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

We decided that the Plan does not have to waive the copayment for urgent care services provided by a
participating provider on December 1, 2020.

You asked the Plan to waive the copayment for urgent care services. You say that you went for a Covid-19 test.
You say that you would like reimbursement. The Plan denied your request. The Plan says the correct
copayment has been 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 $45
copayment for urgently needed services.

You have been asked to pay a $45 copayment for urgent care services. The correct copayment has been applied
to the services that were provided. Urgent care services fall within the urgently needed services 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 urgent care services provided by a participating
provider on December 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional trigger point injections.

You asked the Plan to pre-approve the additional trigger point injections.. You say that you would like reconsideration because the requested service is medically necessary. The Plan denied your request. The Plan says the amount of injection (pain management) services requested is more than what is reasonable and necessary.

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 the additional trigger point injections.. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found only 20553 x1 is allowed. If 3 or more trigger points are injected, then 20553 is used regardless of the total number of sites injected. 

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 additional trigger point injections. have not been met. Therefore, we decided that the Plan does not have to pre-approve additional trigger point injections.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for physician services provided by an out-ofnetwork
provider on October 14, 2020.

You asked the Plan to waive the coinsurance for physician services. You say that you were told this provider
was in-network. You say that you would not have gone if you knew the provider was out-of-network. The Plan
denied your request. The Plan says the correct coinsurance has been 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 50%
coinsurance for physician/practitioner services/out-of-network.

You have been asked to pay a 50% coinsurance of the allowed amount for physician services. The total allowed
amount is $82.71. The total amount you are being asked to pay is $41.35 ($82.71 x 50% = $41.35). Physician
services fall within the physician/practitioner services/out-of-network 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 physician services provided by an out-of-network provider on October 14, 2020.

We note your complaint about being told this provider was in-network. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the cost for the diagnostic colonoscopy and Part B drugs provided on November 11, 2020.

You asked the Plan to waive the cost for the diagnostic colonoscopy and Part B drugs. You say that you were informed the colonoscopy was covered if it was routine and no abnormality was discovered. You say that you never had the endoscopy which was the diagnostic procedure, and they refuse to change the coding. The Plan denied your request. The Plan says the cost share 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 all other outpatient hospital services including a diagnostic colonoscopy and 20% coinsurance for Medicare Part B prescription drugs including administration. 

You have been asked to pay a total of $372.36 for the diagnostic colonoscopy and Part B drugs.

The diagnostic colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The Part B drugs fall within the "Medicare part B prescription drugs" benefit category. The records show a diagnostic colonoscopy was performed. 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 cost for the diagnostic colonoscopy and Part B drugs provided on November 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the repair of a hearing aid provided on January 14, 2021.

You asked the Plan to pay for the repair of a hearing aid. You say that you want the Plan to pay for the service. The Plan denied your request. The Plan says the service at issue is not a covered benefit.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case.

We looked at the file, and the Plan's rules. Though the Plan offers a hearing aid 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 for the repair of a hearing aid provided on January 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for wound repair (12013) provided on September 10, 2020.
You asked the Plan to pay for the wound repair. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says the documentation does not support the service
billed.
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 12013 is simple repair of superficial wounds of face,
ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm.
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 wound repair.
Our reviewer says that the elements of the coverage rule are unable to be evaluated based upon the provided documentation. Our physician reviewer found no description of the procedure is provided. 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 wound repair have not been met. Therefore, we decided that the Plan does not have to pay for wound repair (12013) provided on September 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on January 6, 2021.

You asked the Plan to waive the copayment for the office visit. You say that you never saw this doctor and the bill shouldn't be paid. You say that you owe him nothing. 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 $45 for each Medicare-covered visit with an in-network specialist.

You have been asked to pay a $45 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that services were provided at a specialist's office. 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 office visit provided on January 6, 2021.
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 in the Medicare rules section. 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 the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program.
Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the low dose computed tomography (LDCT) scan for lung cancer screening (G0297) provided on September 23, 2020.
You asked the Plan to pay for the LDCT scan. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of this service.
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung cancer screening for enrollees who meet all the above described criteria. We reviewed the file and the Medicare rules. We find that the enrollee does not meet Medicare criteria for coverage of this service as there is no history of smoking in the medical records provided. Therefore, we decided that the Plan does not have to pay for the low dose computed tomography (LDCT) scan for lung cancer screening (G0297) provided on September 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on January 12, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.
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 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 services provided by an out-of-network provider on January 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on June
12, 2020.

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 had network providers
available who could have provided 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 services provided by an out-of-network provider on June 12,
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you by an out-of-network provider
from August 27, 2020, to October 6, 2020.
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 had network providers
available who could have provided 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 services provided to you by an out-of-network provider from
August 27, 2020, to October 6, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ultrasounds provided on December 9, 2020.

You asked the Plan to waive the copayment for ultrasounds. You say that you disagree with the charges because you have never been charged in the past. 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 each radiological diagnostic service. 

You received two ultrasounds on December 9, 202. Therefore, you are responsible to pay a $110 copayment per each service. The total amount you owe is: $220.

You have been asked to pay the total copayment amount of $220 for ultrasounds. Ultrasounds fall within the outpatient diagnostic tests and therapeutic services and supplies 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 ultrasounds provided on December 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you by an out-of-network provider on August 27, 2020.
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 had network providers available who could have provided 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 services provided to you by an out-of-network provider on August 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the therapeutic CGMs (CPT code(s): K0553, K0554).
You asked the Plan to pre-approve the CGMs. You say that you cannot afford to pay for this equipment on your own. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the CGMs have not been met. The notes sent in must show that you have been using a strip-based diabetic meter, such as True Metrix. The notes must show you need to check your blood sugar at least four (4) times per day. The notes must show you are injecting insulin at least three (3)
times per day or are receiving insulin through a Medicare covered continuous insulin pump. These criteria are not met. Therefore, we decided that the Plan does not have to pre-approve the therapeutic CGMs (CPT code(s): K0553, K0554).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Amitriptyline.
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your
request. The Plan says that this is not covered under Part B.
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 Amitriptyline.
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory test provided by an out-of-network provider on April 22, 2020.
You asked the Plan to pay for the laboratory test. You say that the services were medically necessary, and the claim should be processed for payment. The Plan denied your request. The Plan says prior authorization was required but 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 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 laboratory test provided by an out-of-network provider on April 22, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the acupuncture services provided from January 25, 2021, through February 15, 2021.
You asked the Plan to pay for the acupuncture services. You say that you received a flyer in the mail showing the plan now covers twelve (12) acupuncture visits per year and it did not say "by a licensed medical doctor". The Plan denied your request. The Plan says that the provider is licensed as a chiropractor only.
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. We confirmed this provider is a licensed acupuncturist in the your state. Therefore, the plan's denial rationale is not supported. Therefore, we decided that the Plan has to pay for the acupuncture services provided from January 25, 2021, through February 15, 2021.
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.