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

We decided that the Plan does not have to waive the coinsurance for extracapsular cataract removal provided on September 9, 2020.
You asked the Plan to waive the coinsurance for extracapsular cataract removal. You say that you received a letter stating that you would not owe any copayments through September 2020. 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 $350 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities. You received extracapsular cataract removal on September 9, 2020, at an outpatient hospital facility. Extracapsular cataract removal is considered an outpatient surgical procedure and is not included in the COVID-19 waiver. Therefore, you are responsible to pay the $350 copayment.
You have been asked to pay a $350 copayment for extracapsular cataract removal. Extracapsular cataract removal falls within the outpatient surgery and other medical 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 coinsurance for extracapsular cataract removal provided on September 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on January 22, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says the services were not urgent, emergent, or approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the lab 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 lab services provided on January 22, 2021 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); maxillary sinus ostium, transnasal or via canine fossa (31295) and nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); frontal and sphenoid sinus ostia (31298) provided to the enrollee on October 29, 2020.
You asked the Plan to pay for these services. You say that these services were medically necessary. The Plan denied your request. The Plan says that there was no documentation of a computed tomography report.
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 pay for these services. Our reviewer says that the requested services were not considered medically reasonable and necessary in this case. The CT scan was performed before the patient had undergone maximal medical management.
Before performing the CT, there is no documentation that the patient had been on 2 or 3 rounds of antibiotics, antihistamines, intranasal steroid sprays, sinus rinses/lavages. In addition, the CT showed very minimal sinus disease which does not meet the criteria for a sinus procedure. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); maxillary sinus ostium, transnasal or via canine fossa (31295) and nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); frontal and sphenoid sinus ostia (31298) provided to the enrollee on October 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and laboratory test provided by an out-of-network provider on January 5, 2021.
You asked the Plan to pay for the office visit and laboratory test. You say that the documentation supports the service has been deemed payable. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the service was not approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 office visit and laboratory test provided by an out-of-network provider on January 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (80053, 80061, 36415, 82043, 83036,
84436, 84443, 84480, 85025) and the one-way travel for laboratory specimen collection drawn from a home
bound or nursing home bound patient (P9604) rendered by the OON provider on January 26, 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 laboratory services (80053, 80061, 36415, 82043, 83036, 84436, 84443,
84480, 85025) and the one-way travel for laboratory specimen collection drawn from a home bound or nursing
home bound patient (P9604) rendered by the OON provider on January 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for inpatient hospital care provided on January 19, 2021.

You asked the Plan to waive the co-payment for inpatient hospital care. You say that the co-payment should be waived because you were supposed to only be in the hospital for one day. The Plan denied your request. The Plan says the cost share was applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $360 co-payment each day one through five for inpatient hospital care.

You have been asked to pay a $360 co-payment each day one through five for inpatient hospital care. This service falls within the inpatient hospital 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 co-payment for inpatient hospital care provided on January 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on October 8, 2019 by an out of network (OON) provider.

You asked the Plan to pay for the office visit. You say that the Plan told you that the enrollee did not need approval for the services. The Plan denied your request. The Plan says no prior authorization was obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.

Therefore, we decided that the Plan does not have to pay for the office visit provided on October 8, 2019 by an
out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the dermatology services provided on January 7, 2021 by an out of network provider.

You asked the Plan to pay for the dermatology services. You say that the enrollee was unaware that authorization was needed. The Plan denied your request. The Plan says you did not request 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 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 dermatology services provided on January 7, 2021 by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe two gingival irrigations (D4921 x2), non-intravenous conscious sedation (D9248), and drugs or medicaments dispensed in the office for home use (D9630 x2) provided on December 2, 2020.You asked the Plan to pay forthe gingival irrigations, non-intravenous conscious sedation, and drugs or medicaments. You say that you believe these services should be covered because you paid for extra dental coverage.The Plan denied your request. The Plan says these services are not covered benefits under your dental 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 forthe two gingival irrigations (D4921 x2), non-intravenous conscious sedation (D9248), and drugs or medicaments dispensed in the office for home use (D9630 x2) provided on December 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor.

You asked the Plan to pre-approve a therapeutic continuous glucose monitor. You say that this device would be helpful in managing your diabetes. The Plan denied your request. The Plan says the criteria for coverage have not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.

We looked at the file and Medicare rules. The documentation indicates that you do not perform blood glucose testing at least four times per day and do not require frequent self-adjustment of insulin dosage based on the blood glucose testing results.

Based on this information, we decided that Medicare rules for coverage of a therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forimmunizations and administrations provided on September 2, 2020 and November 3, 2020.You asked the Plan to pay forimmunization administration (90471, 90472) and Zoster vaccine (90750). You say that the Plan should pay the claims.The Plan denied your request. The Plan says administration denied for not having a vaccine billed, Zostavax is not covered, and remaining claims are duplicate charges.You can submit your request for reimbursement to the prescription drug plan.Inthe absence of injury or direct exposure to illness, Medicare does not pay for or provide immunization administration (90471, 90472)without a covered vaccine, or the Zoster vaccine (90750). The Plan follows the same rules. The Zostervaccine is not covered.The immunization administration is not covered without a covered vaccine. Therefore, we decided that the Plan does not have to pay forimmunizations and administrations provided on September 2, 2020 and November 3, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea therapeutic continuous glucose monitor.You asked the Plan to pre-approvea therapeutic continuous glucose monitor. You say that this device is medically necessary for your diabetes.The Plan denied your request. The Plan says the coverage criteria have not been met.The Plan follows Medicare rules. Medicare rules say that therapeutic CGMs may be considered reasonable and necessary for enrollees with diabetes who meet the criteria referenced 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 a therapeutic continuous glucose monitor. Our reviewer says that the criteria for the therapeutic continuous glucose monitor have not been met. Our physician reviewer found the record indicates that the enrollee has diabetes. The enrollee is receiving a set dose of insulin and does not adjust the does based upon the reading. As a result, the elements of the coverage criteria are not satisfied. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a therapeutic continuous glucose monitor have not been met.Therefore, we decided that the Plan does not have to pre-approvea therapeutic continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for specialist visits provided on January 27, 2021, to March 10, 2021.
You asked the Plan to waive the coinsurance for specialist visits. You say that you disagree with the increase in charges and feel that you should owe a lower 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 physician/practitioner services, including doctor's office visits. You had a specialist visit on January 27, 2021, with an out-of-network provider. The total allowed amount is $99.02 and 50% of that is $49.51. You had a specialist visit on March 10, 2021, with an out-of-network provider. The total allowed amount is $99.02 and 50% of that is $49.51. The total amount you owe is: $99.02. You have been asked to pay the total coinsurance amount of $99.02 for specialist visits. specialist visits fall within the physician/practitioner services, including doctor's office 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 for specialist visits provided on January 27, 2021, to March 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe prolonged evaluation services provided on January 26, 2021, by a non-network provider.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were rendered by a non-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. 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 forthe prolonged evaluation services provided on January 26, 2021, by a non-network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forphysical therapy provided bya participating provider on October 1, 2020, to November 17, 2020.You asked the Plan to waive the copayment forphysical therapy. You say that you thought that these copayments were waived until December. You say that no one told you they started again.The Plan denied your request. The Plan says the correct copayments have been applied.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for outpatient rehabilitation services/in-network. You have been asked to pay a $40 copayment for each physical therapy. The total amount you are being asked to pay is $560 ($40 x 14 visits = $560).  Physical therapy falls within the outpatient rehabilitation services/in-network benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forphysical therapy provided by a participating provider on October 1, 2020, to November 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on January 18, 2021.
You asked the Plan to pay for the chiropractor office visit. You say that you would like the Plan to pay this claim. The Plan denied your request. The Plan says all services other than manual manipulation of the spine for treatment of subluxation of the spine are excluded when ordered or performed by a Doctor of Chiropractic.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the office visit provided on January 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided by an out-of-network provider on January 4, 2021.
You asked the Plan to pay for the physician services. You say that the treatment was medically necessary to not compromise the patient's health and well-being. You say that the claim should be considered for payment despite the absence of authorization. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the service was not approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 physician services provided by an out-of-network provider on January 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an astigmatism-correcting function of an intraocular lens (IOL) (V2787) provided on January 12, 2021.
You asked the Plan to pay for the astigmatism-correcting function of an IOL. You say that you received a multi-focal lens that would help to adjust your vision so you would not have to wear eyeglasses or reading glasses. The Plan denied your request. The Plan says this item is not covered by Medicare.
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL or a P-C IOL during cataract surgery, the enrollee will be responsible for the difference in cost between the
A-C IOL or the P-C IOL and a conventional IOL. While an A-C IOL or a P-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatism-correcting feature of an IOL. Therefore, we decided that the Plan does not have to pay for an astigmatism-correcting function of an intraocular lens (IOL) (V2787) provided on January 12, 2021.