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

We decided that the Plan does not have to waive the copayments for the diagnostic mammogram or the ultrasound provided on October 8, 2019. 
 
You asked the Plan to waive the copayments for the diagnostic mammogram and ultrasound. You say that you should not be responsible for the copayments. 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 $40 copayment for each basic imaging service (e.g., general x-rays or ultrasounds).  
 
You have been asked to pay a $40 copayment for the diagnostic mammogram and a $40 copayment for ultrasound. The diagnostic mammogram and ultrasound fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The medical record shows a mammogram on the right breast was performed due to breast pain. Therefore, the mammogram is considered diagnostic in nature. Also, the ultrasound is considered a separate 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 copayments for the diagnostic mammogram or the ultrasound provided on October 8, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiac rehabilitation services (93798) provided on August 5, 2019 to August 31, 2019
You asked the Plan to pay for cardiac rehabilitation services. You say that these services were medically necessary. The Plan denied your request. The Plan says these 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 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 cardiac rehabilitation services (93798) provided on August 5, 2019 to August 31, 2019
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to assign liability for the excess mileage, for services provided on August 23, 2019, to the enrollee.
You asked the Plan to assign liability for the excess mileage (A0888) claim to the enrollee. You say that the excess mileage claim should be denied as patient liability. The Plan denied your request. The Plan says you have been reimbursed for the trip that would have been to the closest facility.
The Plan must follow Medicare rules. The rules state that providers may bill services with a GY modifier and the liability for the service will be assigned to the enrollee. The definition of A0888 is non-covered ambulance mileage (e.g., for miles traveled beyond closest appropriate facility). You did not submit the claim with the GY modifier. Therefore, we decided that the Plan does not have to assign liability for the excess mileage, for services provided on August 23, 2019, to the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit on August 3, 2019.
You asked the Plan to waive the copayment for an office visit. You say that you disagree with the uncovered 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. Your contract with the Plan says that there is a combined in-network and out-of-network deductible of $490 for out-of-network physician/practitioner services, including doctor's office visits. You had an office visit with an out-of-network provider on August 3, 2019. The record shows that you had only paid $308.31 toward the $490 deductible prior to receiving the services. Therefore, you are responsible to pay the allowed amount of $83.31. The item or service you asked the Plan to waive the copayment for falls within the benefit category physician/practitioner services, including doctor's office visits. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a combined in-network and out-of-network deductible of $490 for out-of-network physician/practitioner services, including doctor's office visits. This cost sharing is a contractual obligation that had not been met at the time an office visit was received on August 3, 2019. Therefore, we decided that the Plan does not have to waive the copayment for an office visit on August 3, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the implantation of a cranial nerve stimulator electrode and pulse generator (64568) and the insertion of a chest wall respiratory sensor electrode (0466T).
You asked the Plan to pre-approve these services. You say that the surgery is medically necessary as you have obstructive sleep apnea. The Plan denied your request. The Plan says Medicare does not cover this treatment. The surgery has been determined to be not reasonable and necessary.
The Plan must follow Medicare rules. The Medicare rules say Cranial Nerve (Hypoglossal) Stimulation for the treatment of Obstructive Sleep is not reasonable and necessary. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Specifically, this service is not covered by Medicare or the health plan. Therefore, we decided that the Plan does not have to pre-approve the implantation of a cranial nerve stimulator electrode and pulse generator (64568) and the insertion of a chest wall respiratory sensor electrode (0466T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397)
provided to the enrollee on October 14, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your
request. The Plan says the documentation does not indicate services are necessary for treatment of the
enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a knee orthosis with
suspension sleeve (L1833, L2397) provided to the enrollee on October 14, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services provided August 1 to August 2, 2019.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that the hospital did not help your condition and you were not given sufficient information about the copayment. The Plan denied your request. The Plan says the correct copayment was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $460 per day copayment for days 1-4 for Inpatient Hospital Care. You have been asked to pay a $460 per day copayment for 1 day of inpatient hospital services. The inpatient hospital services fall within the Inpatient Hospital Care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital services provided August 1 to August 2, 2019.
Appeal type: Outpatient Therapies
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 May 1, 2019, and May 8, 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 for the medical services provided to the enrollee by an out-of-network provider on May 1, 2019, and May 8, 2019.
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pre-approve 4 additional home health skilled nursing visits (G0299).
You asked the Plan to pre-approve 4 additional home health skilled nursing visits. You say that you need this care. The Plan denied your request. The Plan says that additional visits are not medically necessary.
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 4 additional home health skilled nursing visits. Our reviewer says that the requested services are medically necessary. Our physician reviewer found there is no evidence that your wounds have healed or that your endurance has improved to the point that you are no longer homebound. Without proper wound care your condition can be expected to deteriorate. The remaining skilled nursing visits are 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 4 additional home health skilled nursing visits have been met. Therefore, we decided that the Plan has to pre-approve 4 additional home health skilled nursing visits (G0299).
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 forthe comprehensive oral evaluation, prophylaxis, and bitewings provided on September 3, 2019.You asked the Plan to pay forthe comprehensive oral evaluation, prophylaxis, and bitewings. You say that friends and business associates who have the same insurance as you referred you to this provider and said they were covered. You also say that you called prior to your appointment and they confirmed they were in-network.The Plan denied your request. The Plan says these services are denied because this dentist is an out-of-network provider. The Plan also says that services are only covered when they are received from 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, thePlan'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 pay forthe comprehensive oral evaluation, prophylaxis, and bitewings provided on September 3, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pathology services to be provided by an out of network provider.
You asked the Plan to pre-approve pathology services. You say that this is medically necessary. The Plan denied your request. The Plan says these services are available in-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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. Though the Plan offers a POS benefit for out-of-network services, it applies only to office visits. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve pathology services to be provided by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the DME purchased on August 19, 2019 by an out-ofnetwork provider. 
 
You asked the Plan to pay for the DME. You say that you have an oxygen concentrator and the columns appear to need replacement on a yearly basis or so. You state the first set of columns were under warranty, the second were not. The Plan denied your request. The Plan says the DME supplies you purchased on August 1, 2019 were purchased by a non-contracting provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the DME purchased on August 19, 2019 by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for screening mammography with digital breast tomosynthesis provided on
January 31, 2019.
You asked the Plan to pay for the screening mammography with digital breast tomosynthesis. The Plan denied your request. The Plan says the health plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented. There is no network deficiency for these services and alternate network providers were found.
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 and the referring provider are not network providers 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 screening mammography with digital breast tomosynthesis provided on January 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the surgical extractions (D7210) for teeth # 8 and 23.
You asked the Plan to pre-approve the dental services. The Plan denied your request. The Plan says the
documentation does not support that surgical techniques would be necessary for tooth removal.
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
services 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 service is more involved than is necessary. Our reviewer found that the criteria for the surgical
extractions (elevation of flap and bone removal) has not been met.
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 services have not been met. Therefore, we decided that the Plan does
not have to pre-approve the surgical extractions (D7210) for teeth # 8 and 23.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a full electric bed with the function of a 30-degree angle.
You asked the Plan to pre-approve the bed. You say that you are unable to use a hand crank due to severe weakness and chronic pain. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a full electric bed with the function of a 30-degree angle.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for wheelchair ramp and installation on October 4, 2019. 
 
You asked the Plan to pay for the wheelchair ramp and installation. You say that you have been prescribed non-weight bearing status. Your doctor states you will require a ramp during this time period to access your medical appointments. The Plan denied your request. The Plan says Medicare and the Plan does not cover a house wheelchair ramp. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pay for wheelchair ramp and installation on October 4, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the services are 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 IRF admission is covered only when it is medically reasonable and necessary as described above. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found based on available records, the enrollee does not meet criteria for coverage of IRF. The enrollee is currently medically stable and there is no evidence of complex medical issues that require monitoring by an inpatient physician three times per week or acute rehab nursing care. While they may benefit from continuing physical therapy (PT) and occupational therapy (OT), there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for shoulder elbow wrist hand orthosis (L3960) provided to the enrollee on August 2, 2019.
You asked the Plan to pay for the orthosis. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says they were unable to discover any evidence of an established relationship between the member and the ordering physician. The Plan states there were no claims submitted for an evaluation and management service. The Plan states the review of claims history for this member, and a review of the submitted documentation does not contain evidence of a prior Telemedicine or Telehealth service with the ordering physician as required per CMS guidelines.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for shoulder elbow wrist hand orthosis (L3960) provided to the enrollee on August 2, 2019.