is included in the transportation fee. Medicare does not allow for separate billing of these services and supplies.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ambulance supplies have not been met.Therefore, we decided that the Plan does not have to pay for Ambulance (als or bls) oxygen and oxygen supplies (A0422) provided June 11, 2019
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe x-ray provided on February 11, 2020.You asked the Plan to waive the copayment forthe x-ray. You say that you have never been charged for x-rays in the past. You say you cannot afford to pay this because you thought insurance would cover it. 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 $0 copayment for x-rays taken in a physician's office and a $150 copayment for x-rays taken at any other location. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $150 copayment for the x-ray.You have been asked to pay a $75.11 copayment for the x-ray. The x-ray 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 forthe x-ray provided on February 11,2020.Our decision is only about the February 11, 2020 service. If you have any questions about prior years billing, please contact the plan directly.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient rehabilitation services provided June 17 to June 22, 2019.You asked the Plan to waive the copayment for the inpatient rehab services. You say that the copayment should be waived.The Plan denied your request. The Plan says the correct copayment was 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 $150 per day copayment for days 1-5 for Inpatient Care. You have been asked to pay a $750 copayment for 5 days of inpatient rehab services. The inpatient rehab services fall within the Inpatient 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 inpatient rehabilitation services provided June 17 to June 22, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro 2, Motion G Orthotic Device (L8702).You asked the Plan to pre-approve the orthotic. You say that You are requesting a GAP exception and prior authorization. This is an orthotic device, not a prosthetic device. It is meant for patients with arm weakness, not for missing limbs.The Plan denied your request. The Plan says this item is considered experimental and investigational. There is insufficient evidence of its effectiveness in those with stroke and hemiparesis.The Plan must follow Medicare rules. Medicare rules say that experimental and investigational devices are not covered.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthotic have not been met.Therefore, we decided that the Plan does not have to pre-approve the MyoPro 2, Motion G Orthotic Device (L8702).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Iron Dextran.You asked the Plan to pre-approve Iron Dextran. The Plan denied your request. The Plan says there is no supporting evidence for multiple doses.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. The documentation shows that 40 doses of Iron Dextran were requested for the enrollee. The Plan has agreed to pre-approve 1 dose. 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 additional doses of Iron Dextran. Our physician reviewer found that the enrollee is noted to have mild, asymptomatic anemia and renal insufficiency. There is no evidence that the enrollee is unable to take oral medications. There is no evidence that the enrollee has failed to respond to oral medications (iron, folic acid, B12). Therefore, the documentation does not support that the additional IV iron is currently medically necessary or reasonable.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Iron Dextran have not been met. Therefore, we decided that the Plan does not have to pre-approve Iron Dextran.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the upper GI endoscopy provided on January 28, 2020.You asked the Plan to waive the copayment for the upper GI endoscopy. You say that you have never had to a pay such a copayment before. 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 $350 copayment per in-network visit. You have been asked to pay a $350 copayment for the upper GI endoscopy. The upper GI endoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 upper GI endoscopy provided on January 28, 2020.Our decision is only about the January 28, 2020 service. If you have any questions about prior years billing, please contact the plan directly.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the rituximab injection provided on September 19, 2019 and October 3, 2019.You asked the Plan to waive the coinsurance for the rituximab injections. You say that you need this drug to be well. You say that 20% coinsurance is too much.The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for Medicare Part B chemotherapy prescription drugs and 20% coinsurance for Medicare Part B non-chemotherapy prescription drugs. You have been asked to pay a total of $3,798.92 for the rituximab injections.  The rituximab injections 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 the rituximab injection provided on September 19, 2019 and October 3, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient rehabilitation services provided November 9, 2018 to November 17, 2018.You asked the Plan to waive the copayment for the inpatient rehab services. You say that the copayment should be waived.The Plan denied your request. The Plan says the cost sharing was 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 $300 per day copayment for days 1-5 for Inpatient Care. You have been asked to pay a $1500 copayment for 5 days of inpatient rehab services. The inpatient rehab services fall within the Inpatient 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 inpatient rehabilitation services provided November 9, 2018 to November 17, 2018.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fornail debridement provided on February 7, 2020.You asked the Plan to waive the copayment fornail debridement. You say that you went to get your toenails cut but received bills.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 $200 copayment per visit for Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient facility.You have been asked to pay $60.07, which is less than the standard $200 copayment for the nail debridement. Nail debridement fallswithin the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. Nail debridement is considered a surgical procedure. 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 fornail debridement provided on February 7, 2020
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approvean evaluation office visit to be provided by a vascular surgery specialist.You asked the Plan to pre-approvevascular surgery office visit. You say that you need an evaluation of blood flow in the leg and foot that would allow for a successful outcome in your procedure.The Plan denied yourrequest. The Plan says that the denial of authorization for this service is correct, because you do not need an additional evaluation with a vascular surgeon and can have a normal pre-operative clearance through your primary care provider.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 vascular surgery office visit. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found you have numerous cardiovascular risk factors. You are being considered for lower extremity surgery, but there is a request for a prior vascular surgery evaluation. If you are operated on with undetected vascular disease present, the results could be limb-threatening. A vascular surgeon would be best equipped to determine what studies, if any, are required and to assess if you have an ischemic component to your leg pain. The vascular surgeon would also be best equipped to determine if lower extremity perfusion is satisfactory for safe healing with your numerous risk factors.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of vascular surgery office visit have been met.Therefore, we decided that the Plan has to pre-approve an evaluation office visit to be provided by a vascular surgery specialist.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 pre-approve services with an out-of-state retinal specialist.You asked the Plan to pre-approve the services with an out-of-state retinal specialist. You say that you need to see the out-of-state retinal specialist in June and July of 2020 for macular degeneration medication injection. You say that your spouse will be working in Idaho in June and July.The Plan denied your request. The Plan says it is not reasonable and medically necessary for the enrollee to see an out-of-network provider.Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and care that cannot be provided by in network providers. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services with an out-of-state retinal specialist have not been met.The service being requested is not unforeseen and,therefore, are not considered urgent in nature. Therefore, we decided that the Plan does not have to pre-approve services with an out-of-state retinal specialist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gingival irrigation (D4921) for all 4 quadrants provided on January 23, 2020.You asked the Plan to pay for the gingival irrigation. You say that the periodontal scaling work was recommended by another provider. You also say that it was performed when you were still covered under your previous plan.The Plan denied your request. The Plan says gingival irrigation 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 gingival irrigation is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay for the gingival irrigation (D4921) for all 4 quadrants provided on January 23, 2020.