Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an observation stay provided from May 21, 2019, to May 24, 2019.

You asked the Plan to waive the copayment for an observation stay. You say that you received a bill from a collections agency and disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $400 copayment for outpatient surgery, including services provided at hospital outpatient facilities. 

You have been asked to pay a $400 copayment for an observation stay. An observation stay 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 copayment for an observation stay provided from May 21, 2019, to May 24, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray (71045), set-up of portable x-ray equipment (Q0092), and transportation of portable x-ray equipment and personnel (R0070) provided on November 5, 2020.

You asked the Plan to pay for the chest x-ray, set-up of portable x-ray equipment, and transportation of portable x-ray equipment and personnel. You say that the enrollee was released from Hospice care on November 4, 2020, which was the day before these services were provided. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. 

The enrollee ended Medicare Hospice benefits on November 4, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the chest x-ray (71045), set-up of portable x-ray equipment (Q0092), and transportation of portable x-ray equipment and personnel (R0070) provided on November 5, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a colonoscopy and laboratory services provided on February 4, 2021.

You asked the Plan to waive the copayments for a colonoscopy and laboratory services. You say that you were told that the colonoscopy would be covered 100%. 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 $300 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers a $20 copayment for laboratory tests for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers outpatient diagnostic tests and therapeutic services and supplies. 

You have been asked to pay a $300 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers a $20 copayment for laboratory tests for a colonoscopy and laboratory services. a colonoscopy and laboratory services falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 copayments for a colonoscopy and laboratory services provided on February 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an electrocardiogram (93010) provided on February 10, 2021, by an out of network (OON) provider.
You asked the Plan to pay for an electrocardiogram. You say that the services were medically necessary. The Plan denied your request. The Plan says services were provided by an out-of-network provider without 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 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 an electrocardiogram (93010) provided on February 10, 2021, by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) (72148).
You asked the Plan to pre-approve an MRI. You say that the service is medically necessary. The Plan denied your request. The Plan says the provider is out-of-network and in-network providers are available to provide this service.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) (72148).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services you received on September 11, 2020.

You asked the Plan to waive the copayment for the ambulance services. You say that this copayment should be waived because it was an emergency. 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 $250 copayment for ambulance services. 

You have been asked to pay a $250 copayment for the ambulance services. This copayment applies to both emergency and non-emergency ambulance services. 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 ambulance services you received on September 11, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (U0003) provided on September 25, 2020.

You asked the Plan to pay for the infectious agent detection. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (U0003) provided on September 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the intraoral complete series of x-rays (D0210) provided on March 8, 2021.

You asked the Plan to pay for the evaluation and x-rays. You say that you have not seen a dentist in a year and do not understand why these services are denied. You say you specifically chose this provider because they accept your insurance. The Plan denied your request. The Plan says a complete series of x-rays is not covered by your dental benefit, and one comprehensive or periodontal evaluation can be covered every three years. The Plan previously paid for you to have a comprehensive oral evaluation in August of 2020, which is less than three years before the date in question. Therefore, payment for these services cannot be made.

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 or are requested in a frequency that exceeds what is covered under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the intraoral complete series of x-rays (D0210) provided on March 8, 2021.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hair restoration services.

You asked the Plan to pre-approve hair restoration services. You say that hair restoration services are medically necessary. The Plan denied your request. The Plan says hair restoration services are not covered by Medicare or the Plan.

The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are coverable. 

We looked the file and Medicare rules. Hair restoration services are considered cosmetic procedures. Based on this information, we decided that Medicare rules for coverage of hair restoration services have not been met. Therefore, we decided that the Plan does not have to pre-approve hair restoration services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray exam of the chest, two views (71046),
transportation of portable x-ray equipment (R0070), and the set-up of the portable x-ray equipment (Q0092)
rendered by the out of network (OON) provider on February 11, 2021.
You asked the Plan to pay for the services. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of
network provider, without 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 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 x-ray exam of the chest, two views (71046), transportation of portable x-ray
equipment (R0070), and the set-up of the portable x-ray equipment (Q0092) rendered by the out of network
(OON) provider on February 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided on December 29, 2020.

You asked the Plan to waive the copayment for a CT scan. You say that you were told that you would 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 a $95 copayment for CT scans. 

You have been asked to pay a $95 copayment for a CT scan. A CT 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 copayment for a CT scan provided on December 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay additional costs above the benefit amount for eyeglasses provided on February 2, 2021.
You asked the Plan to pay additional costs above the benefit amount for the eyeglasses. The Plan denied your request. The Plan says you are responsible for the additional cost above benefit amount for the frames and for the additional copay for anti-glare coating and polycarbonate upgrades or "enhancements."
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 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. The file shows that lens enhancements are not a covered routine vision benefit. Therefore, we decided that the Plan does not have to pay additional costs above the benefit amount for eyeglasses provided on February 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued use of a home ventilator after July 8, 2021.
You asked the Plan to pre-approve home ventilator, any type, used with non-invasive interface (E0466). You say that the enrollee needs continued use of the home ventilator. The Plan denied your request. The Plan says the ventilator is being used to provide BiPAP therapy
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 ventilator, any type, used with non-invasive interface (E0466). Our reviewer says that the service is not medically reasonable and necessary.
Our physician reviewer found there is no documented failure of BiPAP. Medicare does not cover a home
ventilator when used as BiPAP, and certain BiPAP devices can provide the average volume-assured pressure
support mode of support that is ordered for the ventilator. The denial is upheld.
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 ventilator, any type, used with non-invasive interface (E0466) have not
been met. Therefore, we decided that the Plan does not have to pre-approve continued use of a home ventilator
after July 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve diabetic shoes.
You asked the Plan to pre-approve foot orthotics. You say that this is medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve diabetic shoes.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory accession of transepithelial cytologic sample, microscopic examination, preparation and transmission of written report (D0486) received September 29, 2020.
You asked the Plan to pay for the laboratory accession of transepithelial cytologic sample, microscopic examination, preparation and transmission of written report (D0486). You say that the requested service was necessary. The Plan denied your request. The Plan says the requested service is not covered under your supplemental benefit.
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 laboratory accession of transepithelial cytologic sample, microscopic examination, preparation and transmission of written report (D0486) received September 29, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the evaluation of swallowing function (92610) provided on
September 10, 2020.
You asked the Plan to pay for the evaluation of swallowing function. You say that you would like this claim to
be reprocessed for payment. The Plan denied your request. The Plan says Original Medicare would be
responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal
condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the evaluation of swallowing function (92610) provided on September 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is stable and suitable for transfer to an LTACH. Care at a skilled nursing facility would not be sufficient at this point; the enrollee is currently at a short-term acute care hospital and transfer to an LTACH is medically necessary. The Plan denied your request. The Plan says the enrollee is currently receiving appropriate inpatient care and a transfer to an LTACH would not provide a clinical advantage.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no documentation provided necessitating admission to an LTACH. The
enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where they are currently receiving care. The requested LTACH services are not medically necessary, reasonable, and appropriate in this case.
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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the intraoral - complete series of radiographic images (D0210) received April 8, 2021.
You asked the Plan to pay for the comprehensive oral evaluation and the intraoral complete series of radiographic images. You say that the requested services were necessary. The Plan denied your request. The Plan says the requested services are limited to one procedure every three years.
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 covered under this benefit only once every three years. The Plan has submitted evidence that you received, and the Plan covered, a comprehensive oral evaluation and intraoral complete series of radiographic images on June
16, 2020. When you received these services on April 8, 2021 your benefit was exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the intraoral - complete series of radiographic images (D0210) received April 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for pneumatic compression device (E0675) and pressure pneumatic appliance (E0673) provided September 3, 2020.

You asked the Plan to pay for pneumatic compression device and appliance. You say that the DME equipment prescribed by the doctor was issued to the enrollee for use during their surgery. You are not contracted with the facility or the prescribing physician and do not receive payment from either provider. The Plan denied your request. The Plan says pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.

The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient. 

In this case, the enrollee used the equipment in the facility during and/or after surgery. Payment for this service would have been included under the facility claim. Payment for this service is the responsibility of the facility or hospital that provided the surgery. Based on this information, we decided that Medicare rules for coverage of pneumatic compression device and appliance have not been met. Therefore, we decided that the Plan does not have to pay for pneumatic compression device (E0675) and pressure pneumatic appliance (E0673) provided September 3, 2020.