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

We decided that the Plan does not have to reduce the cost share for theProlia injection and its administration provided on August 16, 2019.You asked the Plan to reduce the cost share for the Prolia injection and its administration. You say that you were told you would only be responsible for a $35 copayment for the treatment. 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 20% coinsurance for each in-network Medicare-covered Part B drug and a $15 copayment for services obtained from an in-network specialist, or under certain circumstances by a nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's office. You have been asked to pay $224.28 which is 20% of the allowed amount for the Prolia injection. The allowed amount is $1,121.40. ($1,121.40 x 20% =$224.28). You have also been asked to pay a $15 copayment for the administration of the Prolia. The Prolia injection falls within the "Medicare Part B Prescription Drugs" benefit category. The administration of the Prolia falls 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 reduce the cost share for the Prolia injection and its administration on August 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the lower denture provided on August 7, 2019.
You asked the Plan to pay for the lower denture. You say that you would like to appeal this denial. The Plan denied your request. The Plan says this service exceeded the enrollee's Plan benefit limitation. The Plan also says that the enrollee was told pre-service that these services would not be covered.
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, one upper and lower denture are covered every 3 years. The record shows that the enrollee received an upper and lower denture on July 2, 2018 and your upper and lower dentures benefit has been exhausted. The documents also show that the enrollee was informed pre-service that the lower denture would not be covered. Therefore, we decided that the Plan does not have to pay for the lower denture provided on August 7, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) provided on February 21, 2020.You asked the Plan to waive the copayment for an MRI. You say that you disagree with the increase in 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 $200 copayment for MRI's for outpatient diagnostic tests and therapeutic services and supplies. You have been asked to pay a $200 copayment for an MRI. An 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 fora magnetic resonance imaging (MRI) provided on February 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an injection of immune globulin provided on December 26, 2019.You asked the Plan to pay for injection. You say that you are requesting payment.The Plan denied your request. The Plan says the denial of payment for this service is correct, because you have not furnished necessary information to the Plan to support coverage of this claim.The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the Plan sufficient information to determine whether payment is due. We looked at the file and Medicare rules. No medical records were submitted to support that coverage criteria for the billed service have been met. The Plan requested this information, but it was not provided. Without this information, you have not furnished sufficient information to justify coverage of this claim. Based on this information, we decided that Medicare rules for coverage of injection have not been met.Therefore, we decided that the Plan does not have to pay for an injection of immune globulin provided on December 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy (90832) rendered by the out of network (OON) provider on January 6, 2020.You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says this service was provided by an out of network provider, without prior authorization.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the service 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 this service.Therefore, we decided that the Plan does not have to pay for the psychotherapy (90832) rendered by the out of network (OON) provider on January 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ankle surgery provided from November 7, 2019 through November 8, 2019.
You asked the Plan to waive the copayment for ankle surgery. You say that you were refunded for the pretesting and were billed again four months later. You say that you cannot afford the hospital 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 $295 copayment for all other outpatient services including observation and outpatient surgical services not provided in an ambulatory surgical center. You have been asked to pay a $295 copayment for ankle surgery. Ankle surgery 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 ankle surgery provided from November 7, 2019 through November 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the upgraded intraocular lenses provided on February 19, 2020.
You asked the Plan to pay for the upgraded intraocular lenses. You say that you chose the premium lenses in order to satisfy your professional obligation as well as your day to day lifestyle. The Plan denied your request. The Plan says Medicare only covers basic lens implants for cataract surgery.
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives a P-C IOL during cataract surgery, the enrollee will be responsible for the difference in cost between the P-C IOL and a conventional IOL. While a P-C IOL may be appropriate for you, neither the Plan nor Medicare covers the presbyopia-correcting feature of a P-C IOL. Therefore, we decided that the Plan does not have to pay for the upgraded intraocular lenses provided on February 19, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy (HIT) services provided to the
enrollee from September 11, 2019 to October 1, 2019.
You asked the Plan to pay for the HIT services. The Plan denied your request. The Plan says that this is not a
covered service.
The Plan must follow Medicare rules. The rules say 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. Therefore,
we decided that the Plan does not have to pay for the home infusion therapy (HIT) services provided to the
enrollee from September 11, 2019 to October 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on January 29, 2020.You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says the Plan has to pay for care from out-of-network providers only for emergency care, out-of-network urgent care and pre-approved care.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for a domiciliary, rest home visit provided on January 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that LTACH would be the best treatment option in this case. The Plan denied your request. The Plan says the enrollee's needs can be met in the current facility.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include respiratory support including ventilator management, aggressive pulmonary toilet, and tracheostomy care, surveillance laboratory studies, foley care, tube feedings, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compression device with full leg sleeve rendered on December 30, 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 there is no valid proof of delivery.
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS suppliers are required to maintain proof of delivery. We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 pay for the pneumatic compression device with full leg sleeve rendered on December 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for comprehensive audiometry threshold evaluation (92557) provided February 3, 2020.You asked the Plan to waive the copayment for the audiometry evaluation. You say that you have no problem paying for the specialist visits but was not aware you could be charged an addition for hearing tests. You thought hearing tests were included with all health plans.The Plan denied your request. The Plan says the correct copayment was applied per the plan 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). Your contract with the Plan clearly says that you must pay $40 copay for each Medicare covered hearing service. You have been asked to pay $40 for the audiometry evaluation. The audiometry evaluation falls within the hearing 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 comprehensive audiometry threshold evaluation (92557) provided February 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing facility care provided on July 29, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says there is no
valid referral for this service.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for nursing facility care provided on July 29, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran inpatient hospital stay provided from January 6, 2020 to January 8, 2020.You asked the Plan to waive the copayment foran inpatient hospital stay. You say that you cannot afford the charges and disagree with them because the hospital was unable to perform a surgical procedure.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 $325 copayment for days 1-6 for inpatient hospital care. The medical records show that you had an inpatient hospital stay from January 6, 2020 to January 8, 2020. Therefore, you are responsible to pay a $325 copayment for days 1-2 (January 6, 2020 to January 7, 2020). $325 (copayment) x 2 (inpatient days) = $650.You have been asked to pay the total copayment amount of $650 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital 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 foran inpatient hospital stay provided from January 6, 2020 to January 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator.
You asked the Plan to pre-approve a portable oxygen concentrator. You say that you travel a lot and this machine is a better machine. The Plan denied your request. The Plan says this machine is not covered by Medicare.
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify for oxygen solely based on blood gas studies obtained during sleep. We looked at the file and Medicare rules. Medicare does not cover this machine and purchased oxygen equipment is statutorily non-covered by Medicare. Based on this information, we decided that Medicare rules
for coverage of a portable oxygen concentrator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (G0481) provided on August 27, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the coding criteria is not supported.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code G0481 is "Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 8-14 drug class(es), including metabolite(s) if performed."We find that CPT code G0481 is not supported in the medical record. Specifically, the records do not show that definitive drug testing for 8-14 classes was performed on the date of service in question. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay for the drug testing services (G0481) provided on August 27, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided on February 6, 2020 to February 27, 2020 by an out of network (OON) provider.
You asked the Plan to pay for lab services. 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 the member's primary care physician did not refer these 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 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 lab services provided on February 6, 2020 to February 27, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on February 26, 2020.
You asked the Plan to waive the copayment for a specialist visit. You say that your primary care provider was not available so you had to see the specialist and you feel that you should only owe a $10 copayment. 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 $40 copayment for each visit with a specialist. You have been asked to pay a $40 copayment for a specialist visit. A specialist visit falls 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 copayment for a specialist visit provided on February 26, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay fora retrobulbar injection (67500) provided on December 4, 2019.You asked the Plan to pay fora retrobulbar injection. You say that you would like reconsideration because these services were rendered by different providers.The Plan denied your request. The Plan says that payment is not allowed because this claim contains non-anesthesia services submitted by an anesthesiologist.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a retrobulbar injection have been met. Specifically, this service was provided by a provider different than that of the anesthesia procedure. The Medicare rules referenced by the Plan do not state that the provider type at issue cannot bill for code 67500. The denial is not substantiated and we must find in your favor.Therefore, we decided that the Plan has to pay fora retrobulbar injection (67500) provided on December 4, 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.