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

We decided that the Plan does not have to waive the copayments for a specialist visit, an ultrasound, and neuroplasty and does not have to waive the coinsurance for a Medicare Part B drug injection provided from June 24, 2020, to December 17, 2020.
You asked the Plan to waive the copayments for a specialist visit, an ultrasound, and neuroplasty and to waive the coinsurance for a Medicare Part B drug injection. You say that you were told that the services would be 100% covered. 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 $30 copayment for specialist services. Your contract with the Plan also clearly says that you must pay a $35 copayment for X-rays. Your contract with the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs. Your contract with the Plan also clearly says that you must pay a $200 copayment for outpatient surgery, including services provided at ambulatory surgical centers. You received a specialist visit, an ultrasound, neuroplasty and a Medicare Part B drug injection provided from June 24, 2020, to December 17, 2020. Therefore, you are responsible to pay your share of the cost-sharing charges. Please see the chart below.
Date of Service
Service
Allowed Amount
Amount You Owe
6/24/2020
76942
$59.18
$35
6/24/2020
99214
$112.68
$30
6/24/2020
J0702
$7.31
$1.46
12/17/2020
64721
$796.79
$200
The total amount you owe is: $266.46. You have been asked to pay the total amount of $266.46 for a specialist visit, an ultrasound, neuroplasty and a Medicare Part B drug injection. A specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category. An ultrasound falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. A Medicare Part B drug injection falls within the Medicare Part B prescription drugs benefit category. Neuroplasty 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 copayments for a specialist visit, an ultrasound, and neuroplasty and does not have to waive the coinsurance for a Medicare Part B drug injection provided from June 24, 2020, to December 17, 2020.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the ground mileage (A0425) and emergency ambulance transport (A0427) provided on January 9, 2021.
You asked the Plan to pay for the ground mileage and emergency ambulance transport. You say that the ambulance transport was medically necessary. The Plan denied your request. The Plan says that the documentation provided does not support medical necessity for ambulance transport.
Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. 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 ground mileage and emergency ambulance transport. Our reviewer says that the ground mileage and emergency ambulance transport meet coverage criteria. Our physician reviewer found the enrollee's presenting symptoms met prudent layperson criteria for emergency 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 the ground mileage and emergency ambulance transport have been met. Therefore, we decided that the Plan has to pay for the ground mileage (A0425) and emergency ambulance transport (A0427) provided on January 9, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to provide payment up to the Plan's benefit limit for the hearing aids purchased October 28, 2020.

You asked the Plan to provide payment up to the Plan's benefit limit for the hearing aids. You say that it was not clear to you that there was a specific formulary for hearing aids that you were limited to. The Plan denied your request. The Plan says that the hearing aids at issue are not part of the Plan's hearing aid formulary and therefore are not covered.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan does not say in clear and accurate terms that you are limited to specific hearing aids.

We looked at your contract with the Plan. We did not see where the contract says enrollees must pay purchase specific hearing aids in order to expect coverage for hearing services. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to provide payment up to the Plan's benefit limit for the hearing aids purchased October 28, 2020.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the heavy-duty hospital bed (E0303).
You asked the Plan to pre-approve the heavy-duty hospital bed. You say that this item is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that a heavy duty extra wide hospital bed is covered if the beneficiary meets one of the criteria for a fixed height hospital bed and the beneficiary's weight is more than 350 pounds, but does not exceed 600 pounds We looked at the file and Medicare rules. In this case, your weight is not within the required weight range fo the requested heavy-duty hospital bed. Based on this information, we decided that Medicare rules for coverage of the heavy-duty hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve the heavy-duty hospital bed (E0303).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided on April 21, 2021.

You asked the Plan to pay for the comprehensive periodontal evaluation. You say that you did not know the cost of this service because this examination was your second one. The Plan denied your request. The Plan says benefits for this service have been satisfied and the frequency limitation has been exceeded.

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, comprehensive periodontal evaluation (D0180) and comprehensive oral evaluation (D0150) share a frequency limitation of one procedure code every three years. The record shows that you received a comprehensive oral evaluation (D0150) on March 16, 2021 and your comprehensive periodontal evaluation (D0180) and comprehensive oral evaluation (D0150) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided on April 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided on March 
30, 2021. 
 
You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you were not charged for 
previous injections. 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 20% 
coinsurance for Part B drugs.  
 
You received Medicare Part B drugs on March 30, 2021. The total allowed amount is $6,399.64 and 20% of 
that is $1,279.93. You have been asked to pay the total coinsurance amount of $1,279.93 for Medicare Part B drugs. Medicare 
Part B drugs fall within the Part B drugs 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 Medicare Part B drugs provided on March 30, 2021.
Appeal type: ER
Decision: Unfavorable


We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on 
June 9, 2020. 
 
You asked the Plan to waive the copayment for the ER visit. You say that this visit was medically necessary 
because your eye lashes were scratching the inside of the eye. You said that you cannot afford this copayment. 
The Plan denied your request. The Plan says you were charged this copayment 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 $120 
copayment for emergency room services.  
 
You have been asked to pay a $120 copayment for the ER visit. This means that you have been asked to pay 
the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation  you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for the emergency room (ER) visit you had on June 9, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99283) provided on March 22, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the left, right or is bilateral. If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side.
We looked at the file and Medicare rules. In this case, it is appropriate to report left and right diagnosis codes when a bilateral diagnosis code is available. 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 the services (99283) provided on March 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dupixent.
You asked the Plan to pre-approve Dupixent. You say that Dupixent would greatly help the enrollee with Atopic Dermatitis and asthma. The Plan denied your request. The Plan says Dupixent is a self-administered drug and does not fall under Part B coverage.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Dupixent.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for the Prolia injection you received on April 23, 2021.
You asked the Plan to reduce the coinsurance for the Prolia injection. You say that you cannot afford this bill and that the injection took less than five minutes. The Plan denied your request. The Plan says you were charged this coinsurance correctly. The Plan says that the allowed amount for the Prolia injection is $1205.64, so your 20% coinsurance equals $241.13.
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 20% coinsurance for Medicare Part B drugs. You have been asked to pay 20% coinsurance for the Prolia injection. The Prolia injection falls within the Medicare Part B drugs 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 reduce the coinsurance for the Prolia injection you received on April 23, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for emergency care provided on March 18, 
2021. 
 
You asked the Plan to waive the copayment for emergency care. You say that you think the charges are too 
high. 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 $110 
copayment for emergency care.  
 
You have been asked to pay a $110 copayment for emergency care. Emergency care falls within the emergency 
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 emergency care provided on 
March 18, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on February 22, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the lab services. You say that the services were necessary expenses. 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 had network providers available who could have provided the lab 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 lab services provided on February 22, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for two (2) office visits with a specialist (99202, 17110, 11102) provided on March 16, 2021, and March 30, 2021, by an out-of-network (OON) provider. You asked the Plan to pay for office visits. You say that you tried to get an appointment with a participating provider but there were no appointments available. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services rendered by an out-of-network 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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. The records provided for review do not show that the services at issue were urgent or emergent. 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 two (2) office visits with a specialist (99202, 17110, 11102) provided on March 16, 2021, and March 30, 2021, by an out-of-network (OON) provider.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to pay for an emergency department visit (99283) provided on October 23, 2020.

You asked the Plan to pay for an emergency department visit. You say that this is supported in the records. The Plan denied your request. The Plan says that this was billed incorrectly because the physician was consulted while the enrollee was in the emergency department.

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. If the emergency department physician requests that another physician evaluate a given patient, the other physician should bill an emergency department visit code. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has stated that this was billed incorrectly because the physician was consulted while the enrollee was in the emergency department, but Medicare rules state that if an emergency department physician requests that another physician evaluate a given patient, the other physician should bill an emergency department visit code. The Plan has not provided information to support that this was not billed correctly. Therefore, we decided that the Plan has to pay for an emergency department visit (99283) provided on October 23, 2020.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an external urinary collection device.
You asked the Plan to pre-approve an external urinary collection device. You say that the enrollee cannot get out of bed on her own to use the commode at night. The Plan denied your request. The Plan says the enrollee does not have a history of decubitus ulcers or catheter associated urinary tract infections.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The medical records do not show permanent impairment of urination, a history of ulcers or urinary tract infections. Based on this information, we decided that Medicare rules for coverage of an external urinary collection device have not been met. Therefore, we decided that the Plan does not have to pre-approve an external urinary collection device.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for emergency care and an inpatient hospital
stay provided from April 7, 2021, to April 11, 2021.

You asked the Plan to waive the copayments for emergency care and an inpatient hospital stay. You say that
you got an infection due to an injection and feel that you should not be responsible for 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 $90
copayment for emergency care. Your contract with the Plan also clearly says that you must pay a $250
copayment for days 1-6 for inpatient hospital care.

You received emergency care on April 7, 2021. Therefore, you are responsible to pay the $90 copayment.
You had an inpatient hospital stay from April 9, 2021, to April 12, 2021. Therefore, you are responsible to pay
a $250 copayment for days 1-3 (April 9, 2021, to April 11, 2021). The total amount you owe is: $250
(copayment) x 3 (inpatient days) = $750.

The total amount you owe is: $840.

You have been asked to pay the total copayment amount of $840 for emergency care and an inpatient hospital
stay. Emergency care falls within the emergency care benefit category. 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 copayments for emergency
care and an inpatient hospital stay provided from April 7, 2021, to April 11, 2021.

Your quality of care concerns have been handled separately by the health plan. Medicare does not permit
the Qualified Independent Contractor to make a decision on this type of complaint.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lower extremity prosthetic additions.
You asked the Plan to pre-approve addition to lower extremity, above knee or knee disarticulation, silesian bandage (L5698) and addition to lower extremity, below knee, removable medial brim suspension (L5972). You say that you need a hydraulic ankle and foot to match your left foot and ankle. The Plan denied your request. The Plan says your needs for a power wheelchair is inconsistent with K3 ambulatory function.
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 pre-approve addition to lower extremity, above knee or knee disarticulation, silesian bandage (L5698) and addition to lower extremity, below knee, removable medial brim suspension (L5972). Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found the medical progress reports and need for a power wheelchair do not support that the patient is a K3 ambulator therefore the requested items exceed the patient's medical need. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of addition to lower extremity, above knee or knee disarticulation, silesian bandage (L5698) and addition to lower extremity, below knee, removable medial brim suspension (L5972) have not been met. Therefore, we decided that the Plan does not have to pre-approve lower extremity prosthetic additions.