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

We decided that the Plan does not have to pre-approvea referral to an out-of-area cardiologist.You asked the Plan to pre-approvethese services. You say that you moved to THE County temporarily and need to follow up with a cardiologist.ThePlan denied your request. The Plan says the services are available from in-area network providers.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 pre-approved care.  We looked at the file and Medicare rules. The file shows that you left the Plan's service area with a known need for cardiology care. The Plan has cardiologists available within the service area that can provide your care. 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-approvea referral to an out-of-area cardiologist.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe surgery assistant services provided on June 18, 2020.You asked the Plan to pay forthe surgery assistant services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services rendered are not a covered benefit.The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS.In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners.Therefore, we decided that the Plan does not have to pay forthe surgery assistant services provided on June 18, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services provided to the enrollee on May 23, 2019.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says according to the Medicare Claims Processing Manual Chapter 34,a corrected claim must be receivedwithin one year (12 months) from the processed date of the original claim submission. The original claim has a processed date of June 3, 2019. A corrected claim was not received until September 8, 2020 which is past the allowed 12-monthtimeframeThe Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.The record shows that a valid claim for this service was not filed until September 8, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay forphysician services provided to the enrollee on May 23, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy with lesion removal
provided on October 29, 2019.
You asked the Plan to waive the copayment for the colonoscopy with lesion removal. You say that this was a
screening colonoscopy which is a health prevention service and should be covered. 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 $250
copayment for each Medicare-covered ambulatory surgical center visit. For this date of service, you have been
asked to pay the allowed amount of the claim because this amount is less than the $250 copayment for the
colonoscopy with lesion removal.
You have been asked to pay a $246.91 copayment for the colonoscopy with lesion removal. The colonoscopy
with lesion removal falls within the "Outpatient surgery, including services provided at hospital outpatient
facilities and ambulatory surgical centers" benefit category. The record shows diagnosis codes for benign
neoplasms of the colon, rectum, anus and anal canal which changes the colonoscopy from a screening
colonoscopy to a diagnostic colonoscopy.
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 colonoscopy with lesion removal provided on October
29, 2019.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay forthe ambulance services (A0398, A0425, A0427) provided on July 4, 2020.You asked the Plan to pay forthe ambulance services. You say that the service provided was medically necessary.The Plan denied your request. The Plan says that the information provided does not support medical necessity for ambulance transport.Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. 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 ambulance services. Our reviewer says that the service was medically necessary. Our physician reviewer found the patient was in a lot of discomfort and would be considered impaired. Severe constipation can be the sign of a minor or severe illness. The transport appears necessary given the unrelieved symptoms of patient.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 ambulance services have been met.Therefore, we decided that the Plan has to pay forthe ambulance services (A0398, A0425, A0427) provided on July 4, 2020.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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forinjection, ferric carboxymaltose, 1 mg (J1439) provided on June 25, 2020, and July 2, 2020.You asked the Plan to waive the coinsurance forinjection of ferric carboxymaltose. You say that the services should be covered.The Plan denied your request. The Plan says the cost share 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 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a 20% coinsurance for injection of ferric carboxymaltose. This service falls 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 forinjection, ferric carboxymaltose, 1 mg (J1439) provided on June 25, 2020, and July 2, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the chemotherapy administration provided
on October 8, 2020.
You asked the Plan to waive the copayment for the chemotherapy administration. You say that you should not
be charged a coinsurance for having the medication administered in the office. 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 $45
copayment for each specialist in-person office visit.
You have been asked to pay a $18.26 copayment, which is less than the standard copayment amount, for the
chemotherapy administration. The chemotherapy administration falls within the "Physician/Practitioner
services, including doctor's office visits" benefit category. The record shows the chemotherapy administration
is considered a physician service in a specialist's office.
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 chemotherapy administration provided on October 8,
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B drug administration provided.

You asked the Plan to waive the coinsurance for the Part B drug administration. You say that there should not be a cost share for the service. The Plan denied your request. The Plan says you were charged this coinsurance 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 prescription drugs injected while you are getting physician services. 

You have been asked to pay 20% coinsurance for the Part B drug administration. The Part B drug administration falls within the Medicare Part B prescription drugs 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 Part B drug administration provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services provided from July 14, 2020, to September 14, 2020 by an out of network provider.
You asked the Plan to pay for the chiropractic services. You say that you should not be limited on who you are able to see if you are able to get the care you need to fix your condition. The Plan denied your request. The Plan says only manual manipulation of the spine to correct subluxation is covered and only 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 had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the chiropractic services provided from July 14, 2020, to September 14, 2020 by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine vision exam and frames and lenses provided on
August 27, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the routine vision exam and frames and lenses. You say that you were under the
impression the services you received would be covered. The Plan denied your request. The Plan says services
rendered by a provider other than the Plan's routine vision vendor will not be covered.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers these services when the services are received from the Plan's routine vision vendor.
We looked at the file and the Plan's rules. The file indicates that you received these services from a provider
other than the Plan's routine vision vendor. Based on this information, we decided that the Plan's rules for
coverage of the routine vision exam and frames and lenses have not been met. Therefore, we decided that the
Plan does not have to pay for the routine vision exam and frames and lenses provided on August 27, 2020 by
an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery and lab work provided by a participating provider on September 3, 2020.You asked the Plan to waive the copayment for an outpatient surgery and lab work. You say that you do not agree with these charges. The Plan denied your request. The Plan saysthe correct charges have been 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 $390 copayment for outpatient hospitalservices/surgery services and a $40 copayment for outpatient hospital services/lab services. You have been asked to pay less than a $390 copayment for an outpatient surgery and less than a $40 copayment for lab work. The total amount you are being askedto pay is $20.83 ($14.10 (surgery) + $6.73 (lab work) = $20.83). An outpatient surgery and lab work falls within the outpatient hospital services/surgery services benefit category and outpatient hospital services/lab 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 copaymentfor an outpatient surgery and lab work provided by a participating provider on September 3, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay forthe trigger point injection provided on August 10, 2020.You asked the Plan to pay forthe injections. The Plan denied your request. The Plan says that this injection were not medically necessary.The Plan follows Medicare rules. Medicare rules say that trigger point injections are covered for the above indications.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 injections. Our reviewer says that the requested trigger point injections were medically reasonable and necessary. Our physician reviewer found that the enrollee is a 71-year-old woman with chronic low back pain. She has tried physical therapy, chiropractic, bed rest, heat, ice, and NSAIDs. The enrollee has received trigger point injections with good effect. The requested trigger point injections were medically reasonable and necessary. The documentation meets the LCD criteria.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 injections have been met.Therefore, we decided that the Plan has to pay forthe trigger point injection provided on August 10, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe Aflibercept injection (J0178) received August 19, 2020.You asked the Plan to waive the coinsurance forthe Aflibercept injection. You say that you should not be charged a coinsurance for this injection.The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a total cost share of $372.71 for the Aflibercept injection. Aflibercept 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 forthe Aflibercept injection (J0178) received August 19, 2020
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided from August 31, 2020, through September 5, 2020.You asked the Plan to pay for the inpatient hospital care. The Plan denied your request. The Plan says that generally speaking, the enrollee must usenetwork providers to receive covered care. However, there are two (2) exceptions; the Plan provides benefits for use of out of network providers for emergency care provided in a hospital emergency room worldwide, urgently needed services as are commonly provided in an urgent care center, out of area renal dialysis received from any Medicare-certified providerthroughout the U.S., or if you are in need of specialized care that is not available within the Plan's provider network when such care is prior authorized in advance by 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 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 inpatient hospital care provided from August 31, 2020, through September 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on February 17, 2020.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plansays 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 Plandid 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 February 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided by a non-participating provider on November 4, 2020.
You asked the Plan to pay for the dental services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the dental services are not covered when provided by a dentist who does not participate with the dental 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, these dental services are not covered when provided by a non-participating dental provider. The file shows that your dental provider is not participating with the plan's dental network. Therefore, we decided that the Plan does not have to pay for the dental services provided by a non-participating provider on November 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99203), the x-ray exam of the lumbar spine (72100), and the x-ray exam of the cervical spine (72040) provided on October 5, 2020.
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 these services are not a covered benefit under your contractual policy or by Medicare.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the office visit (99203), the x-ray exam of the lumbar spine (72100), and the x-ray exam of the cervical spine (72040) provided on October 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvecore buildup and crowns for the enrollee.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysonly Medicare-covered dental services are part of the benefit.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of the enrollee'steeth or the structures directly supporting the enrollee's teeth. These are dental services that are not covered or paid for by Medicare.Therefore, we decided that the Plandoes not haveto pre-approvecore buildup and crowns for the enrollee
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room services provided from August 27, 2020 to September 3, 2020.
You asked the Plan to waive the copayment for the emergency room services. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received emergency care services on the date of service at issue in this appeal. The Plan says that 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 $90 copayment for Emergency care. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received emergency room services. You have been asked to pay a $90 copayment for the emergency room services. The emergency room services fall 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 the emergency room services provided from August 27, 2020 to September 3, 2020.