Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the CT scan provided on June 22, 2020.
You asked the Plan to pay for the CT scan. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed you, the provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the CT scan until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the CT scan provided on June 22, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to provide further reimbursement for outpatient mental health services provided from April 20, 2020, to May 28, 2020.
You asked the Plan to provide further reimbursement. You say that you believe you are owed further reimbursement for these services. The Plan denied your request. The Plan says you were issued a check on August 27, 2020 for $202.35. The Plan states you were entitled to an additional $277.65. The enrollee's Evidence of Coverage for 2020 clearly states, outpatient mental health services provided by a mental health professional other than a psychiatrist has a $40 copayment for services received in-network. The Plan states you are to be reimbursed the full billed amount minus the applicable cost-share ($600-$120 = $480). The cost-share of $480 minus what he has already been reimbursed, $202.35, equals $277.65. The Plan states you were issued the additional $277.65 on November 9, 2020. The Plan states that the claim referenced that you should be reimbursed in full or without copayment was an error. The Plan states that now that this mistake has been caught, the Plan cannot continue to process payment erroneously and must stay compliant with CMS guidelines as well as the guidelines set forth by the enrollee's plan benefit coverage.
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 outpatient mental health visit. 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 provide further reimbursement for outpatient mental health services provided from April 20, 2020, to May 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive periodontal exam (D0180) provided on July 9, 2020.
You asked the Plan to pay for comprehensive periodontal exam. You say that the service should be covered.
The Plan denied your request. The Plan says the service is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Specifically, the service is not listed as covered benefit in the Plan's
2020 EOC. Therefore, we decided that the Plan does not have to pay for comprehensive periodontal exam
(D0180) provided on July 9, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan of the thorax (71250) performed on June 10, 2020.
You asked the Plan to waive the copayment for a CT scan of the thorax. You say that you should not be responsible for more than a $35 copayment. The Plan denied your request. The Plan says the correct copayment was 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 $180 copayment for advanced imaging services. You have been asked to pay a $159.34 copayment for a CT scan of the thorax. A CT scan of the thorax falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay less than or equal to 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 CT scan of the thorax (71250) performed on June 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the sales tax for durable medical equipment rendered on June 29, 2020.
You asked the Plan to reimburse you for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that Medicare does not make any additional payment for sales taxes. We looked at the file and Medicare rules. You are requesting reimbursement for sales tax. These services are not covered by Medicare. Therefore, we decided that the Plan does not have to reimburse you for the sales tax for durable medical equipment rendered on June 29, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on March 12, 2020.
You asked the Plan to pay for the ambulance services. You say that you were following the COVID 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 March 12, 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 March 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments charged for chiropractic services provided from January 15, 2020, to August 5, 2020.
You asked the Plan to waive these copayments. You say that you do not believe these copayments are correct. The Plan denied your request. The Plan says these copayments were charged based on the service provided and the Plan contract agreement.
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 copayment for each chiropractic visit. 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 copayments charged for chiropractic services provided from January 15, 2020, to August 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on July 30, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the office visit. 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.
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 the office visit provided on July 30, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy with dental code D3320 provided on
August 5, 2020.
You asked the Plan to pay for dental code D3320. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says the services are not 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, endodontic therapy with dental code
D3320 is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay
for the endodontic therapy with dental code D3320 provided on August 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health treatment.
You asked the Plan to pre-approve inpatient mental health treatment. You say that the services are necessary.
The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage
criteria has not been met.
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 inpatient mental health treatment. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found based upon review of the records provided, this enrollee does not meet the
criteria for continued acute inpatient mental health treatment for the dates in question of December 28, 2020
forward. This enrollee was not shown to be a danger to herself or others. She was not showing any auditory or
visual hallucinations and was cooperative/compliant with treatment.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of inpatient mental health treatment have not been met. Therefore, we decided that
the Plan does not have to pre-approve inpatient mental health treatment.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the respiratory infectious agent detection services coded 87633 provided on July 10, 2020.
You asked the Plan to pay for the respiratory infectious agent detection services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are non-covered.
The Plan must follow Medicare rules. Medicare rules say that code 87633 is non-covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the respiratory infectious agent detection services have not been met. Therefore, we decided that the Plan does not have to pay for the respiratory infectious agent detection services coded 87633 provided on July 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on July 1, 2020 by an OON provider.
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that your Summary of Benefits 2020 states that for OON preventive routine dental services, there is a $0 copay for exams, cleanings, x-rays, and fluoride. You also say that if the service is only covered at 100% of the allowed amount, it should be stated that way in the Summary of Benefits 2020. The Plan denied your request. The Plan says this claim processed correctly.
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, you are responsible for the difference between the billed amount and allowed amount. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on July 1, 2020 by an OON provider.
Your complaint about being misled by the Plan's Summary of Benefits 2020 is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the portable oxygen concentrator provided on July 26, 2020
by an out of network provider.
You asked the Plan to pay for the portable oxygen concentrator. You say that you did not know the provider
was not in-network. The Plan denied your request. The Plan says you did not request prior authorization for the
out-of-network provider.
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 the portable oxygen concentrator provided on July
26, 2020 by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cardiology services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve OON services. You say that you would feel more comfortable seeing the requested provider. The Plan denied your request. The Plan says there are in-network cardiologists who are 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 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve cardiology services to be provided by an out of network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for practitioner services provided to the enrollee on June 9,
2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says due to the enrollee's hospice election at the time of service, this claim should be
submitted to Original Medicare.
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
practitioner services provided to the enrollee on June 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 16, 2020 by an out of
network (OON) provider.
You asked the Plan to pay for physician visit. You say that during this date of service there was a widespread
coronavirus outbreak within the facility, and this visit was completed out of medical necessity. The Plan denied
your request. The Plan says the denial of payment for this service is correct, because this provider is out-ofnetwork
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 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 the medical services provided on June 16, 2020 by
an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 21, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the home visit (99349). You say that you would like reconsideration because authorization should not be required. The Plan denied your request. The Plan says these 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 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 the medical services provided on July 21, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided from July 2, 2020 to July 4, 2020.
You asked the Plan to waive the copayment for the inpatient hospital 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 inpatient hospital care on the dates 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 $295 copayment per day for days 1-5 for Inpatient hospital care. We looked at the file, the Pan's contract and Medicare rules. The file shows that you received inpatient hospital services from July 2, 2020 to July 4, 2020. You have been asked to pay a $295 copayment per day for days 1-2 for the inpatient hospital services, totaling $590. The inpatient hospital services fall 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 for the inpatient hospital services provided from July 2, 2020 to July 4, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve cryoablation for the enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that that the clinical value and effectiveness of cryoablation in the setting of lytic bone lesions from myeloma have not been demonstrated in the peer-reviewed literature.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 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 these services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. For patients who have persistent or recurrent pain attributed to one or a few skeletal sites after palliative radiation therapy, are not amenable to radiation therapy, or refuse radiation therapy, cryoablation is an important therapeutic option. Prospective, single-arm, multicenter trials have shown cryoablation to be safe and highly effective for treatment of symptomatic skeletal metastases. Our physician reviewer found that the enrollee's condition meets Medicare criteria for these services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-approve cryoablation for the enrollee.
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.