Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1851) and suspension sleeve (L2397) provided to the enrollee on September 9, 2019. You asked the Plan to pay for the orthosis and sleeve. 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 knee orthosis (L1851) and suspension sleeve (L2397) provided to the enrollee on September 9, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost share for the psychotherapy visits provided from May 1, 2019 to December 26, 2019.
You asked the Plan to reduce the cost share for the psychotherapy visits. You say that you would like your visits to be covered at the in-network rate for 2019. 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 $1,000 deductible that applies towards out-of-network psychotherapy visits and 25% coinsurance for each out-of-network Medicare-covered visit. The psychotherapy visits you asked the Plan to reduce the cost share for falls within the "Outpatient mental health care" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,000 deductible that applies towards out-of-network psychotherapy visits and 25% coinsurance for each out-of-network Medicare-covered visit. The record shows the provider is out-of-network.
You have been asked to pay $909.11 for the following claims which applied towards your out-of-network deductible: 191029H05723, 191029H05720, 191029H05719, 191029H05722, 191029H05721, 1029H05724, 191015H04194, 191029H05725, 191015H04195.
You have been asked to pay a total of $93.42 for claim number 191029H05726. This claim applied the remaining deductible amount and coinsurance amount. The allowed amount of the claim was $101.01. Therefore, $90.89 was applied to the deductible and this is where you met the out-of-network deductible amount. The remaining allowed amount was $10.12. ($101.01 - $90.89 = $10.12). You are responsible for 25% of the allowed amount after the deductible is met. ($10.25 x 25% = $2.53). ($90.89 + $2.53 = $93.42).
You have been asked to pay $277.75 for the remaining claims which processed with 25% coinsurance: 191029H05730, 191029H05731, 191029H05732, 191029H05729, 191029H05727, 200129H06344, 200129H06345, 200129H06348, 200129H06346, 200129H06349, 200129H06347. You have been asked to pay $25.25 per claim, which is 25% of the allowed amount. The allowed amount per claim is $101.01. ($101.01 x 25% = $25.25) ($25.25 x 11 claims = $277.75).
This cost sharing is a contractual obligation that had not been met at the time the psychotherapy visits were received from May 1, 2019 to December 26, 2019. Therefore, we decided that the Plan does not have to reduce the cost share for the psychotherapy visits provided from May 1, 2019 to December 26, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the observation stay provided from January 9, 2020 to January 11, 2020.
You asked the Plan to waive the copayment for the observation stay. You say that the emergency room copayment should apply. The Plan denied your request. The Plan says the copayment 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $200 copayment for outpatient hospital observation services. The enrollee has been asked to pay a $200 copayment for the observation stay. The observation stay falls within the "Outpatient hospital observation" benefit category. The records show that the enrollee was admitted to outpatient observation. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the observation stay provided from January 9, 2020 to January 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on September 25, 2019. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the services were not referred by a network provider, or rendered in a participating 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 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 lab services provided to the enrollee on September 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for laboratory services provided on January 6, 2020.
You asked the Plan to waive the deductible for laboratory services. You say that you met your deductible 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. Your contract with the Plan says that there is a $300 deductible for outpatient diagnostic tests and therapeutic services and supplies. You received laboratory services on January 6, 2020. The record shows that you had paid $0 toward the $300 deductible prior to receiving the services. Therefore, you are responsible to pay the allowed amount of $179.28. The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $300 deductible for outpatient diagnostic tests and therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time laboratory services was received on January 6, 2020. Therefore, we decided that the Plan does not have to waive the deductible for laboratory services provided on January 6, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the mental health services provided on July 29, 2019 by an
out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that the facility obtained an authorization for the
services. The Plan denied your request. The Plan says prior authorization from the plan is required for out-of-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 documentation shows the enrollee was seen for continued management. 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 the mental health services provided on July 29, 2019 by an out of network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Genvisc (J7320).
You asked the Plan to pre-approve Genvisc. You say that the requested medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria for a step therapy exception has not been met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Genvisc. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the provided medical records do not indicate that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Genvisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Genvisc (J7320).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two periodontal maintenance services provided on April 19, 2019 and November 6, 2019. You asked the Plan to pay for the periodontal maintenance services. You say that these were preventive services based on your 2019 EOC. The Plan denied your request. The Plan says periodontal maintenance is not included in your dental benefit, nor is it considered a preventative dental 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, the requested items or services are not among those covered under this benefit. The Plan says that periodontal maintenance is not a preventative cleaning because it is considered a deep cleaning, scaling or root planing to remove bacteria, calculus (tartar), and debris that has collected under the gum. Therefore, we are unable to approve your request. Therefore, we decided that the Plan does not have to pay for the two periodontal maintenance services provided on April 19, 2019 and November 6, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (CPT 71046) provided to the enrollee on January 2, 2020. You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says as multiple interpretations were done for the same date of service, the 77 modifier would be required to distinguish a second interpretation by another physician. 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 71046 is "Radiologic examination, chest; 2 views." We asked our coding 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 were not coded correctly. Our coding reviewer found CPT 71046 was paid to one provider. There was no modifier documented to support a second chest x-ray needed to be repeated or second interpretation. We looked at this coder'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 radiology services (CPT 71046) provided to the enrollee on January 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the federally-qualified health center (FQHC) services rendered on June 27, 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 claim was not billed correctly. The Plan must follow Medicare rules. The rules say that FQHCs must use the specific payment code that corresponds to the type of visit that qualifies the encounter for Medicare payment. We looked at the file and Medicare rules. The file shows that the FQHC claim was not billed with the required valid payment code. 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 federally-qualified health center (FQHC) services rendered on June 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve home health services. You say that you cannot find any in-network providers for these services. The Plan denied your request. The Plan says there are in-network providers available 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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 home health services to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the cholecystectomy provided from November 21, 2019 through November 22, 2019.
You asked the Plan to waive the copayment for the cholecystectomy. You say that you heard that you were an inpatient. You say that the hospital should be satisfied with the insurance payment. The Plan denied your request. The Plan says the copayment 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 $200 copayment for each Medicare-covered outpatient hospital facility visit. You have been asked to pay a $200 copayment for the cholecystectomy. The cholecystectomy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that this was an outpatient 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 cholecystectomy provided from November 21, 2019 through November 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the three periodontal maintenance services provided from February 27, 2019 to October 23, 2019. 
 
You asked the Plan to pay for the periodontal maintenance services. You say that you get four cleanings each year and some x-rays. You also say that your EOC states you are eligible for $150 for preventive dental services. The Plan denied your request. The Plan says periodontal maintenance is not included in your dental benefit, nor is it considered a preventive dental 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, the requested items or services are not among those covered under this benefit. The Plan says that periodontal maintenance is not a preventative cleaning because it is considered a deep cleaning, scaling or root planing to remove bacteria, calculus (tartar), and debris that has collected under the gum. Therefore, we decided that the Plan does not have to pay for the three periodontal maintenance services provided from February 27, 2019 to October 23, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that the enrollee lives alone in a rural area. You say that on the date of service the enrollee was waiting for a ride into town when she fell to the ground. You stated that the senior bus driver was not allowed to help her up and instead called for local EMS to give assistance. When the responders arrived, they helped her up and she told them that she did not have any injuries that required transport. You say that it doesn't make sense that the enrollee should have be transported in order for the Plan to cover it. You stated that it would have cost the insurance more if the enrollee had been transported and that the enrollee did not make the call for the EMS. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on October 1, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the charges for the fulvestrant injection and lab testing provided by an out of network facility on November 21, 2019.
You asked the Plan to waive the charges for the injection and lab testing. You say that you are asking for this to be waived because you need this medication and cannot afford this high coinsurance. The Plan denied your request. The Plan says you have been correctly assessed the cost sharing for the services rendered by the out of network provider.
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 Medicare Part B prescription drugs when provided out of network. You have been asked to pay 30% coinsurance for the injection and a $20 copayment for the lab testing. 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 charges for the fulvestrant injection and lab testing provided by an out of network facility on November 21, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for gauze(A6219) provided on December 23, 2019. 
 
You asked the Plan to pay for the gauze. You say that you would like reconsideration as this supply was denied in error. The Plan denied your request. The Plan says DME furnished to inpatients in a covered Part A stay is included in the SNF PPS rate. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the gauze was used in a SNF or hospital. When DME is furnished for use in an SNF during a covered Part A stay, the DME MACs shall not make separate payment for DME, since the DME is already included in the payment that the SNF receives for the covered stay itself. Therefore, we decided that the Plan does not have to pay for gauze(A6219) provided on December 23, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the 20% coinsurance charged for a Medicare Part B injection
provided on January 29, 2020.
You asked the Plan to waive this coinsurance. You say that you should only have your specialist copayment for
this service. The Plan denied your request. The Plan says the contract is clear that drugs or injections provided
or administered by your physician have a 20% coinsurance.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees
must pay 20% coinsurance for Medicare Part B drugs, such as injections for pain.
You have been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a
contractual obligation you agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does
not have to waive the 20% coinsurance charged for a Medicare Part B injection provided on January 29, 2020.