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

We decided that the Plan does not have to pay for the physician's services provided on September 13, 2019.
You asked the Plan to pay for the physician's services. You say that you believed that this provider was in-network and that the Plan had approved these services. The Plan denied your request. The Plan says prior authorization and referral is required for specialist 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 contract with the Plan also says that prior authorization and referral is required for specialist services. 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 physician's services provided on September 13, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran ultrasound provided on November 22, 2019.You asked the Plan to waive the copayment foran ultrasound. You say that you were not aware that you would owe a $35 copayment for an ultrasound.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 $35 copayment for each x-ray or diagnostic procedure and test. Youhave been asked to pay a $35 copayment for an ultrasound. An ultrasound falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment foran ultrasound provided on November 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe rest home visit services provided on December 3, 2019 by an out of network (OON) provider.You asked the Plan to pay forthese out-of-network services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not a covered benefit.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 forthe rest home visit services provided on December 3, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a referral to an out-of-network provider.
You asked the Plan to pre-approve the referral. You say that this is needed to help treat for "other general symptoms and signs." The Plan denied your request. The Plan says that there was no documentation of the enrollee's assessment and treatment at the primary care level.
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. As the enrollee's primary care provider is clearly a network provider, it is the plan's responsibility to receive these records. The enrollee should not be penalized for the plan's inability to obtain records that are within their purview. No medical records have been provided, so the denial has not been substantiated. Therefore, we decided that the Plan has to pre-approve a referral to an out-of-network provider.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient mental health stay provided from October 2, 2019 to October 10, 2019.You asked the Plan to waive the copayment for an inpatient mental health stay. You say that you were taken to the emergency room briefly and then admitted back to the hospital.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 $425 copayment per admission for inpatient mental health care. You have been asked to pay a $425 copayment per admission for an inpatient mental health stay. An inpatient mental health stay falls within the inpatient 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 an inpatient mental health stay provided from October 2, 2019 to October 10, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the MRI provided on October 18, 2019.
You asked the Plan to waive the copayment for the MRI. You say that you do not agree with this higher 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 $175 copayment for advanced diagnostic radiology services (such as MRIs and CT scans). You have been asked to pay a $175 copayment for the MRI. The MRI 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 for the MRI provided on October 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve retreatment of a root canal (teeth #3 and #18) (D3348)
You asked the Plan to pre-approve the dental services. You say that this is a life or death situation. The Plan denied your request. The Plan says this service is not covered under the enrollee's benefit package.
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 pre-approve retreatment of a root canal (teeth #3 and #18) (D3348)
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran office visit provided on July 25, 2017 by an out of network (OON) provider.You asked the Plan to pay foran office visit. You say that this was a follow-up appointment. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that these services were not emergent in nature.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 foran office visit provided on July 25, 2017 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided to the
enrollee from October 25, 2019 through October 29, 2019 provided by an in-network provider.
You asked the Plan to waive the copayment for inpatient hospital care. You say that other times the enrollee
was in the same hospital they had to pay $90. The Plan denied your request. The Plan says the claim was
processed accordingly with the member's 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).
Review of the file shows that the enrollee was admitted on October 25, 2019 and discharged on October 29,
2019. The enrollee was asked to pay a $225 copayment per day from October 25, 2019 through October 28,
2019, days 1-5 of their inpatient hospital care. The enrollee was discharged on October 29, 2019 and there was
no copayment charge for the day of discharge. Per the enrollee's contract there is a $225 copayment per day
required for days 1-5 for in-network inpatient hospital care. 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 inpatient hospital care provided to the enrollee from October 25, 2019 through October 29, 2019
provided by an in-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided to the enrollee on March 21, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that the services were billed correctly. The Plan denied your request. The Plan says there is no network deficiency for these services, and alternate providers were found.
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 lab 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 OON services. Therefore, we decided that the Plan does not have to pay for the lab services provided to the enrollee on March 21, 2019 by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health services provided on June 20, 2019 to October 31, 2019 by an out of network (OON) provider.
You asked the Plan to pay for outpatient mental health services. You say that you would like to get through these tough times with your mental health intact. The Plan denied your request. The Plan says no prior authorization was obtained for these services. The Plan says that these services can be provided in-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 outpatient mental health services provided on June 20, 2019 to October 31, 2019 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services
You asked the Plan to pay for the ambulance services. You say that the ambulance service was medically
necessary. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when
they meet certain origin and destination requirements. A doctor's office is not a covered destination.
The services you have asked the Plan to pay for are ambulance transport services to a doctor's office.
Therefore, we decided that the Plan does not have to pay for the ambulance services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the upgraded electronics.You asked the Plan to pre-approve the power wheelchair Electronic connection (E2311), Expandable controller harness (E2313), and Expandable controller (E2377). You say that the upgraded electronics are necessary because the enrollee has operated a power wheelchair this way for many years. The Plan denied your request. The Plan says the notes do not show a medical need to control the power options through the joystick.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. Documentation shows that upper limb strength and range of motion are adequate for the enrollee to be able to control the power options using their own switches which are included in the allowance of these power options. Based on this information, we decided that Medicare rules for coverage of the power wheelchair Electronic connection (E2311), Expandable controller harness (E2313), and Expandable controller (E2377) have not been met.Therefore, we decided that the Plan does not have to pre-approve the upgraded electronics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on November 5, 2019.You asked the Plan to waive the copayment for the office visit. You say that you went for an annual visit. You say that you were told there was no copayment.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 $10 copayment for in-network PCP office visits. You have been asked to pay a $10 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that a chest injury, arthritis and diabetes were addressed during the office 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 office visit provided on November 5, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) (K0861) and accessories (E2361, E2377, E2313, E1007, E2311, E1012, E0955, E1028, E1020, E0954, E2601, and E2611).
You asked the Plan to pre-approve a Group 3 PWC and accessories. You say that these items are necessary for the enrollee. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that a Group 3 PWC is covered if the beneficiary's mobility limitation is due to a neurological condition, myopathy, or congenital skeletal deformity. We looked at the file and Medicare rules. The record shows that the beneficiary's mobility limitation is not due to a neurological condition, myopathy, or congenital skeletal deformity Based on this information, we decided that Medicare rules for coverage of a Group 3 PWC and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) (K0861) and accessories (E2361, E2377, E2313, E1007, E2311, E1012, E0955, E1028, E1020, E0954, E2601, and E2611).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on November 13, 2019.
You asked the Plan to pay for lab tests. You say that you did not know these tests would not be covered. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these tests are not covered by Medicare when performed as a requirement from your employer.
The Plan must follow Medicare rules. Medicare rules say that routine services required by a third party such as an employer are excluded from Medicare coverage, unless a specific statute exists to provider coverage. We looked at the file and Medicare rules. These tests were performed as part of a pre-employment examination and are therefore excluded from Medicare coverage. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on November 13, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMS implant for the enrollee.
You asked the Plan to pre-approve the implant. You say that this is medically necessary. The Plan denied your request. The Plan says the CardioMEMS is not clinically indicated for a patient who is documented to be stable, and even improved with no evidence of recent hospital admissions for decompensation.
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 the implant. Our reviewer says that the requested implant is not considered medically reasonable and necessary in this case. Our physician reviewer found in this circumstance therapy change based on data obtained from a CardioMEMs device has been demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results. Therefore the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure. Medicare coverage criteria are not met since the device should still be considered experimental or investigational. 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 implant have not been met. Therefore, we decided that the Plan does not have to pre-approve a CardioMEMS implant for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided to the enrollee on November 21, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says there is no network deficiency for the 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 has network providers available who can provide the lab 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 OON services. Therefore, we decided that the Plan does not have to pay for the lab services provided to the enrollee on November 21, 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 forX-rays provided on October 30, 2019.You asked the Plan to waive the copayment forX-rays. 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 basic radiological services provided in a specialist's office. You have been asked to pay the allowed amount of $46.69, which is less than the $50 copayment for X-rays. X-rays fall within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount basedon 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 forX-rays provided on October 30, 2019.