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

We decided that the Plan does not have to waive the copayments for office visits provided from January 24, 2019 to March 22, 2019. You asked the Plan to waive the copayments for office visits. You say that you disagree with the 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 $25 copayment for services obtained by an out-of-network primary care physician. You had office visits with an out-of-network provider from January 24, 2019 to March 22, 2019 for a total of 3 visits. Therefore, you are responsible to pay a $25 copayment per each visit. The total amount you owe is: $75. You have been asked to pay the total copayment amount of $75 for office visits. Office visits fall within the physician/practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for office visits provided from January 24, 2019 to March 22, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on January 16, 2020. You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says that since transport was refused this is not covered. 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 January 16, 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 January 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible charges for the services you received on December 10, 2019. You asked the Plan to waive the deductible. The Plan denied your request. The Plan says you are responsible for the cost share. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $1,000 deductible for covered medical services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,000 deductible for covered medical services. This cost sharing is a contractual obligation that had not been met at the time the services were received on December 10, 2019. Therefore, we decided that the Plan does not have to waive the deductible charges for the services you received on December 10, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where the enrollee is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intravenous immune globulin (IVIG)(J1569). You asked the Plan to pre-approve IVIG. You say that the medication is 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. 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 IVIG. Our reviewer says that the medication is not medically necessary. Our physician reviewer found compendia does not support the use of IVIG for this condition. At this time, the treatment is considered experimental and not 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 IVIG have not been met. Therefore, we decided that the Plan does not have to pre-approve intravenous immune globulin (IVIG)(J1569).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids (V5257, V5267, 99199) provided on August 19, 2019. You asked the Plan to pay for the hearing aids. You say that the hearing aid and related services should be covered. The Plan denied your request. The Plan says the $1,000 allowance has already been exhausted. Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only in the form of a $1,000 allowance every 3 years. We looked at the file, and the Plan's rules. The $1,000 allowance for the hearing aids was already paid. The remaining $198.00 is the member's responsibility after the allowance was exhausted. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids (V5257, V5267, 99199) provided on August 19, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for bus transportation to and from your office. You asked the Plan to provide coverage for the bus transportation. The Plan denied your request. The Plan says bus transportation is not a non-covered service. The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when they meet certain origin and destination requirements. A doctor's office is not a covered destination. The services you have asked the Plan to provide coverage for are ambulance/bus transport services to a doctor's office. Therefore, we decided that the Plan does not have to provide coverage for bus transportation to and from your office.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit on December 16, 2019. You asked the Plan to waive the copayment for the emergency room visit. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received emergency room services on the date of service at issue in this appeal. The Plan states 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 $90 copayment for Emergency care. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received emergency room services on December 16, 2019. You have been asked to pay a $90 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 on December 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a home visit provided on December 14, 2019. You asked the Plan to pay for the home visit. The Plan denied your request. The Plan says there is no valid referral for this service. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for a home visit provided on December 14, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered from October 2, 2019 to October 23, 2019. You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claims were not billed correctly. The Plan must follow Medicare rules. The rules say that a treatment authorization code and type of bill are required for home health claims. We looked at the file and Medicare rules. The file shows that the home health claims were not billed with a valid treatment authorization code or correct type of bill. Based on this information, we decided that Medicare rules for coverage of these services have not been met. The Plan confirmed that they will reprocess this claim for payment when a corrected claim is received from the provider. Therefore, we decided that the Plan does not have to pay for the home health services rendered from October 2, 2019 to October 23, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical assistant services on a laparoscopy provided by an RNFA on October 24, 2019. You asked the Plan to pay for surgical assistant services. You say that this should be covered because the facility is in-network. The Plan denied your request. The Plan says surgical assistant services are not covered from this type of provider. The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS. In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for surgical assistant services on a laparoscopy provided by an RNFA on October 24, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the wheelchair van transports provided from December 13, 2019 to January 3, 2020. You asked the Plan to pay for the wheelchair van transports. You say that since you do not have a vehicle that can accommodate your wheelchair safely, you had to use the van transport. The Plan denied your request. The Plan says that this is not covered by Medicare. The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport services. The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided that the Plan does not have to pay for the wheelchair van transports provided from December 13, 2019 to January 3, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve the crown -porcelain fused to high noble metal (D2750) for tooth 15. You asked the Plan to pre-approve the dental service. You say that please reconsider for benefits. Tooth #15 does show significant breakdown due to decay. The Plan denied your request. The Plan says that placing a crown on tooth 15 is not reasonable or necessary and does not meet the coverage criteria. 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. The Plan covers the dental service when the services are medically necessary and reasonable. 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 dental service. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found removal of caries and the old restoration in tooth #15 would result in a significant compromise of the coronal structure of tooth #15. Restoration with a crown is reasonable and necessary to restore tooth #15 to adequate masticatory function. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental service have been met. Therefore, we decided that the Plan has to pre-approve the crown - porcelain fused to high noble metal (D2750) for tooth 15. 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 medical services provided on November 22, 2019 by an out of network (OON) provider. You asked the Plan to pay for these services. You say that this provider specializes in the care you needed. The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without prior authorization. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The 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 November 22, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound rendered to you on December 4, 2019. You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. 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 $10 copayment for outpatient diagnostic imaging at an in-network specialist's office. Review of the file shows that you received an ultrasound on December 4, 2019. You have been asked to pay a $10 copayment for these services. These services fall within the outpatient diagnostic imaging at an in-network specialist's office 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 ultrasound rendered to you on December 4, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-ray rendered on May 17, 2019. You asked the Plan to waive the copayment for these services. You say that the Plan's two radiology facilities were unable to x-ray your back for weeks. 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 $50 copayment for each x-ray in the outpatient department of a network hospital or facility. Review of the file shows that you received an x-ray in an outpatient hospital facility on May 17, 2019. You have been asked to pay a $50 copayment for these services. These services fall within the x-ray in the outpatient department of a network hospital or facility 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 x-ray rendered on May 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the specialist services rendered on December 16, 2019 and December 23, 2019. You asked the Plan to waive the copayments for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the copayments were 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 $45 copayment for in-network specialist's office services. Review of the file shows that you received specialist services on December 16, 2019 and December 23, 2019. You have been asked to pay a $45 copayment per visit for these services, for a total of $90. These services fall within the in-network specialist's office 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 the specialist services rendered on December 16, 2019 and December 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the LifeVest, automatic external defibrillator (K0606) provided on November 25, 2019 by an out of network (OON) provider. You asked the Plan to pay for the LifeVest. You say that please review the appeal and allow payment for services rendered based on medical necessity. The Plan denied your request. The Plan says enrollee's must get durable medical equipment through the plan's approved suppliers. Providers must get prior-authorization prior to the enrollee receiving DME items. 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 LifeVest, automatic external defibrillator (K0606) provided on November 25, 2019 by an out of network (OON) provider.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pay for the abdominal ultrasound rendered on October 21, 2019. You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says that the claim was billed with an invalid NDC code. 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 procedure code 76705 (abdominal ultrasound) was billed with an invalid NDC code; however, these services are not drug services and do not require an NDC code. The Plan has not provided any documentation or Medicare rules to support that the claim is not payable as billed. Therefore, we decided that the Plan has to pay for the abdominal ultrasound rendered on October 21, 2019. If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on December 16, 2019. You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not separately payable. The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component (TC) indicator of 1 identifies codes with a professional and technical component. We looked at the file and Medicare rules. Procedure codes 95938, 95870, and 95937 have a PC/TC indicator of 1. The claims were billed with a place of service code for an inpatient hospital. The PC and TC were not performed in a different payment locality and therefore cannot be separately paid. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the testing services rendered on December 16, 2019.