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

We decided that the Plan does not have to pre-approve acupuncture services.

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 only covered for long-term low back pain.

The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year.

We looked at the file and Medicare rules. Your diagnosis is neck pain, which is not an indication for acupuncture. It is only covered for chronic low back pain. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Therefore, we decided that the Plan does not have to pre-approve acupuncture services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services.

You asked the Plan to pay for the psychotherapy 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 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 psychotherapy 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 psychotherapy services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have 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 medically necessary. The Plan denied your request. The Plan says there are in-network providers that could provide the same 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic ultrasounds of the right and left breasts.

You asked the Plan to waive the copayment for the diagnostic ultrasound of the breasts. You say that you preferred an ultrasound to an X-ray. The Plan denied your request. The Plan says your screening was diagnostic, therefore the correct copayment 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 $10 copayment for outpatient diagnostic tests and therapeutic services.

You have been asked to pay a total of $20 in copayments (a $10 copayment for each of two of the diagnostic ultrasounds of the breasts). The diagnostic ultrasound of the breasts falls within the outpatient diagnostic tests and therapeutic 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 the diagnostic ultrasounds of the right and left breasts.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management.

You asked the Plan to pay for the hospital discharge day management. You say that the enrollee was not in hospice at the time of this service. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the hospital discharge day management.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy.

You asked the Plan to waive the copayment for the colonoscopy. You say that the procedure was interrupted and was not completed. You say no specimen was taken and you should not be charged a 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 $275 copayment for freestanding ambulatory surgical center.

You have been asked to pay a $275 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical center" benefit category. The medical record shows the colonoscopy was performed due to a positive fecal immuochemical test, which makes the colonoscopy diagnostic in nature. The medical record also shows anesthesia was administered before the procedure was stopped.

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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME and related supplies.

You asked the Plan to waive the coinsurance for DME and related supplies. You say that you disagree with the high charges because you could have gotten the supplies for much cheaper. 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 20% coinsurance for DME and related supplies.

You received DME and related supplies. Therefore, you are responsible to pay your share of the cost-sharing charges. Please see the chart provided.

The total amount you owe is: $1,821.38.

You have been asked to pay the total coinsurance amount of $1,821.38 for DME and related supplies. DME and related supplies fall within the DME and related 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 coinsurance for DME and related supplies.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an X-ray.

You asked the Plan to waive the copayment for an X-ray. You say that you already paid the $50 copayment and disagree with the additional 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 $35 copayment for X-rays.

You have been asked to pay a $35 copayment for an X-ray. An X-ray 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 an X-ray.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment and coinsurance for the MRI scan of the brain and the gadobutrol injection.

You asked the Plan to waive the copayment and coinsurance for the MRI scan of the brain and gadobutrol injection. You say that you thought the MRI scan was included in your hearing aid costs and you cannot afford a separate copayment. The Plan denied your request. The Plan says that advanced imaging services require a separate copayment.

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 $300 copayment for advanced imaging services and a 20% coinsurance for Part B drugs.

You have been asked to pay a total of $305.55 in copayment and coinsurance, (a $300 copayment for advanced imaging services and $5.55 in coinsurance for the gadobutrol injection ($5.55 = 20% of $27.75)). The MRI scan of the brain falls within the advanced imaging services benefit category and the gadobutrol injection falls within the Part B drug 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 and coinsurance for the MRI scan of the brain and the gadobutrol injection.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit with a specialist.

You asked the Plan to waive the copayment for the office visit with a specialist. You say that this visit was a follow up to a surgery you had, and you should not be charged for an office visit. The Plan denied your request. The Plan says that for a copayment to be waived for a follow up visit, the visit must take place within 90 days of the date of surgery. This visit was provided greater than 90 days from the surgery, and therefore is subject to a copayment.

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 an office visit with a specialist.

You have been asked to pay a $50 copayment for the office visit with a specialist. An office visit with a specialist falls within the physician and practitioner services benefit category. This visit was provided by a specialist and took place more than 90 days from the date of your relevant surgery. 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 with a specialist.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the physical therapy services (97140).

You asked the Plan to waive the copayment for the physical therapy services. You say that you should not be responsible for the copayment. 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 $35 copayment for each Medicare-covered therapy visit.

You have been asked to pay a $35 copayment for the physical therapy services. Physical therapy services fall within the Outpatient rehabilitation 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 the physical therapy services (97140).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for post-stabilization care provided to the enrollee.

You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required.

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 services. Our physician reviewer found all inpatient care provided was not needed on an emergent basis. The enrollee was hemodynamically stable and appropriate for ambulance transport with oxygen and monitoring to a Plan facility. The post stabilization care services were not medically necessary or reasonable. The treating physician did not document (in the physician notes, on a form, or in an order) that the patient was not stable for transfer on any dates of service.

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 pay for post-stabilization care provided to the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe complete echocardiogram (93306), duplex scan (93970), diagnostic nuclear medicine (78582) and CT of the thorax (71260).You asked the Plan to pre-approvethe testing. You say that you would like reconsideration because you require a second opinion for your condition.The Plan denied your request. The Plan says there is no clinical evidence to suggest new testing is required.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 testing. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found when the enrollee is evaluated, it can be determined whether additional diagnostic testing is medically necessary.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 testing have not been met.Therefore, we decided that the Plan does not have to pre-approvethe complete echocardiogram (93306), duplex scan (93970), diagnostic nuclear medicine (78582) and CT of the thorax (71260).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for chemotherapy services provided on April 23, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the OON chemotherapy services. You say that the services were authorized. You say that the claim should be reprocessed and paid per this authorization. The Plan denied your request. The Plan says the services in dispute were not urgent/emergent and were not pre-authorized by the Plan. The Plan says that the services were available 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 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. The authorization you reference was not issued through the Plan. You may contact the provider to inquire about the authorization they issued and what that authorization means. There is no evidence that the Plan pre-approved the services in dispute. Therefore, we decided that the Plan does not have to pay for chemotherapy services provided on April 23, 2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided on July 2, 2020.You asked the Plan to pay forthe ambulance services. You say that you were treated in place by the medics.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 does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on July 2, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services provided on July 2, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on June 10, 2020.
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive order for treatment in place. 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 does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on June 10, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on June 10, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided on June 28, 2020.You asked the Plan to pay forthe ambulance services. You say that you were following the COVID executive order for treatment in place.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 does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on June 28, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services provided on June 28, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an out of network (OON) provider.

You asked the Plan to pay for the OON services. You say that the treatment received was medically necessary. The Plan denied your request. The Plan says the services were not urgent, emergent, or approved in advance.

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 had network providers available to provide 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 medical services provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (G0483 and 80307).

You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted claim form indicates the laboratory specimen was obtained in a laboratory setting; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

We find that CPT code G0483 and 80307 is not supported in the record. Specifically, the claim form indicates that the specimen was collected in a laboratory, but the medical records indicate that the face-to-face service was rendered in an office setting. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services (G0483 and 80307).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular stimulator.

You asked the Plan to pay for the provided services. You say that the records prove medical necessity. The Plan denied your request. The Plan says the reasonableness of the provided durable medical equipment has not been established.

The Plan must follow Medicare rules. Medicare rules say that the patient's medical record must contain sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered.

We looked at the file and Medicare rules. The provided record appears to be taken via phone conversation with the enrollee. There are no medical records that document a physical exam of the enrollee's condition. There are no medical records to show the enrollee's clinical course, or the full extent of functional limitations. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the neuromuscular stimulator.