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

We decided that the Plan does not have to pay for the medical services provided on April 15, 2019 by out of network provider.
You asked the Plan to pay for physician visit. You say that you were assigned this enrollee at the time of admission to the nursing facility, and were not aware of the enrollee's insurance. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and prior 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 April 15, 2019 by out of network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve aquatic therapy.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the documentation does not contain sufficient medical records that the requested aquatic therapy is effective therapy for your condition. There are no records that support that the unique skills of a professional therapist are required to safely and effectively provide treatment, or that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The services are not reasonable or medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve aquatic therapy.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 11, 2019 by out of network provider.
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 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 referring provider 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 September 11, 2019 by out of network provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on May 6, 2019.
You asked the Plan to waive the copayment for the emergency room visit. You say that you should not be responsible for the copayment because you would not have gone to the emergency room had it not been for someone else's negligence. 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 $100 copayment for emergency room services. You have been asked to pay a $100 copayment for the emergency room visit. The emergency room visit falls within the "Emergency services" benefit category. The record shows you received services in the emergency room.
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 provided on May 6, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services rendered to the enrollee from February 6, 2019 to March 4, 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 covered.
The Plan must follow Medicare rules. The rules say that payment will be made to Federal hospitals that furnish emergency services, on an inpatient basis, to individuals entitled to hospital benefits. The rules say that plans can require enrollees to get care from network providers. We looked at the file and Medicare rules. The file shows that the enrollee presented to a federal hospital as a transfer from a previous facility. The enrollee could have been transferred to a Plan facility. 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 inpatient hospital services rendered to the enrollee from February 6, 2019 to March 4, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 7, 2019 by out of
network provider.
You asked the Plan to pay for outpatient lab work. You say that you do not have any control over what
laboratory office sends the specimen. The Plan denied your request. The Plan says there was no
prior authorization obtained for these services. The Plan says that the referring provider is also out-of-
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 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 August 7, 2019
by out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), intraoral x-ray, initial
(D0220), intraoral x-ray, additional (D0230), bitewings (D0274), and prophylaxis (D1110) provided from
August 29, 2019 to September 18, 2019.
You asked the Plan to pay for the dental services. You say that you went for a dental cleaning and the services
would be covered. You also say that you received a bill after you received the services. The Plan denied your
request. The Plan says the bitewings are not listed as a covered service. The Plan says the intraoral x-rays are
not listed as covered service. The Plan says the limited oral evaluation is not listed as a covered service. The
Plan says that services must be provided by an in-network provider in order to be covered by the Plan. The Plan
also says that the dentist is not an in-network provider.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage and prophylaxis is listed as a covered
service, it is not covered when you receive this service from an out of network provider. Additionally, the
limited oral evaluation, intraoral x-rays, and bitewings are not among those covered under this benefit.
Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), intraoral xray,
initial (D0220), intraoral x-ray, additional (D0230), bitewings (D0274), and prophylaxis (D1110) provided
from August 29, 2019 to September 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for testing services provided to the enrollee on March 4, 2019 and billed under code G0249.
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 Medicare billing criteria are not met. The Plan says that Medicare Local Coverage Article A5574 states that a unit of service is four tests. One unit of G0249 is therefore four tests which have been completed and reported to the provider over a period of four weeks or greater. The billing date of service is either on or after the completion and reporting of the fourth test. The member received G0249 code February 18, 2019 this is less than the 25 days frequency allowed therefore the claim for services on March 4, 2019 is not eligible for payment. The Plan states the claim was billed more than the frequency allowance.
The Plan must follow Medicare rules. Medicare has specific frequency limitations on the billing of G0249. Based on the record provided, the claim submitted does not meet the required criteria. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for testing services provided to the enrollee on March 4, 2019 and billed under code G0249.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 9, 2019 by out of network provider.
You asked the Plan to pay for these services. You say that you were advised you would have no copayment. 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. The Plan cannot be held responsible for possible misinformation given by an out-of-network provider regarding your coverage. Therefore, we decided that the Plan does not have to pay for the medical services provided on September 9, 2019 by out of network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services provided on March 1, 2019.
You asked the Plan to waive the copayment for the ambulance services. You say that the doctor told you there would be no charge. The Plan denied your request. The Plan says you were charged this cost sharing 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 $275 copayment for each ambulance day of service. You had one ambulance day of service. The Plan charged you $275 for these services. 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 ambulance services provided on March 1, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy and biopsy provided on August 1, 2019.
You asked the Plan to waive the copayment for the colonoscopy and biopsy. You say that you were told by the facility that the service was preventive and there would be no charge. 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 $100 copayment for each Medicare-covered outpatient hospital services. You have been asked to pay a $100 copayment for the colonoscopy and biopsy. The colonoscopy and biopsy fall within the "Outpatient hospital services" benefit category. The record shows that a biopsy is considered a surgical procedure.
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 and biopsy provided on August 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to you on April 18, 2019 to April 22, 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 covered when performed by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. The file shows that the provider submitted claims for procedure codes 97110 (therapeutic exercises) and 99214 (office visit).
The file shows that the provider also submitted a claim for procedure code 98941 (chiropractic manipulation of the spine). This is a Medicare-covered chiropractic service. You have been asked to pay a 35% coinsurance for these services. These services fall within the out-of-network Medicare-covered chiropractic visit benefit category. This means that you have been asked to pay the correct amount based on the contract with the Plan.
Therefore, we decided that the Plan does not have to pay for the services rendered to you on April 18, 2019 to April 22, 2019.
Appeal type: Surgery
Decision: Partially Favorable

We decided that the Plan has to reduce the coinsurance for the neurostimulator implantation provided and waive the remaining charge. We decided that the Plan does not have to waive the coinsurance for the neurostimulator implantation provided.
You asked the Plan to waive the coinsurance for the neurostimulator implantation. You say that you cannot afford the whole cost. You say that the Plan should pay the whole thing. The Plan says that the coinsurance applied correctly.
We decided that the Plan has to reduce the cost-share for the neurostimulator implantation provided and waive the remaining charge.
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 in-network specialist visit for Medicare-covered benefits. The explanation of benefits supports that the doctor in-network. Therefore, we decided that the Plan has to reduce the coinsurance for the neurostimulator implantation provided from $85.25 to $35.
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. There was no documentation submitted to support what the $169.39 charge is for. This means that the Plan has not shown the amount you are being asked to pay is correct or justified by the Plan contract. Therefore, we decided that the Plan has to waive the remaining charge.
We also decided that the Plan does not have to waive the coinsurance for the neurostimulator implantation provided.
Your contract with the Plan clearly says that you must pay 30% of the cost for each Medicare-covered out-of-network ambulatory surgical center visit. You have been asked to pay $580.11, which is less than the standard 30% coinsurance for the neurostimulator implantation. Therefore, we decided that the Plan does not have to waive the coinsurance for the neurostimulator implantation provided.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (code D0140)
provided on September 10, 2019.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that the dentist asked you
to come back so they could look at it. You also say that you were there no longer than one minute. The Plan
denied your request. The Plan says this procedure is covered once every 6 months. The Plan also says that you
have exceeded the benefit limitation for this 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, you are limited to 1 oral exam every 6
months. The record shows that you received a comprehensive oral evaluation on September 5, 2019 and your
oral exam benefit was then exhausted for the 6 month time period. Therefore, we decided that the Plan does not
have to pay for the problem focused limited oral evaluation (code D0140) provided on September 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
You asked the Plan to pre-approve the compression stockings. You say that the stockings are needed to avoid ulcers and hospitalization The Plan denied your request. The Plan says gradient compression stockings A6530 are non-covered.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are non-covered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued use of the Trilogy 100 home ventilator.
You asked the Plan to pre-approve continued use of the home ventilator (E0466). You say that the enrollee needs to continue to use the Trilogy 100 home ventilator. The Plan denied your request. The Plan says there is not enough information to establish medical necessity.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. We looked at the file, and Medicare rules. There is no statement from the treating physician declaring the enrollee is compliant and benefiting from use. Based on this information, we decided that Medicare rules for coverage of continued use of the home ventilator (E0466) have not been met. Therefore, we decided that the Plan does not have to pre-approve continued use of the Trilogy 100 home ventilator.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's assistant surgery services provided on August 23, 2019.
You asked the Plan to pay for the physician's assistant surgery services. The Plan denied your request. The Plan says the service was rendered by a provider who is not under contract with the Plan and there was not an approved authorization for these services.
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 physician's assistant surgery services provided on August 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve presbyopia correcting lens (V2787).
You asked the Plan to pre-approve the corrective lens. You say that you had cataract surgery and gets sinus infections. The corrective glasses put too much pressure on your face. The Plan denied your request. The Plan says this item is not a Medicare covered benefit.
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a conventional IOL. While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatism-correcting feature of an IOL. Therefore, we decided that the Plan does not have to pre-approve presbyopia correcting lens (V2787).