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

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider, at the in-network benefit level.You asked the Plan to pre-approve the referral. You say that this is medically necessary.The Plan denied your request. The Plan says if you use an out-of-network provider, your share of the costs for the services may be higher. 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 this referral at the in-network benefit level. The provider can be seen, but you will have to pay out-of-network benefit rates.Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network provider, at the in-network benefit level.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment  for the ER visit provided on October 2, 2019.You asked the Plan to waive the copayment for the ER visit. You say that you went to urgent care. You say that you are protesting the ER charge.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 $75 copayment for each Medicare-covered emergency room visit.You have been asked to pay a $75 copayment for the ER visit. The ER visit falls within the "Emergency care" benefit category. The records show that you were treated in the ER. 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 ER visit provided on October 2, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gym membership initiation fee purchased January 30,
2020.
You asked the Plan to pay for the gym membership initiation fee. You say that you were denied the initiation
fee and you do not agree with that statement because it is included in the cost and the cost is for 36 months.
The Plan denied your request. The Plan says initiation fees is not covered under the plan benefits.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan does not reimburse
for initiation fees.
The Plan's rules for coverage of gym benefits have not been met because The health plan contract specifically
says that the Plan does not reimburse for initiation or registration fees, prorated fees, annual fees, account
freeze fees, maintenance fees and any miscellaneous fees or other penalties. Therefore, we decided that the
Plan does not have to pay for the gym membership initiation fee purchased January 30, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services (90791, 99213) provided on May 17, 2019 to September 18, 2019.
You asked the Plan to pay for the outpatient mental health services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not emergent or preauthorized. There were network providers available.
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 service 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 outpatient mental health services (90791, 99213) provided on May 17, 2019 to September 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a segmented pneumatic compression device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says the notes indicate that a basic pump was tried for one day with no continued use.
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 device. Our reviewer says that the requested device is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee does not have objective physical exam findings of lymphedema of the chest, trunk, or abdomen. The patient does not have unique characteristics that would indicate the segmented pump over a standard pump. The documentation does not indicates a sufficient trial of a standard pump with four-week trial of conservative therapy demonstrating failed response to treatment with and E0650 or E0651. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve a segmented pneumatic compression device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve modifications to the wheelchair, for the enrollee.
You asked the Plan to pre-approve the modifications to the wheelchair. You say that the enrollee needs
modifications to their current wheelchair. The Plan denied your request. The Plan says the cost of repairs is
more than the wheelchair when it was new. The plan states the enrollee would be better suited to have a brand
new wheelchair with the specific modifications that the enrollee needs and the plan has reached out to the
provider to start the process to obtain a new wheelchair.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the modifications to the wheelchair have not been met. The
enrollee's current wheelchair is two (2) years old. The enrollee's needs have changed and this wheelchair is not
meeting the enrollee's needs. The enrollee's doctor and therapist are asking to modify the enrollee's current
wheelchair to meet their needs. The cost of fixing the wheelchair is a lot. It is greater than the cost of the
wheelchair when it was new. Since your wheelchair needs a lot of changes, the Plan is recommending that you
have a new wheelchair instead of fixing the enrollee's current one. Therefore, we decided that the Plan does not
have to pre-approve modifications to the wheelchair, for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forassisted living provided from January 1, 2020 to January 6, 2020.You asked the Plan to pay forassisted living. You say that you disagree with the Plan's denial and feel this claim should be reimbursed completely.The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is not eligible to participate in Medicare and custodial care services are not covered by Medicare.The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered Medicare items or services, a provider must be enrolled in the Medicare program. We looked at the file and Medicare rules. The servicing facility is an assisted living, memory care, and independent living community which is not eligible to participate in Medicare. Based on this information, we decided that Medicare rules for coverage of assisted living have not been met.Therefore, we decided that the Plan does not have to pay forassisted living provided from January 1, 2020 to January 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for five (5) sets of intraoral x-rays (D0230 and D0220) provided on January 30, 2020.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says the services are not a covered benefit under the 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. The services are not listed in your EOC as a covered benefit; therefore, the services are not covered. Therefore, we decided that the Plan does not have to pay for five (5) sets of intraoral x-rays (D0230 and D0220) provided on January 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided February 2, 2020 to February 14, 2020.You asked the Plan to pay for the dental services. You say that you were led to believe the provider was in-network and the services would be covered.The Plan denied your request. The Plan says this service is not listed as covered benefits.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 periodontal maintenance (D4910) provided February 2, 2020 to February 14, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services (99213) provided on October 18, 2019.
You asked the Plan to pay for the outpatient mental health services. You say that the services were medically necessary. The Plan denied your request. The Plan says there were network providers available.
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 service 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 outpatient mental health services (99213) provided on October 18, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the myocardial perfusion imaging provided on October 24, 2019.
You asked the Plan to waive the copayment for the myocardial perfusion imaging. You say that you refuse to pay this unless you get a subsidy. 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 $150 copayment for CT, MRI, MRA and SPECT scans. You have been asked to pay a $150 copayment for the myocardial perfusion imaging. The myocardial perfusion imaging falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The myocardial perfusion imaging is considered a SPECT scan. 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 myocardial perfusion imaging provided on October 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (A4550) provided on December 31, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "B" under the Physician Fee Schedule indicates that payment for covered services are always bundled into payment for other services not specified. We looked at the file and Medicare rules. Code A4550 is assigned a status indicator of "B" under the Physician Fee Schedule, which means that this is a bundled service. Payment for this service is bundled into payment for other services. No separate payment can be made for the services. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (A4550) provided on December 31, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe emergency room visit provided on April 11, 2019.You asked the Plan to waive the copayment forthe emergency room visit. You say that you did not request the emergency services that were provided to you. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose toits 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 emergency care. You have been asked to pay a $50 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. The medical record shows you were treated for high blood pressure.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 emergency room visit provided on April 11, 2019
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 for the enrollee. You asked the Plan to pre-approve IRF care. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that the enrollee's therapy needs can be provided at a lower level of care. The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient does require skilled physical therapy and occupational therapy but based on the medical records provided the patient does not require treatment in an intensive rehabilitation therapy program. Based on the medical records provided there is concern that the patient would not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy-duty total electric hospital bed (E0265). You asked the Plan to pre-approve a total electric hospital bed. You say that a total electric hospital bed is medically necessary for the enrollee.The Plan denied your request. The Plan says a total electric hospital bed is not a covered benefit under the member's contractual policy.The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate for the enrollee 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 heavy-duty total electric hospital bed (E0265).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on September 12, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
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. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on September 12, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the inpatient hospital stay and the MRI
provided from January 8, 2020 to February 9, 2020.
You asked the Plan to waive the copayments for the inpatient hospital stay and the MRI. You say that you are
requesting a review of the situation and would not like to be held responsible for the MRI and hospital
copayments. 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 $195
copayment per day, days 1-7 for inpatient hospital care and a $125 copayment for diagnostic radiology other
than CT scans when services are performed by a provider other than your primary care physician.
You have been asked to pay a $195 copayment for each day of your inpatient hospital stay. ($195 x 4 = $780).
You have also been asked a $125 copayment for the MRI. The inpatient hospital stay falls within the "Inpatient
hospital care" benefit category. The MRI 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 copayments for the inpatient hospital and the MRI provided from January
8, 2020 to February 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 4, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 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 physician's services provided on October 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe hearing aids purchased on May 2, 2019.You asked the Plan to pay forthe hearing aids. You say that the provider promised that they were in-network andyou paid in full with the thought of getting your reimbursement.The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. Non-emergent services with non-contracted providers require prior-authorization prior to services being rendered.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. The Plan pays for hearing aids only when purchased from an in-network provider. In most cases, care you receive from an out-of-network provider will not be covered. This information is on page 53 of the 2019 Evidence of Coverage. We looked at the file and thePlan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met.Therefore, we decided that the Plan does not have to pay forthe hearing aids purchased on May 2, 2019.