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

We decided that the Plan has to pay for the electromyography (EMG) services rendered to you on November 8, 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 that the services are considered experimental/investigational in nature and not covered.
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. 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 states that billed procedure codes 96002 (dynamic surface EMG) and 96004 (physician review of motion tests) are experimental/investigational in nature and not medically necessary; however, the Plan has not provided any medical records. Without medical records, a determination based on medical necessity cannot be supported. The Plan has not provided any documentation or Medicare rules to support that the codes are not payable as billed. Therefore, we decided that the Plan has to pay for the electromyography (EMG) services rendered to you on November 8, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 17, 2019 by an out of network (OON) provider.
You asked the Plan to pay for laboratory testing. You say that the enrollee presented for urgent treatment and lab tests were ordered. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and prior authorization was not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on October 17, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the visual field exam provided on July 16, 2019.
You asked the Plan to waive the copayment for the visual field exam. You say that the copayment is higher than the total charge for the service. 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 diagnostic procedures and tests at an in-network outpatient hospital. You have been asked to pay $129.21 for the visual field exam.

The visual field exam 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 visual field exam provided on July 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe specialist office visit provided on October 22, 2019.You asked the Plan to waive the copayment forthe specialist office visit. You say that you should not be responsible for the copayment. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $30 copayment for services obtained from an in-network specialist, or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's office. The enrollee has been asked to pay a $30 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. This means that the enrollee has beenasked 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 forthe specialist office visit provided on October 22, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the bladder ultrasound provided on November 27, 2019.
You asked the Plan to waive the copayment for the bladder ultrasound. You say that you paid the specialist visit copayment. You say that you don't know why you are required to pay another 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 each covered diagnostic procedure or test at a network doctor's office. You have been asked to pay $12.44, which is less than the standard $50 copayment for the bladder ultrasound. The bladder ultrasound falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. Outpatient diagnostic tests are considered a separate service. 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 bladder ultrasound provided on November 27, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ER visit provided on October 28, 2019.
You asked the Plan to waive the copayment for an ER visit. You say that you were told that you would only owe a $15 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 a $90 copayment for emergency care. You have been asked to pay a $90 copayment for an ER visit. An ER visit 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 an ER visit provided on October 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee on December 4, 2019 by an out of network (OON) provider. You asked the Plan to pay for the OON services. You say that the nursing home is responsible to obtain prior authorization. The Plan denied your request. The Plan says the enrollee's plan requires utilization of network providers, and authorization for certain 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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these OON services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee on December 4, 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 guided tissue regeneration (D4266) and bone replacement graft for ridge preservation (D7953) provided on December 14, 2019.

You asked the Plan to pay for the guided tissue regeneration and bone replacement graft. You say that the services were medically necessary. You also say that because of your situation, these services should be paid for. The Plan denied your request. The Plan says these services are not covered 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 Plan offers 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 for the guided tissue regeneration (D4266) and bone replacement graft for ridge preservation (D7953) provided on December 14, 2019. 

Your complaint about your experience with the first two providers is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug injection provided on June 19, 2019.
You asked the Plan to waive the coinsurance for a Medicare Part B drug injection. You say that you will pay the $35 copayment but disagree with the additional 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 20% coinsurance for Medicare Part B prescription drugs. You received a Medicare Part B drug on June 19, 2019. The allowed amount is $378.84 and 20% of that is $75.77. You have been asked to pay the total coinsurance amount of $75.77 for a Medicare Part B drug injection. A Medicare Part B drug injection falls within the Medicare Part B prescription 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 a Medicare Part B drug injection provided on June 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultraviolet light therapy system provided on September 19, 2019.
You asked the Plan to pay for the ultraviolet light therapy system. You say that the Plan should pay this claim. The Plan denied your request. The Plan says there is no documentation that the enrollee has psoriasis or any condition that would be appropriately treated with ultraviolet light. 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. There is no medical documentation of skin conditions or treatment with ultraviolet light therapy. Based on this information, we decided that Medicare rules for coverage of the ultraviolet light therapy system have not been met. Therefore, we decided that the Plan does not have to pay for the ultraviolet light therapy system provided on September 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B injection provided on May 28, 2019.You asked the Plan to waive the coinsurance for the Part B injection. You say that you were not asked if you wanted the injection. You say you were told to had to have one. 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 ascopayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% of the Medicare-allowed amount for in-network Medicare Part B covered drugs. You have been asked to pay $60.61 which is 20% of the allowed amount for the Part B injection. The allowed amount is $303.07. ($303.07 x 20% = $60.61). The Part B injection falls within the "Medicare Part B prescription 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 the Part B injection provided on May 28, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a PET scan provided on March 11, 2019.
You asked the Plan to waive the coinsurance for a PET scan. You say that this should be considered preventative and you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for diagnostic tests and or radiology services. You received a PET scan on March 11, 2019. PET scans are considered diagnostic. Therefore, you are responsible to pay your share of the cost-sharing charges. The allowed amount is $1,385.86 and 20% of that is $277.17. You have been asked to pay the total coinsurance amount of $277.17 for a PET scan. A PET scan 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 coinsurance for a PET scan provided on March 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on October 16, 2019.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 has network providers available who can provide 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 medical services provided to the enrollee by an out-of-network provider on October 16, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a stress test (78452) provided December 6, 2019.
You asked the Plan to waive the copayment for a stress test. You say that you haven't had to pay for stress tests in the past. The Plan denied your request. The Plan says this service processed 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 $275 copayment for each advanced imaging service (e.g., MRI, CT and PET scans, nuclear medicine, and stress tests). You have been asked to pay a $275 copayment for a stress test. 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 a stress test (78452) provided December 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acupuncture for the enrollee.

You asked the Plan to pre-approve these services. You say that the enrollee has multiple complex medical issues. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90 period, and no more than 20 sessions per year. 

We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the enrollee does not have a condition for which Medicare covers acupuncture. Therefore, we decided that the Plan does not have to pre-approve acupuncture for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health skilled nursing visits.
You asked the Plan to pre-approve home health care. You say that the enrollee requires continued skilled nursing services for medication management. The Plan denied your request. The Plan says the denial of authorization for home health service is correct.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 home health care. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested home health visits. Our physician reviewer found the records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services which are medically necessary for the enrollee beyond what was approved by the Plan. There are no complex wounds, intravenous medications, new enteral feedings, or other skilled nursing needs. The enrollee can be educated on medications, monitored for medication use, and trained in his medication and disease regiment with the skilled nursing already approved by the Plan. There are no extenuating factors that would require these additional skilled nursing visits.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health care have not been met. Therefore, we decided that the Plan does not have to pre-approve home health skilled nursing visits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlab work provided on November 18, 2019 by an out of network (OON) provider.You asked the Plan to payforlab work. You say that you have never had to pay this much for lab work.The Plan denied your request. The Plan says 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 forlab work provided on November 18, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the Hand (73218).You asked the Plan to pre-approve the MRI. You say that the MRI is medically necessary.The Plan denied your request. The Plan says coverage rules were not met.The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. 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 MRI. Our reviewer says that the MRI is not medically necessary. Our physician reviewer found no follow-up evaluation has been submitted for review. While ongoing evaluation is medically necessary and reasonable, it is unclear that MRIs of the entire right upper extremity, right wrist and right hand are the best course of action.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 MRI have not been met.Therefore, we decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the Hand (73218).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services provided on December 23, 2019 by an out of network (OON) provider.You asked the Plan to pay forphysician services. You say that these services were essential for the enrollee's health treatment and were rendered in good faithThe Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring facility is also out-of-network.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 forphysician services provided on December 23, 2019 by an out of network (OON) provider.