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

We decided that the Plan has to waive the copayment for the office visit provided on December 6, 2019.
You asked the Plan to waive the copayment for the office visit. You say that you went for a preventive checkup
and should not be billed for an office visit. The Plan denied your request. The Plan says that you have been
charged the correct cost sharing amount.
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 were no medical records or claim form with the diagnosis code submitted
to support that services in addition to an annual wellness visit were performed. Therefore, we decided that the
Plan has to waive the copayment for the office visit provided on December 6, 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued home health services.
You asked the Plan to pre-approve the continued home health care. You say that you feel that this service should continue as it benefits you. The Plan denied your request. The Plan says you no longer meet the homebound criteria and your treating providers do not believe you require continued care in the home health setting.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 continued home health care. Our reviewer says that the documentation does not support that home health services are medically reasonable and necessary at this time. Our physician reviewer found the medical records do not support that home health skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the patient's condition, or to establish/perform a maintenance program to maintain the patient's condition and/or prevent deterioration. The documentation does not reveal complex wound care, IV antibiotics, or other skilled nursing need. The patient does not appear homebound as the 5/13/20 documentation indicated he was walking to the bank and out doing laundry. For these reasons, the request for continued home health visits is 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 the continued home health care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued home health services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care services provided on
January 14, 2020 by an out of network (OON) provider.
You asked the Plan to pay for these OON services. 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 subsequent nursing facility care services
provided on January 14, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the thoracentesis with image guidance rendered on November 19, 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 procedure code 32555 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 32555 is thoracentesis, needle or catheter, aspiration of the pleural space; with imaging guidance. We find that CPT code 32555 is not supported in the medical record. Specifically, the documentation does not indicate that imaging guidance was used for the thoracentesis. 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 thoracentesis with image guidance rendered on November 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the medical eye exam provided on January 16, 2020.You asked the Plan to waive the copayment for the medical eye exam. You say that you went to the eye doctor for a preventive glaucoma screening which should be 100% covered. 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 $35 copayment for Medicare-covered eye exams to diagnose and treat diseases and conditions of the eye. You have been asked to pay a $35 copayment for the medical eye exam. The medical eye exam falls within the "Vision Care" benefit category. The record shows you had a burning sensation, redness, and discharge in your eyes and were prescribed a medication which makes the eye exam medical in nature.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 forthe medical eye exam provided on January 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Continuous Glucose Monitor (CGM). You asked the Plan to pre-approve the CGM. You say that the CGM is medically necessary.The Plan denied your request. The Plan says coverage criteria is not met.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor.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 CGM. Our reviewer says that rules for coverage were not met. Our physician reviewer found insufficient medical records were provided to establish that the CGM was medically necessary. There is no notation of treatment regimen.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 CGM have not been met.Therefore, we decided that the Plan does not have topre-approve  a Continuous Glucose Monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on January
15, 2020.
You asked the Plan to pay for the knee orthosis (L1833) and suspension sleeve (L2397). You say that the Plan
should pay this claim. The Plan denied your request. The Plan says the documentation submitted did not
indicate the provider discussed the need for the billed supply codes, therefore the billed supply codes cannot be
verified.
The Plan must follow Medicare rules. Medicare rules say that there must be information in the patient's
medical record that supports the medical necessity for the item.
We looked at the file and Medicare rules. The medical records do not mention or support medical necessity for
the orthoses. Based on this information, we decided that Medicare rules for coverage of the knee orthosis
(L1833) and suspension sleeve (L2397) have not been met. Therefore, we decided that the Plan does not have
to pay for the knee orthosis and suspension sleeve provided on January 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the special fixed partial denture sectioning (D9120) provided from January 14, 2020 through January 30, 2020 by an out-of-network provider.
You asked the Plan to pay for the dental services. You say that there are no in-network providers that could perform the services. The Plan denied your request. The Plan says the service is not a covered benefit under the plan.
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. This service is not listed in your EOC as a covered benefit; therefore, it is not covered. Therefore, we decided that the Plan does not have to pay for the special fixed partial denture sectioning (D9120) provided from January 14, 2020 through January 30, 2020 by an out-of-network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips (A0100).
You asked the Plan to pre-approve additional routine transportation trips. You say that the requested additional
transportation trips are necessary since you have no other way to get to your appointments. The Plan denied
your request. The Plan says the requested additional transportation trips exceed the benefit limit. Therefore,
coverage criteria has not been met.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers a maximum of 24 one-way transportation trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we
decided that the Plan does not have to pre-approve additional routine transportation trips (A0100).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for SNF care from August 26, 2019 through September 19, 2019.
You asked the Plan to waive the copayment for SNF care. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that the Plan received a claim for skilled nursing services for dates September 1, 2019 through September 19, 2019 (covering 18 days). The Plan processed the claim, covering 14 additional days at 100% per your plan benefit ($0 copay per day for days 1-20). The remainder of 4 days billed on the claim processed, applying your copay responsibility per plan benefits. You are asked to pay a $160 copay per day for days 21-100 for SNF care. Your total copay responsibility is $640.00. 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 SNF care from August 26, 2019 through September 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for catheter/supplies provided on January 30, 2020.
You asked the Plan to waive the coinsurance for the supplies. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received catheter/supplies on January 30, 2020. You are asked to pay 20% coinsurance for the supplies. 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 catheter/supplies provided on January 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on November 1, 2019.You asked the Plan to pay for the services. You say that you are appealing because there was no payment on this claim.The Plan denied your request. The Plan says the provider did not submit progress notes that are needed in order to determine the clinical utility of this testing.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 pay for the services. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found per the documentation, attempts to obtain the ordering provider's progress notes were documented by the Resolution specialist on dates 3/10/2020, 3/16/2020, 3/20/2020 and 3/23/2020. The denial is being upheld due to the provider not submitting progress notes that are needed in order to determine the clinical utility of the testing. The rules say that, upon request, the entity that submitted the claim (e.g., the laboratory) must provide documentation of the order for the service billed as well as diagnostic or other medical information that the entity received from the ordering physician. If a laboratory bills for a diagnostic laboratory test and documentation to support the medical necessity of the test is not submitted, the claim is denied. The review has determined that given the documentation provided for review, the enrollee did not meet the criteria for testing provided on November 1, 2019.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay for drug testing services provided to the enrollee on November 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for face mask interface, replacement for full face mask, each (A7031) and filter, disposable, used with positive airway pressure device (A7038) provided to the enrollee on August 26, 2019.
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code A7031 and CPT code A7038 are not supported in the medical record. Specifically, Healthcare Common Procedure Coding System (HCPCS) code A7031 NU KX (3 units) remains not supported. The documentation submitted do not supports the units billed; therefore, the billed service cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information. We have insufficient documentation to corroborate the services so we can confirm Medicare coverage has been met. Healthcare Common Procedure Coding System (HCPCS) code A7038 NU KX (6 units) remains not supported. The documentation submitted do not supports the units billed; therefore, the billed service cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information. We have insufficient documentation to corroborate the services so we can confirm Medicare coverage has been met. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. Therefore, we decided that the Plan does not have to pay for face mask interface, replacement for full face mask, each (A7031) and filter, disposable, used with positive airway pressure device (A7038) provided to the enrollee on August 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on October 2, 2019.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 has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on October 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from December
11, 2019 to December 13, 2019.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you are being billed
more than your contracted amount. 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 $345
copayment each day for days 1-5 for inpatient hospital care.
You had an inpatient hospital stay from December 11, 2019 to December 13, 2019. Therefore, you are
responsible to pay a $345 copayment for days 1-2 (December 11, 2019 to December 12, 2019). $345
(copayment) x 2 (inpatient days) = $690.
You have been asked to pay the total copayment amount of $690 for an inpatient hospital stay. An inpatient
hospital stay falls 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 an inpatient hospital stay from December 11, 2019 to December 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the wound repair provided on January 8,
2020.
You asked the Plan to waive the deductible for the wound repair. You say that you do not think the removal of
stitches should have such a high cost for a simple procedure. 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. Your
contract with the Plan says that there is a $750 deductible that applies towards surgical services.
The wound repair you asked the Plan to waive the deductible for falls within the "Physician/Practitioner
services, including doctor's office visits" benefit category. The Plan has followed Medicare rules by clearly
disclosing in the contract that there is a $750 deductible that applies towards surgical services. The record
shows the wound repair provided at the physician's office is considered a surgical procedure.
This cost sharing is a contractual obligation that had not been met at the time the wound repair was received on
January 8, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the simple
wound repair provided on January 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown and prefabricated post and core in addition to crown.
You asked the Plan to pre-approve the crown and prefabricated post and core. You say that these services are too expensive. You also say that you did not know it would cost so much. The Plan denied your request. The Plan says your plan does not cover these procedures.
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. Therefore, we decided that the Plan does not have to pre-approve a crown and prefabricated post and core in addition to crown.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient pathology testing provided on November 14, 2019
by an out of network (OON) provider.
You asked the Plan to pay for outpatient pathology testing. You say that these services were provided per the
referring physicians request. The Plan denied your request. The Plan says the referring provider is out-of-network.
The Plan says that no prior authorization was 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 outpatient pathology testing provided on
November 14, 2019 by an out of network (OON) provider.