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

We decided that the Plan does not have to pay for the ambulance services.You asked the Plan to pay for the ambulance services. You say that you felt dizzy and fainted while walking outside of your home. You say that you called an ambulance when you regained consciousness. When the ambulance responders arrived, you had already begun to feel better and was able to great them and reenter your home. You say you believe that by not going to the hospital you did not incur additional expenses for yourself and the Plan.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on October 10, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the office visit, hearing test and eardrum testing provided on July 22, 2019.
You asked the Plan to waive the copayments for the office visit, hearing test and eardrum testing. You say that you were not asked if you wanted a hearing test. You say that you paid the copayment and thought everything else was covered. The Plan denied your request. The Plan says the copayments 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 $45 copayment for each covered specialist office visit and a $45 copayment for each Medicare-covered hearing exam to determine if you need medical treatment for a hearing condition.
You have been asked to pay a $45 copayment for the office visit and a $45 copayment for the hearing test and eardrum testing. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The hearing test and eardrum testing fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. 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 copayments for the office visit, hearing test and eardrum testing provided on July 22, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-ray provided on September 20, 2019.
You asked the Plan to waive the copayment for the x-ray. You say that you should not be responsible for the duplicate x-ray 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). Your contract with the Plan clearly says that you must pay a $30 copayment for each Medicare-covered test. You have been asked to pay a $30 copayment for the x-ray. The x-ray falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows the order was for an ankle x-ray and you received the 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 x-ray provided on September 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for portable oxygen contents provided from June 19, 2019 through September 19, 2019.You asked the Plan to waive the coinsurance for portable oxygen contents. You say that you never used to pay for oxygen contents. You say that it is not fair to pay for supplies in the middle of the benefit year.The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for durable medical equipment. You have been asked to pay $13.28, which is 20% of the allowed amount for the portable oxygen contents each month. The allowed amount is $66.38 ($20% x $66.8 = $13.28). The total amount you owe is $53.12 ($13.28/month x 4 months = $53.12). Portable oxygen contents fall within the "Durable medical equipment (DME) and related 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 portable oxygen contents provided from June 19, 2019 through September 19, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the Spinal
Canal (72156, 72142, 72141).
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 the record has not shown that an MRI is medically necessary at this time.
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
coverage criteria has not been met. Our physician reviewer found the provider did not outline a differential
diagnosis, clinical concern, or conservative plan of care. Without the support of the documentation, medical
necessity cannot be determined.
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 Spinal Canal (72156, 72142, 72141).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on August 14, 2019 by out of network provider.
You asked the Plan to pay for the out-of-network services. You say that the notes support the need for services. The Plan denied your request. The Plan says non-emergent services by non-participating 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 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 out-of-network services. Therefore, we decided that the Plan does not have to pay for the physician services provided on August 14, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by the out of network (OON) thoracic surgeon.
You asked the Plan to pre-approve the OON thoracic surgery services. You say that the enrollee needs this surgery and you feel that the enrollee's chosen university is the closest facility to provide this surgery. The Plan denied your request. The Plan says there are several other network providers who are closer to the enrollee's residence who can provide this thoracic surgery. There is no need for referral to the enrollee's chosen university.
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 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. 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 the medical services to be provided by the out of network (OON) thoracic surgeon.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gelsyn-3 (J7328). You asked the Plan to pre-approve Gelsyn-3. You say that Gelsyn-3 is medically necessary.The Plan denied your request. The Plan says a trial of plan preferred agents is required first.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 Gelsyn-3. Our reviewer says that coverage criteria has not been met. Our physician reviewer found the documents do not show a trial of the plan preferred agents Orthovisc and Monovisc or any reason why they would be contraindicated for this enrollee.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gelsyn-3 have not been met.Therefore, we decided that the Plan does not have to pre-approve Gelsyn-3 (J7328).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an out-of-network provider on May 7, 2019.You asked the Plan to pay for the services. You say that you did not know that prior authorization was needed.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 forthe medical services provided by an out-of-network provider on May 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiopulmonary exercise testing and diagnostic testing provided on June 28, 2019.
You asked the Plan to pay for the cardiopulmonary exercise testing and diagnostic testing. The Plan denied your request. The Plan says non-urgent, non-emergent services require prior authorization. The Plan requires utilization of network providers when possible and 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 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 cardiopulmonary exercise testing and diagnostic testing provided on June 28, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on July 3, 2019.You asked the Plan to pay for the drug testing. The Plan denied your request. The Plan says non-urgent, non-emergent services require prior authorization. The Plan requires utilization of network providers when possible and 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 and the referring provider in this case are not network providers 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 drug testing provided on July 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on August 9, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan 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 laboratory services provided on August 9, 2019
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe hip x-ray, set up, and transportation of x-ray equipment provided on June 26, 2019 by the out of network provider.You asked the Plan to pay forthe radiology services. You say that the enrollee wasreferred to you for the services.The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan says the enrollee's primary care physician did not refer them for the services. The Plan also says the service was not urgent or emergent.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 a network provider with the Plan, but is not a network provider with the enrollee's Medical Group. The referring provider is not a network provider either. 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 forthe hip x-ray, set up, and transportation of x-ray equipment provided on June 26, 2019 by the out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for bone and/or joint imaging; whole body (78306), bone and/or joint imaging; tomographic (78320), and technetium tc-99m medronate (A9503) provided on January 28,2019 by out of network provider.You asked the Plan to pay for bone and/or joint imaging; whole body, bone and/or joint imaging; tomographic, and technetium tc-99m medronate. You say that the services were provided and payment should be rendered.The Plan denied your request. The Plan says the services were obtained from an out-of-network provider without prior authorization, therefore coverage criteria has not been met.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 bone and/or joint imaging; whole body (78306), bone and/or joint imaging; tomographic (78320), and technetium tc-99m medronate (A9503) provided on January 28, 2019 by out of network provider.
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.
You asked the Plan to pre-approve IRF care. You say that the enrollee requires IRF care to return to his previous level of function. The Plan denied your request. The Plan says the enrollee's needs could be met 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. Our physician reviewer found the records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a SNF. The enrollee is mostly minimal/standby assist for functional transfers and activities of daily living. A less intensive, longer duration of therapy will allow for measurable gains to be attained within a predicted period. 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.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for the office visit provided on August 15, 2019.
You asked the Plan to waive the copayment for the office visit. You say that you should not be charged a
copayment for a primary care office visit. The Plan denied your request. The Plan says that 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. Your
contract with the Plan says that enrollees must pay a $0 copayment for each primary care doctor visit for
Medicare-covered benefits.
The Plan says you must pay a $35 copayment for the office visit. Based on the Plan contract, however, you
cannot be asked to pay more than a $0 copayment for the office visit. The record shows the provider is a
primary care provider. Therefore, we decided that the Plan has to waive the copayment for the office visit
provided on August 15, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient hospital visit provided by an out-of-network provider, on April 18, 2019.You asked the Plan to waive the copayment for an outpatient hospital visit. You say that you cannot afford to incur over $1,200 annually for these periodic finger pricks. You say that you will contest any attempts to charge you for these sums in the future if they are not clearly warranted.The Plan denied your request. The Plan says the correct copayment has been applied to the services in question.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 outpatient surgery/out-of-network/outpatient hospital facility. You have been asked to pay $128.97 which is less than your copayment amount of $250 for an outpatient hospital visit. The correct copayment has been applied to the outpatient hospital visit that wasprovided. An outpatient hospital visit falls within the outpatient surgery/out-of-network/outpatient hospital facility 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 fo ran outpatient hospital visit provided by an out-of-network provider, on April 18, 2019.