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

We decided that the Plan does not have to pay for the medical services provided on December 9, 2019
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services were rendered by a non-participating 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 requested provider in this case is not a network provider with the Plan. The referring provider is not a
network provider with the Plan. The Plan has network providers available who can provide the items/services
at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that
would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay
for the medical services provided on December 9, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 15, 2019 by an
out of network (OON) provider.
You asked the Plan to pay for physician visit. You say that you are appealing for payment. The Plan denied
your request. The Plan says the denial of payment for this service is correct, because this provider is out-ofnetwork
with the Plan and prior authorization was not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the medical services provided on November 15,
2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical assistant services on the incision and drainage of an
abscess (10061) provided on August 13, 2019.
You asked the Plan to pay for surgical assistant services on the incision and drainage of an abscess. You say
that these services were medically necessary. The Plan denied your request. The Plan says surgical assistant
services are not covered for this procedure.
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1,
assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT code
10061. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means
that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based
upon this information, we find that Medicare coverage criteria for surgical assistant services on the incision and
drainage of an abscess have not been met. Therefore, we decided that the Plan does not have to pay for surgical
assistant services on the incision and drainage of an abscess (10061) provided on August 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the hip orthosis and addition to lower extremity
You asked the Plan to pay for the hip orthosis (L1686) and addition to lower extremity (L2624). You say that the orthoses were medically necessary. The Plan denied your request. The Plan says rules for telehealth services were not met.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for the hip orthosis and addition to lower extremity provided
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transports provided on
September 15, 2019, October 5, 2019, October 22, 2019 and November 8, 2019.
You asked the Plan to waive the copayment for the ambulance transports. You say that the skilled nursing
center should have provided the transportation instead of the ambulance. The Plan denied your request. The
Plan says the copayments 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). The enrollee's contract with the Plan clearly says that enrollees
must pay $200 per one-way trip.
The enrollee has been asked to pay a $200 copayment for each ambulance transport. The total amount you owe
is $800 ($200/transport x 4 transports = $800). The ambulance transports fall within the "Ambulance services"
benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract
with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.
Therefore, we decided that the Plan does not have to waive the copayment for the ambulance transports
provided on September 15, 2019, October 5, 2019, October 22, 2019 and November 8, 2019.
Appeal type: SNF
Decision: Unfavorable

Explanation of decision
We decided that the Plan does not have to pay for the skilled nursing services provided from February 11, 2018 to February 12, 2018.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says SNF care beyond 100 days per benefit period is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that the enrollee received 100 days of SNF care during the benefit period from November 24, 2017 to March 18, 2018. The Plan has covered 100 days of SNF care.
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from February 11, 2018 to February 12, 2018.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the mammogram provided on November 7, 2019.You asked the Plan to waive the copayment for the mammogram. You say that this was a breast diagnostic for a check on a dark spot on the screen. You say you should not be responsible for the copayment. 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 $35 copayment for a diagnostic mammogram provided at an in-network specialist's office. You have been asked to pay a $35 copayment for the mammogram. The mammogram falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows a diagnosis of an abnormal and inconclusive findings on diagnostic imaging of breast. Therefore, the mammogram was diagnostic in nature.This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the mammogram provided on November 7, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for an urgent care visit provided on October 20, 2019
You asked the Plan to waive the copayment for the urgent care visit. You say that you were told there would
not be a copayment to go to urgent care. The Plan denied your request. The Plan says that 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. Your
contract with the Plan says that enrollees pay nothing for in-network and out-of-network Medicare-covered
urgently needed services.
The Plan says you must pay a $10 copayment for the urgent care visit. Based on the Plan contract, however,
you cannot be asked to pay more than a $0 copayment for the urgent care visit. The record shows the office
visit was provided at an urgent care center. Therefore, we decided that the Plan has to waive the copayment for
the urgent care visit provided on October 20, 2019
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ranibizumab 0.1 MG injection.You asked the Plan to pre-approve Ranibizumab. You say that the Ranibizumab is medically necessary.The Plan denied your request. The Plan says a trial of Avastin is required before alternatives can be considered.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 Ranibizumab. Our reviewer says that coverage criteria was not met. Our physician reviewer found the record does not show any reason why the plan preferred drug would be unsafe or ineffective for this enrollee.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Ranibizumab have not been met.Therefore, we decided that the Plan does not have to pre-approve Ranibizumab 0.1 MG injection.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan provided by September 16, 2019.
You asked the Plan to waive the copayment for the CT scan. You say that your insurance statement indicated that you were not responsible for the $100 charge and that your share is $0 for the CT scan. 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 $100 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a free-standing facility. You have been asked to pay a $100 copayment for the CT scan. The CT scan falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The record shows you were billed by the facility for the CT scan.
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 CT scan provided by September 16, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from October 22, 2019 to November 20, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not receive skilled nursing or skilled rehabilitation services during this time frame.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.
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 skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from October 22, 2019 to November 20, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered on October 6, 2019 to October 13, 2019.
You asked the Plan to pay for these 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 for the home infusion therapy rendered on October 6, 2019 to October 13, 2019.
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the four resin-based composites (codes D2335, D2332, D2392, and D2393) provided from February 13, 2019 to May 14, 2019.
You asked the Plan to pay more for the resin-based composites. You say that the amount you were billed is inconsistent with the benefits of your plan. The Plan denied your request. The Plan says you are responsible for 50% coinsurance for fillings.
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 contract clearly states that you must pay a 50% coinsurance for restorations that are provided in-network. The record shows that you received 4 resin-based composites and you were appropriately charged a 50% coinsurance for each of these services. Therefore, we decided that the Plan does not have to pay more for the four resin-based composites (codes D2335, D2332, D2392, and D2393) provided from February 13, 2019 to May 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for office visits provided on February 8, 2019 and September 25, 2019.
You asked the Plan to waive the copayments for office visits. You say that your copayment should have been $10 per visit, and you believe these charges are in error. The Plan denied your request. The Plan says the copayment amounts you are being charged are 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 $50 copayment for each out-of-network primary care visit. There were 2 visits, resulting in a total copayment obligation of $100. You have been asked to pay $50 copayment for each office visit. Office visits fall within the Physician/Practitioner Services, Including Doctor's Office Visits 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 copayments for office visits provided on February 8, 2019 and September 25, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost share for Performist nebulizer solution
You asked the Plan to reduce the cost share for Performist solution. The Plan denied your request. The Plan says Part B products are not eligible for cost-sharing reduction.
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 20% coinsurance for Medicare Part B prescription drugs. The enrollee has been asked to pay a 20% coinsurance for Performist solution. Performist solution falls within the Medicare Part B prescription drugs benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to reduce the cost share for Performist nebulizer solution
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF admission and services
You asked the Plan to pre-approve SNF services. You say that the enrollee needs physical therapy to get stronger to be able to walk on his own. The Plan denied your request. The Plan says the enrollee is medically stable and has no skilled medical needs.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 SNF services. Our physician reviewer found that the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee's care needs at this point are custodial and, as a practical matter, can be provided at 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the outpatient office visit, full mouth x-ray of teeth, x-ray exam of TMJ, and maxillofacial prosthetic procedure provided on October 24, 2019 and October 31, 2019.You asked the Plan to pay for the outpatient office visit, full mouth x-ray of teeth, x-ray exam of temporomandibular joint, and maxillofacial prosthetic procedure. You say that your dentist referred you to this provider because he was a specialist in fixing jaws. You also say that you feel these services were medically necessary.The Plan denied your request. The Plan says that these services are not covered benefits. The Plan also says that these services were rendered by a non-participating provider.The Plan must follow Medicare rules. The rules say that Medicare covers treatment for TMJ syndrome only when the condition or symptom is medical in nature. The treatment must also be medically 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 pay for the outpatient office visit, full mouth x-ray of teeth, x-ray exam of temporomandibular joint, and maxillofacial prosthetic procedure. Our reviewer says that these services were medically reasonable and necessary. Our physician reviewer found the documentation does support the billed diagnosis of Articular disc disorder of bilateral TMJ and Arthralgia of right TMJ. Our reviewer found that the documentation supports these services as being primarily focused on a medical condition and not services to treat structures supporting the teeth. Our physician reviewer found that the documentation does support that the requested procedures are medically reasonable for the diagnosis. Our reviewer also found that the documentation provided supports the contention that the procedures are medically appropriate for the diagnosis and initial conservative treatment of TMJ disorders.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 outpatient office visit, full mouth x-ray of teeth, x-ray exam of temporomandibular joint, and maxillofacial prosthetic procedure have been met. Therefore, we decided that the Plan has to pay for the outpatient office visit, full mouth x-ray of teeth, x-ray exam of TMJ, and maxillofacial prosthetic procedure provided on October 24, 2019 and October 31, 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.