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

We decided that the Plan does not have to waive the copayment for laboratory services provided on November 20, 2020.
You asked the Plan to waive the copayment for laboratory services. You say that the lab work was connected to the COVID test so you should not have a copayment. 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 $10 copayment for diagnostic lab services and diagnostic procedures and tests (per day, per facility). You have been asked to pay $7.59, which is less than the standard $10 copayment for laboratory services. Laboratory services falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show this was a throat culture to test for strep throat, which is considered a diagnostic lab test. 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 laboratory services provided on November 20, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve Neulasta Onpro for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your
request. The Plan says that this is not being planned for a compendium or LCD-supported use and is not
considered reasonable and necessary at this time.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and 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 the drug. Our reviewer says that the
requested drug is medically reasonable and necessary. Our physician reviewer found white blood cell (WBC)
growth factors are generally recommended to reduce the risk of neutropenic fever when the anticipated risk of
neutropenic fever for a chemotherapy regimen is approximately 20% or higher. However, to minimize possible
emergency care needs during the COVID-19 pandemic, it may be reasonable to provide prophylactic WBC
growth factors to patients at a lower anticipated neutropenic fever risk (e.g. - 10% or more). The enrollee has
several comorbidities (chronic obstructive pulmonary disease, congestive heart failure, anemia) in addition to
recent COVID. The service is reasonable and 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 drug have been met. Therefore, we decided that the Plan has to pre-approve
Neulasta Onpro 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care (99309) specialty absorptive dressing, wound cover, sterile (A6252) provided by an out of network (OON) provider.

You asked the Plan to pay for the wound care. You say that as an enrolled physician supplier with Medicare you have dispensed surgical dressing for use by the enrollee at home. These dressing supplied are in fact separately reimbursable from the physician services provided. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 subsequent nursing facility care (99309) specialty absorptive dressing, wound cover, sterile (A6252) provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Computed tomography (CT) scan (74178) and contrast drug (Q9967).

You asked the Plan to waive the coinsurance for the CT scan and contrast drug. You say that you would like clarification about what your final cost-sharing amount should be. The Plan denied your request. The Plan says the coinsurance was applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% of the cost of complex diagnostic radiology (such as PET, CT, MRI, MRA, nuclear medicine). The contract also says that you must pay 20% of the cost of Medicare-covered Part B prescription drugs.

You have been asked to pay $562.25 ($2,811.26 allowed amount x 20% coinsurance = $562.25) for the CT scan and $51.75 ($258.76 allowed amount x 20% coinsurance = $51.75) for the contrast drug. The CT scan falls into the Outpatient hospital services benefit category and the contrast drug falls within the Medicare Part B Prescription 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 coinsurance for the Computed tomography (CT) scan (74178) and contrast drug (Q9967).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Duplex scan of extremity veins (93970) provided by an out of network (OON) provider.

You asked the Plan to pay for the Duplex scan. You say that the services should be covered by the Plan because the enrollee came through the Emergency Room. The Plan denied your request. The Plan says the services were provided without prior authorization and do not meet criteria for OON coverage.

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. The documentation provided did not show that services provided were urgent or emergent. 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 Duplex scan of extremity veins (93970) provided by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for ambulance services.

You asked the Plan to waive the copayments for ambulance services. You say that you are on a fixed income and cannot afford these copayments. The Plan denied your request. The Plan says the copayment 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 $220 copayment for each one-way ambulance trip. There were 3 trips, resulting in a total copayment of $660.

You have been asked to pay $220 copayment for each one-way ambulance trip. Ambulance services fall within the Ambulance 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 copayments for ambulance services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation and set-up related to mobile radiology services.

You asked the Plan to pay for the mobile radiology transportation and set-up. You say that these services were ordered from the provider to be rendered at the skilled nursing facility. These charges for transport and set-up should be covered. The Plan denied your request. The Plan says these services cannot be paid when billed with POS code 31 since they are technical component only services.

The Plan must follow Medicare rules. Medicare rules say that providers must use the correct POS code for billing claims. It is also noted that, for Part A-covered SNF residents, payment cannot be made for the technical component of services or for transportation and set-up.

In this case, the claim was billed with POS code 31. This is a facility setting POS which is reported for enrollees in a Part A-covered stay. Transportation and set-up cannot be paid in the facility setting. There is also no evidence that the enrollee was in a Part A stay to support the use of POS 31. POS 32 would be required for noncovered SNF stays and to allow these charges to be paid. Therefore, we decided that the Plan does not have to pay for the transportation and set-up related to mobile radiology services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 powered wheelchair and related accessories.
You asked the Plan to pre-approve a group 3 powered wheelchair and related accessories. You say that this device is medically necessary for your condition. The Plan denied your request. The Plan says the items do not meet Medicare criteria.
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation that is due to: 1. A neurological condition; 2. Myopathy; or 3. Congenital skeletal deformity. 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 group 3 powered wheelchair and related accessories. Our reviewer says that the requested items are not medically reasonable and necessary. Our physician reviewer found the power mobility device is not medically necessary as the documentation does not support that the patient's mobility limitation is due to a neurological condition, myopathy, or congenital skeletal deformity therefore does not meet the Group 3 power mobility device criteria. Furthermore, the patient has confusion on the physician progress notes and it is not clear that the patient would be able to safely use the power mobility device. Given the conflicting information and the lack of support in the documentation for a Group 3 power mobility device this request is not medically necessary. In addition, the request for the related accessories will not be approved if the base wheelchair is denied. 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 group 3 powered wheelchair and related accessories. Therefore, we decided that the Plan does not have to pre-approve a group 3 powered wheelchair and related accessories.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit.

You asked the Plan to waive the copayment for the emergency room visit. You say that you should be forgiven this charge since it has been four years. 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 maximum out-of-pocket copayment of $65 for emergency services in an in-network emergency room.

You have been asked to pay a $65 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency room visit.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Vitamin D 25 hydroxy panel assay.

You asked the Plan to pay for vitamin assay panel testing. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because Medicare considers vitamin assay panels a non-covered screening procedure.

The Plan must follow Medicare rules. Medicare rules say that vitamin assay panels are considered to be non-covered screening procedures.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of vitamin assay panel testing have not been met. Therefore, we decided that the Plan does not have to pay for Vitamin D 25 hydroxy panel assay.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation, first intraoral periapical x-ray, each additional intraoral periapical x-ray, and bitewings provided on May 13, 2020 by an OON provider.
You asked the Plan to pay for the comprehensive oral evaluation, intraoral periapical x-rays, and bitewings. You say that you would like these services to be covered. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that in-network providers were available and accessible to provide this same services.
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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation, first intraoral periapical x-ray, each additional intraoral periapical x-ray, and bitewings provided on May 13, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider on July 21, 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 to the enrollee by an out-of-network provider on July 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids provided to you by an out-of-network provider.

You asked the Plan to pay for the hearing aids. 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 hearing aids provided to you by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endosteal implant for tooth #28.

You asked the Plan to pay for the endosteal implant. You say that you were not advised that implants were only covered for certain teeth prior to receiving your implant. The Plan denied your request. The Plan says your implant does not qualify for benefits because tooth #28 is a posterior (back) tooth.

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, implant services are limited to replacing a single missing anterior (front) tooth. The record shows that you received the endosteal implant for tooth #28, which is a posterior tooth. Therefore, we decided that the Plan does not have to pay for the endosteal implant for tooth #28.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the root canal (D3310) provided on June 22, 2020.
You asked the Plan to pay for the dental service. You say that your appointment had to be rescheduled multiple times due to Covid-19. You say that Covid-19 has impacted your financial status and you had to cancel your dental rider. You also say that you would like this service covered due to the delays caused by Covid-19. The Plan denied your request. The Plan says you were not enrolled in the dental rider on the date of service. The Plan also says that root canal is not listed as a covered service.
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. The record shows that you disenrolled from the dental rider effective April 30, 2020, before you received this service. Therefore, we decided that the Plan does not have to pay for the root canal (D3310) provided on June 22, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs.

You asked the Plan to pay for the self-administered drugs. You say that these medications were given to you at the hospital because you did not have your medications with you. The Plan denied your request. The Plan says self-administered drugs are not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs

Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to waive the cost-sharing for inpatient hospital stays provided from July 31, 2020, to August 27, 2020.
You asked the Plan to waive the cost-sharing for inpatient stays. You say that your maximum out-of-pocket amount had already been met. The Plan denied your request. The Plan says that the copayment amounts you are being charged are correct.
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 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 $250 copayment per day for days 1 to 4 for in-network inpatient care, up to a maximum out-of-pocket amount of $3,300 for 2020. 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 did not provide a summary of the cost-sharing amounts applied to your maximum out-of-pocket amount for 2020. We requested this information, but it was not provided to us. The plan stated that they verified your maximum out-of-pocket amount had not been met when these claims were processed, but the Plan did not provide evidence to support this.
You say that your maximum out-of-pocket amount for 2020 had already been met, so you should not owe these amounts. Without this information, the Plan has not shown that its decision to ask you to pay these copayment amounts it is correct or justified by the Plan contract. Therefore, we decided that the Plan has to waive the cost-sharing for inpatient hospital stays provided from July 31, 2020, to August 27, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the abdomen you had on July 8, 2020.
You asked the Plan to waive the copayment for the CT scan. You say that you don't believe you should have to pay anything for this service. The Plan denied your request. The Plan says you were charged this copayment 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 $100 copayment for CT scans. You have been asked to pay a $100 copayment for the CT scan. This copayment applies regardless of the reason for this test. 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 computed tomography (CT) scan of the abdomen you had on July 8, 2020.