Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the oxygen concentrator purchased January 5, 2020.
You asked the Plan to pay for the oxygen concentrator. You say that you would like this claim reprocessed and
approved for payment. The Plan denied your request. The Plan says the claim processed correctly.
The Plan must follow Medicare rules. Medicare rules say that the Plan may not pay for oxygen purchased on or
after June 1, 1989.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the oxygen concentrator have not been met. Therefore, we decided that the Plan does not have to
pay for the oxygen concentrator purchased January 5, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric evaluation provided on December 30, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the psychiatric evaluation. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was 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 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 psychiatric evaluation provided on December 30, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the core build up (D2950) for tooth # 31 provided on December 29, 2020.
You asked the Plan to reimburse you for the dental service. You say that you went to the dentist to have 2 crowns installed. You say that this required 2 build ups. You also say that the Plan only covers 1. The Plan denied your request. The Plan says 1 core build up is covered per year. The Plan also says that the frequency limit has been exceeded.
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 and core build up is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for core build up for tooth # 18 that was performed on the date of service in this case. Therefore, we decided that the Plan does not have to reimburse you for the core build up (D2950) for tooth # 31 provided on December 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 services. Our reviewer says that the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found the enrollee is not at high risk for a pressure ulcer, as his Braden score is 13. The enrollee does not use intermittent catherization for bladder management and does not have increased tone or spasticity. The criteria for the requested Group 3 wheelchair with multiple power option accessories has not been met. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the mammogram provided on January 20,
2021.
You asked the Plan to waive the copayment for the mammogram. You say that your mammogram should have
been covered because the doctor requested a second mammogram. The Plan denied your request. The Plan says
you have been asked to pay 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 $50
copayment for each covered x-ray services, including diagnostic mammograms.
You have been asked to pay a $50 copayment for the mammogram. The mammogram falls within the
"Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows a
screening mammogram was performed on January 12, 2021, which exhausted the breast cancer screening
benefit.
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 January 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit and laboratory test provided on December 21, 2020 by an out of network (OON) provider.You asked the Plan to pay for office visit and lab test. You say that you provided medically necessary services in good faith.The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and 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 must 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 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 an office visit and laboratory test provided on December 21, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (83036, 80053, 80061, 36415) provided on January 15, 2021 to January 19, 2021.You asked the Plan to pay for the lab services. You say that the services were medically necessary.The Plan denied your request. The Plan says the services were not emergent or pre-authorized. There were network providers available. 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 lab services (83036, 80053, 80061, 36415) provided on January 15, 2021 to January 19, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional physical therapy (PT) visits (97164).
You asked the Plan to pre-approve the additional visits. You say that due to the progressive nature of her diagnosis, the enrollee will likely require PT on-going. The Plan denied your request. The Plan says the records do not support that this request is medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 additional visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health plan. The enrollee has had extensive prior therapy for this condition and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The documentation does not support that the specialized skill, knowledge and judgment of a qualified therapist is required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. 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 additional visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 10 additional physical therapy (PT) visits (97164).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on November 6, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 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 the services provided by an out-of-network provider on November 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for pneumatic compressor, segmental home model without calibrated gradient pressure (CPT code E0651) and segmental pneumatic appliance for use with pneumatic compressor, full leg, left and right (CPT Code E0667 X2) provided to the enrollee on September 17, 2020.
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. The Plan says documentation submitted did not sufficiently document the enrollee's medical condition to support the medical necessity for the billed supply code; nor did documentation indicate the provider discussed the need for the billed supply code on the date it was ordered.
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 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 DME. Our physician reviewer found the clinical records do not support that a pneumatic compressor, segmental home model without calibrated gradient pressure, and segmental pneumatic appliance for use with pneumatic compressor, full leg, left and right, were medically reasonable and necessary for the enrollee in this case. 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 DME have not been met. Therefore, we decided that the Plan does not have to pay for pneumatic compressor, segmental home model without calibrated gradient pressure (CPT code E0651) and segmental pneumatic appliance for use with pneumatic compressor, full leg, left and right (CPT Code E0667 X2) provided to the enrollee on September 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a Positron Emission Tomography (PET)
scan and fluorodeoxyglucose (F-18 FDG) imaging supplies provided on February 9, 2021.
You asked the Plan to waive the copayment for PET scan and imaging supplies. You say that you were told
your copayment would be $175 but you are being charged more. The Plan denied your request. The Plan says
the cost-sharing 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 $175
copayment for PET scan and 20% coinsurance for imaging supplies. The allowed amount of the imaging
supplies is $455, resulting in a coinsurance amount of $91. Your total cost-sharing amount is therefore $266.
You have been asked to pay $175 copayment for PET scan and 20% coinsurance for imaging supplies. PET
scan and imaging supplies 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 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 Positron Emission
Tomography (PET) scan and fluorodeoxyglucose (F-18 FDG) imaging supplies provided on February 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2300, K0108, K0669, E0978, A9900, E2331).

You asked the Plan to pre-approve the additional accessories. You say that this is not medically necessary. The Plan denied your request. The Plan says this is not medically necessary.

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 additional accessories. Our reviewer says that the requested additional accessories are not considered medically reasonable and necessary in this case. Our physician reviewer found the E0978 safety belt/pelvic strap exceeds your medical need as this was already included in the power wheelchair. The K0108 Ability Drive/TOLT Technologies and associated items does not meet Medicare Criteria as this device is not FDA approved and does not meet Medicare criteria as safe and effective. The E2331 attendant control exceeds the enrollee's medical need as the patient was approved for a patient operated drive control system.

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 additional accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2300, K0108, K0669, E0978, A9900, E2331).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist services rendered on January 8, 2021.
You asked the Plan to waive the copayment for these services. You say that you went for a COVID test and were told the services would be covered in full. The Plan denied your request. The Plan says the copayment 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 $30 copayment per visit for in-network specialist services.
Review of the file shows that you received specialist services on January 8, 2021. Per the contract with the Plan, there is a $30 copayment per visit for in-network specialist services. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. However, the Medicare allowed amount for these services was $22.54. Given that the allowed amount was less than the $30 copayment, you have been asked to pay $22.54 for these services.
Therefore, we decided that the Plan does not have to waive the copayment for the specialist services rendered on January 8, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the laboratory services rendered on May 18, 2020.

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 that the procedure codes are not covered by the Physician Fee Schedule.

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. The Plan states that the billed procedure codes are not covered by the Physician Fee Schedule; however, the codes are payable under the Medicare Clinical Laboratory Fee Schedule. The Plan has not provided any documentation to support that the codes are not payable under the Medicare Clinical Laboratory Fee Schedule. Therefore, we decided that the Plan has to pay for the laboratory services rendered on May 18, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the urgent care visit for nail removal and abscess drainage
provided by an out-of-network provider on August 17, 2020.
You asked the Plan to pay for the urgent care visit for nail removal and abscess drainage. You say that medical
providers must render treatment when they are needed. You say that the treatment complies with the policy
terms regarding medical necessity. The Plan denied your request. The Plan says in-network providers were
available.
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 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 urgent care visit for nail removal and abscess drainage provided by an out-of-network provider on August 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost for the MRI's provided on November 6, 2020 and January 26, 2021.
You asked the Plan to waive the cost for the MRI's. You say that the doctor did not explain the findings of the MRI and did not stay long enough for questions. You say that you are disputing the reading and charges of the MRI's. The Plan denied your request. The Plan says the cost share 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 2020 contract with the Plan clearly says that enrollees must pay a $200 copayment after the deductible is met for each advanced imaging service. The enrollee's 2021 contract with the Plan clearly says that the deductible is $750. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost of your covered services. The enrollee has been asked to pay $192.09, which is less than the standard $200 copayment for the MRI provided on November 6, 2020. The enrollee has also been asked to pay $290.51 toward the deductible for the MRI provided on January 26, 2021. The MRI's fall within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 cost for the MRI's provided on November 6, 2020 and January 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora CT scan provided by a participating provider on January 18, 2021.You asked the Plan to waive the copayment fora CT scan. You say that you did not pay this much last time.The Plan denied your request. The Plan says the correct copayment has 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 $250 copayment for outpatient diagnostic tests/CT scan. You have been asked to pay $131.37 which is less than your copayment amount of $250 copayment for a CT scan. The correct copayment has been applied to the services that were provided. A CT scan falls within the outpatient diagnostic tests/CT scan 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 CT scan provided by a participating provider on January 18, 2021.