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

We decided that the Plan does not have to pay for the services rendered to the enrollee on August 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 95861 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 95861 is needle electromyography; 2 extremities with or without related paraspinal areas. We find that CPT code 95861 is not supported in the medical record. Specifically, there is no documentation that needle electromyography of two extremities was performed. 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 services rendered to the enrollee on August 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM) and supplies.
You asked the Plan to pre-approve a Dexcom G6 CGM and supplies. You say that you were told you needed to change to a Dexcom G6 because it is more accurate. The Plan denied your request. The Plan says that there is not indication that your current unit is malfunctioning.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that you have a Dexcom G5 CGM. A Dexcom G5 CGM serves the same purpose as a Dexcom G6 CGM. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM) and supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on June 27, 2019.
You asked the Plan to waive the copayment for an office visit. You say that you have never been charged in the past and 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 $15 copayment for primary care provider visits. You have been asked to pay a $15 copayment for an office visit. An office visit falls 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 copayment for an office visit provided on June 27, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for arthroplasty provided from June 24, 2019 to June 25, 2019.
You asked the Plan to waive the coinsurance for arthroplasty. You say that you should be charged inpatient charges instead of outpatient. 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 30% coinsurance for surgery services provided in an outpatient hospital. You received arthroplasty from June 24, 2019 to June 25, 2019. Arthroplasty is considered an outpatient surgical procedure. Therefore, you are responsible to pay your share of the outpatient cost-sharing charges. The total allowed amount is $12,439.24 and 30% of that is $3,731.77. You have been asked to pay the total coinsurance amount of $3,731.77 for arthroplasty. Arthroplasty falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for arthroplasty provided from June 24, 2019 to June 25, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional mileage.
You asked the Plan to pre-approve the additional mileage. You say that this is medically necessary. The Plan denied your request. The Plan says the benefit only allows for 50 miles one-way.
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 routine transportation when the trip does not exceed 50 miles one-way.. We looked at your request, the records in the case file, and the rules. Rides that are over 50 miles one-way cannot be covered. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve additional mileage.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on September 19, 2019.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the laboratory services. 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 laboratory services provided on September 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefoot orthotics.You asked the Plan to pre-approvefoot orthotics. You say that you have severe pain.The Plan denied your request. The Plan says this item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pre-approvefoot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 4, 2019 by an out of network (OON) provider.You asked the Plan to pay for the nursing facility care. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says prior authorization is required and was not obtained by the provider or facility.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 nota 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 4, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term custodial care for the enrollee.You asked the Plan to pre-approvethese services. You say that the services are needed until a discharge plan is in place.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. The rules say that custodial care is not covered.We looked at the file and Medicare rules. The requested services are long term custodial care. Custodial care is not covered by Medicare.Therefore, we decided that the Plan does not have to pre-approvelong term custodial care for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forperiodic oral evaluation -established patient (D0120), bitewings -four radiographic images (D0274) and prophylaxis -adult (D1110)provided on December 7, 2019.You asked the Plan to pay forthe dental services. You say that the dentist checked your insurance plan and said that you had complete coverage and would not be charged or responsible for a copay.The Plandenied your request. The Plan says they called the provider and they do not tell their patients something is going to be covered.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. The services are not listed in your EOC as a covered benefit; therefore, the services are not covered.Therefore, we decided that the Plan does not have to pay forperiodic oral evaluation -established patient (D0120), bitewings -four radiographic images (D0274) and prophylaxis -adult (D1110) provided on December 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on September 6, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe out-of-network services. You say that you were referred to the doctor for services.The Plan denied your request. The Plan says you must receive your care from a network provider, and you do not meet the criteria for continuity of care.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. There is no record of a referral from your primary care physician. We found no exception that would require the Plan to pay for these out-of-network services. Therefore, we decided that the Plan does not have to pay forthe medical services provided on September 6, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on March 29, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe out of network medical services. You say that the medical records provided support the medical necessity of the services in dispute.The Plan denied your request. The Plan says the Hospital is out of network with and prior authorization was not obtained for the services in dispute.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 forthe medical services provided on March 29, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pay fortetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) vaccines received on November 1, 2019.You asked the Planto pay forthe vaccines. You say that this should be paid for.The Plandenied your request. The Plansaysthe vaccinations could be covered under the Part D benefits.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccines. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the vaccines.Therefore, we decided that the Plandoes not haveto pay fortetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) vaccines received on November 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on September 23, 2019 by an out of network (OON) provider.You asked the Plan to pay foroffice services. You say that you are appealing.The Plan denied your request. The Plan says the denial of payment for these services 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 forthe medical services provided on September 23, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forMagnetic Resonance Imaging (MRI) of the cervical spine (72141) provided on April 22, 2019. You asked the Plan to waive the coinsurance forthe MRI. You say that the cost sharing should be waived.The Plan denied your request. The Plan says the correct coinsurance 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 20% coinsurance for Outpatient diagnostic tests. You have been asked to pay a 20% coinsurance for the MRI. The MRI falls within the Outpatient diagnostic tests benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the coinsurance forMagnetic Resonance Imaging (MRI) of the cervical spine (72141) provided on April 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pay fortetanus, diphtheria toxoids and acellular pertussis vaccine received on October 23, 2019.You asked the Planto pay forthe vaccines. You say that this should be paid for.The Plandenied your request. The Plansaysthe vaccination could be covered under the Part D benefits.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccines. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the vaccines.Therefore, we decided that the Plandoes not haveto pay fortetanus, diphtheria toxoids and acellular pertussis vaccine received on October 23, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan hasto pay forthe acute inpatient hospital care provided from March 13, 2019 through March 16, 2019.You asked the Plan to pay foracute inpatient hospital care. You say that the stay was medically necessary.The Plan denied your request. The Plansays that the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusualcases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan wascorrect in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the recordshowed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met.Therefore, we decided that the Plan has to pay forthe acute inpatient hospital care provided from March 13, 2019 through March 16, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forwound debridementprovided on August 20, 2019 and August 27, 2019.You asked the Plan to waive the copayment forwound debridement. You say that the provider is an in-network hospital. You say that the claim should be paid in full.The Plan denied your request. The Plan says the copayments 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 $350 copayment for Medicare-covered outpatient surgery at an in-network outpatient hospital.You have been asked to pay a total of $617.32 for wound debridement. Date of ServiceServiceAllowed AmountStandard CopaymentMember LiabilityAugust 20, 2019Debridement$308.66$350$308.66August 27, 2019Debridement$308.66$350$308.66TOTAL:$617.32Wound debridement falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 forwound debridement provided on August 20, 2019 and August 27, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forresin-based composite -one surface, anterior (D2330) provided on October 28, 2019.You asked the Plan to pay forthe dental services. You say that you are appealing for reconsideration of the denied charges.The Plandenied 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. The plan only has routine dental benefits coverage.Therefore, we decided that the Plan does not have to pay forresin-based composite -one surface, anterior (D2330) provided on October 28, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay forlab services provided to the enrollee on October 8, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysneither the lab nor the ordering physician are network providers.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 providerin 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 thePlan to pay for these items/services.Therefore, we decided that the Plandoes not haveto pay forlab services provided to the enrollee on October 8, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay fordrug testing services provided to the enrollee on April 4, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthe records do not support the service billed.The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be covered. The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were to be performed. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pay fordrug testing services provided to the enrollee on April 4, 2019.