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

We decided that the Plan does not have to waive the copayment forthe colonoscopy provided on October 28, 2019.You asked the Plan to waive the copayment forthe colonoscopy. You say that you were informed there would be no additional charges for a routine screening. You say that the billing should be changed to a routine screening.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 $300 copayment for each Medicare covered ambulatory surgical center visit.You have been asked to pay a $300 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that a polyp was removed, which is considered a surgical 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 forthe colonoscopy provided on October 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the shingle vaccine you received on October 28, 2019.
You asked the Plan to pay for the vaccine. The Plan denied your request. The Plan says this vaccine is not a covered benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The Plan follows the same rules. The records do not show that you have been injured or directly exposed to any illness related to the shingles vaccine. Therefore, we decided that the Plan does not have to pay for the shingle vaccine you received on October 28, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) services provided to the enrollee from August 21, 2019 through September 12, 2019.You asked the Plan to waive the copayment for the SNF services. You say that that the enrollee was not given the correct information from the SNF regarding copayments, and therefore should not be responsible for a mistake on their part.The Plan denied your request. The Plan says that the enrollee received the applicable procedure and as such the copayment is due.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 $100 copayment per day for days 21-100 of Skilled nursing facility (SNF) care. The enrollee has been asked to pay a $198.99 copayment for the SNF services. The SNF services fall within the days 21-100 of Skilled nursing facility (SNF) care benefit category. This means that the enrollee has been asked to pay less than 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 skilled nursing facility (SNF) services provided to the enrollee from August 21, 2019 through September 12, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve residential rehab for substance abuse.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation is lacking as to the need for this request, as there is no documentation of severity of withdrawal symptoms for the substance abuse issues listed. The criteria for treatment is not met for a substance abuse rehabilitation treatment program as you were not documented to be showing severity of symptoms. You could be treated in a lesser restrictive environment. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve residential rehab for substance abuse.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 30, 2019 by an out of network (OON) provider. You asked the Plan to pay for office visit. You say that you are appealing for payment. The Plan denied your request. The Plan says the denial of payment for this service 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 for the medical services provided on October 30, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the patient screening (D0190) provided on November 18, 2019.
You asked the Plan to pay for the dental service. You say that you got a denial letter about your teeth cleaning. The Plan denied your request. The Plan says the patient screening is not listed as a covered 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 patient screening is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the patient screening (D0190) provided on November 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodontal maintenance provided on October 14, 2019.You asked the Planto pay forthe periodontal maintenance. You say that you have two cleanings per year with your dental plan. You also say that this was the first cleaning you have gotten since being enrolled with this plan.The Plan denied your request. The Plan says this is not a covered service under your 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 Planoffers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe periodontal maintenance provided on October 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on October 22,
2019.
You asked the Plan to waive the copayment for the office visit. You say that you do not agree with the
copayment. 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 $50
copayment for subsequent visits.
You have been asked to pay a $50 copayment for the office visit. The office visit falls within the "Vision 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 the office visit provided on
October 22, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a static progressive stretch elbow device.You asked the Plan to pre-approvea static progressive stretch elbow device. You say that the enrollee needs the device to improve flexion of the elbow.The Plan denied your request. The Plan says the enrollee has exceeded the four month post-operative window in which this device would be covered.The Plan must follow Medicare rules. The rules say that static progressive stretch elbow device coverage is a carrier judgement.The enrollee does not meet Plan coverage criteria.Therefore, we decided that the Plan does not have to pre-approve a static progressive stretch elbow device.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the chest CT scan or the abdominal CT scan provided on September 27, 2019.You asked the Plan to reduce the copayment for the chest CT scan and the abdominal CT scan. You say that you were told your copayment would be $225. You say you are being charged an additional $190. You say you would not have had it done if you knew it would be this much. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 copayment for each in-network Medicare-covered diagnostic radiology service. You have been asked to pay a $225 copayment for the chest CT scan and a $190.83 copayment for the abdominal CT scan, which is less than the standard copayment. The chest CT scan and the abdominal CT scan 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 reduce the copayment for the chest CT scan or the abdominal computed tomography CT scan provided on September 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the infusion supplies provided on July 15, 2019.
You asked the Plan to pay for the infusion supplies (A4222). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the supplies are inclusive under services approved and paid to the facility.
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 A4222 is infusion supplies for external drug infusion pump. Medicare's payment for the supplies billed includes payment for the equipment and they are not separately payable. Based on this information, we decided that Medicare rules for coverage of the infusion supplies (A4222) have not been met. Therefore, we decided that the Plan does not have to pay for the infusion supplies provided on July 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an annual wellness visit provided on May 15, 2019.You asked the Plan to waive the coinsurance for an annual wellness visit. You say that this was an annual wellness visit and you should not owe a copayment.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 50% coinsurance for out-of-network annual wellness visits. You had an annual wellness visit on May 15, 2019 with an out-of-network provider. Therefore, you are responsible to pay your share of the out-of-network cost-sharing charges. The allowedamount is $95.34 and 50% of that is $47.67.You have been asked to pay the total coinsurance amount of $47.67 for an annual wellness visit. An annual wellness visit falls within the annual wellness 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 coinsurance foran annualwellness visit provided on May 15, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient behavioral health facility for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says this can be done at a lower level of care, such a partial hospitalization treatment.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found the enrollee does not meet the criteria for continued treatment beyond March 6, 2020. The enrollee was not shown to be a danger to herself or others. The enrollee was not showing any auditory hallucinations, and was cooperative/compliant with treatment, while not showing any threats to safety. 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient behavioral health facility for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve, and the wrist hand orthosis provided on September 17, 2019.You asked the Plan to pay forthe knee orthosis (L1833) and suspension sleeve (L2397), and the wrist hand orthosis (L3916). You say that the orthoses were medically necessary.The Plan denied your request. The Plan says rules for telehealth services were not met.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.Also, the order and packing list show one knee brace and one knee wrap but the claim is for two of each. Therefore, we decided that the Plan does not have to pay forthe knee orthosis and suspension sleeve, and the wrist hand orthosis provided on September 17, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe implant surgery (41899) provided on July 22, 2019.You asked the Plan to pay forthe dental services. You say that the enrollee's teeth and gums have suffered due to his health issues. You say that the services had to be provided in a hospital setting due to the enrollee's fragile health. You also say thatyou contacted the hospital prior to the enrollee receiving the services and were advised that the services would be 100% covered by your insurance.The Plan denied your request. The Plan says the services that the enrollee received are dental in nature.The Plan also says that routine dental services are not covered.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that are not covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pay forthe implant surgery (41899) provided on July 22, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that you are appealing the denial of the shower chair due to your gait instability. You say you have difficulty bathing and are at risk of falling due to your age and diagnosis. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services.You asked the Plan to pay forthe ambulance services. You say that you were confused and could not walk. You were going in and out of consciousness because your blood sugar was low and 911was called. The responders came and after treating you, your blood sugar reached normal levels. You say that the responders said there was no need to go to the hospital because you were doing better. Your vitals were all normal again and you say that you had needed the responders help badly. You say that the total cost was much less than if you would have had to go to the hospital.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 27, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on August 2, 2019. You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says this service was ordered by a non-contract physician and the enrollee did not have prior authorization for out of network care. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The billing laboratory provider 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 these lab services. These services were ordered and submitted by a non-contract provider. 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 August 2, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transport provided by provider on September 29, 2019.You asked the Plan to pay for the non-emergent ambulance transport. You say that this transport was medically necessary.The Plan denied your request. The Plan says the transport was not authorized.Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the non-emergent ambulance transport have not been met.Therefore, we decided that the Plan does not have to pay for the ambulance transport provided by provider on September 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the PAP supplies provided on November 8, 2019 by out of network provider.
You asked the Plan to pay for the PAP supplies. You say that the supplies were medically necessary. The Plan denied your request. The Plan says you did not have 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 has network providers available who can provide the items at issue in this appeal. The Plan did not pre-approve the items at issue. We found no exception that would require the Plan to pay for these items. Therefore, we decided that the Plan does not have to pay for the PAP supplies provided on November 8, 2019 by out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory work provided on November 18, 2019.
You asked the Plan to waive the copayment for the laboratory work. You say that it should not matter where the blood work is done. You say you were just following the doctor's orders and went to the clinic to have the laboratory work done. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for each Medicare-covered laboratory tests for services in an in-network outpatient hospital facility. You have been asked to pay a $40 copayment for the laboratory work. The laboratory work falls 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 the laboratory work provided on November 18, 2019.