Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor.
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your
request. The Plan says the enrollee only tests their blood glucose twice a day and does not take insulin.
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 monitor. Our reviewer says that the
requested services are not considered medically reasonable and necessary 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 monitor have not been met. Therefore, we decided that the Plan does not
have to pre-approve a Freestyle Libre continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 28, 2020, by an OON provider.
You asked the Plan to pay for a domiciliary or rest home visit. You say that these services were rendered in good faith to the enrollee. The Plan denied your request. The Plan says rules for payment have 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 the medical services provided on January 28, 2020, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the pacemaker check you had on August 18, 2020.
You asked the Plan to waive the copayment for the pacemaker check. You say that this copayment should be waived during the COVID-19 pandemic. 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 $25 copayment for non-radiological diagnostic services. You have been asked to pay a $25 copayment for the pacemaker check. The pacemaker check falls within the non-radiological diagnostic services benefit category. There is no provision in your Plan contract for a waiver of this copayment. 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 pacemaker check you had on August 18, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER visit provided on January 12, 2020,
and February 2, 2020.
You asked the Plan to waive the copayment for the ER visits. You say that the copayment is waived if you are
admitted to the hospital following an ER visit. You say that the copayments were billed incorrectly. 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). The enrollee's contract with the Plan clearly says that she must pay
a $90 copayment for each emergency room visit.
You have been asked to pay a $90 copayment for each emergency room visit. The total amount you owe is
$180 ($90/visit x 2 visits = $180). The ER visits fall within the "Emergency Care" benefit category. The
records do not show that the enrollee was admitted to outpatient observation or inpatient care. This means that
you have been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a
contractual obligation agreed to pay when the enrollee enrolled in the Plan. Therefore, we decided that the Plan
does not have to waive the copayment for the ER visit provided on January 12, 2020, and February 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on September
8, 2020.
You asked the Plan to pay for the dental services. You say that you had a very bad toothache your filling and
tooth was falling out. You say that you were not sure if the service should have been pre-approved because this
was the first time you had been in that situation. You also say that if a provider refers someone to a specialist, it
is assumed that everything is being done according to the plan. The Plan denied your request. The Plan says 1
limited oral evaluation per plan year is covered. The Plan says that the frequency limit for this service has been
exceeded.
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 and limited oral evaluations are listed
as a covered service, the frequency limit of 1 per plan year has been exceeded. The record shows that the Plan
paid for a limited oral evaluation that you received on August 11, 2020. Therefore, we decided that the Plan
does not have to pay for the limited oral evaluation (D0140) provided on September 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac joint radiofrequency ablation for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the medical research articles have not shown that the use of this kind of treatment improves the outcomes.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is considered experimental/investigational due to the wide variation in efficacy in the peer-reviewed literature. Therefore, the request is considered not medically reasonable or necessary. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroiliac joint radiofrequency ablation for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance transportation provided on July 25, 2020 and July 30, 2020.
You asked the Plan to waive the copayment for ambulance transport. You say that this is the only ambulance provider in the area and should be processed as in-network. The Plan denied your request. The Plan says the copayment amounts the enrollee is being charged are correct.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that the enrollee must pay $265 copayment per date of service, regardless of the number of trips, for ambulance transportation. There were two dates of service, resulting in a total copayment amount of $530. The enrollee has been asked to pay $265 copayment per date of service for ambulance transport. Ambulance transport falls within the Ambulance Services benefit category. This means that the enrollee has been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay when they enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance transportation provided on July 25, 2020 and July 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory tests provided on June 22, 2020,
and August 5, 2020.
You asked the Plan to waive the copayment for laboratory tests. You say that you have never been charged a
copayment in the past 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 $20
copayment for labs.
You received labs on June 22, 2020, and August 5, 2020. Therefore, you are responsible to pay a $20
copayment per each visit. The total amount you owe is: $40.
You have been asked to pay the total copayment amount of $40 for laboratory tests. Laboratory tests fall 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 laboratory tests provided on June 22, 2020, and August 5, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on March 3, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are available in-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on March 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on August 18, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on August 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on January 4, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not authorized.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on January 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe psychotherapy services provided on July 22, 2020.You asked the Plan toreimburse you forthe psychotherapy services. You say that the Plan should reimburse you because you are required to see this provider.The Plan denied your request. The Plan says the provider has opted out of Medicare.The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program.Therefore, we decided that the Plan does not have to reimburse you forthe psychotherapy services providedon July 22, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea pneumatic compression device for the enrollee.You asked the Planto pre-approvethe device. You say that this is medically necessary.The Plandenied your request. The Plansaysthere has not been a failure of a four week trial of conservative therapy.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 services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee does not have objective evidence of lymphedema on a physical exam that in in the chest, trunk, or abdomen. The enrollee does not have unique characteristics that would indicate the segmented pump over a standard pump. There is no documentation of a trial and failure of the standard pump.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 Plandoes not haveto pre-approvea pneumatic compression device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the repair resin partial denture base (D5611), problem
focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), additional intraoral periapical
x-ray (D0230), two extractions (D7140 x2), periodic oral evaluation (D0120), and prophylaxis (D1110)
provided from July 16, 2020, to August 20, 2020, by an OON provider.
You asked the Plan to pay for the dental services. You say that prior to being treated, you contacted the Plan
and were advised that this treating provider was in-network. You also say that you would like these fees waived
because you were misinformed by the Plan. The Plan denied your request. The Plan says when you use an
OON provider, the cost can be higher. The Plan also says that your call with them was reviewed, and your
benefits were explained correctly.
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, you are responsible for the difference
between the billed amount and allowed amount. Therefore, we decided that the Plan does not have to pay for
the repair resin partial denture base (D5611), problem focused limited oral evaluation (D0140), first intraoral
periapical x-ray (D0220), additional intraoral periapical x-ray (D0230), two extractions (D7140 x2), periodic
oral evaluation (D0120), and prophylaxis (D1110) provided from July 16, 2020, to August 20, 2020, by an
OON provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography services coded 70450 provided on
August 30, 2020.
You asked the Plan to pay for the computed tomography services. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately
payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450
for the computed tomography service has a bundled relationship with code 70496 and cannot be paid as billed.
This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have
not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography services
coded 70450 provided on August 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the compression stockings identified with code A6530 that were issued on August 11, 2020.
You asked the Plan to pay for the compression stockings. You say that you were told that your insurance company required using these stockings before surgery to see if your condition could be corrected. The Plan denied your request. The Plan says the denial of payment for these supplies is correct, because these compression stockings are not covered by Medicare.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression stockings identified with code A6530 that were issued on August 11, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for a cardiovascular stress test, Single-Photon Emission Computed Tomography (SPECT) test, and technetium imaging contrast supplies provided on June 10, 2020.
You asked the Plan to waive the cost-sharing for stress test, SPECT test, and imaging supplies. You say that these cost-sharing amounts should be waived. The Plan denied your request. The Plan says the cost-sharing amounts you are being charged are correct.
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 copayment for stress test, $75 copayment for SPECT test, and 20% coinsurance for imaging supplies. The allowed amount of the imaging supplies is $243.40, resulting in a coinsurance amount of $48.68. Your total cost-sharing responsibility is therefore $143.68. You have been asked to pay $20 copayment for stress test, $75 copayment for SPECT test, and 20% coinsurance for imaging supplies. Stress test, SPECT test, and imaging supplies fall 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 cost-sharing for a cardiovascular stress test, Single-Photon Emission Computed Tomography (SPECT) test, and technetium imaging contrast supplies provided on June 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for orthotic items provided on May 27, 2020.
You asked the Plan to pay for orthotic items. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for these items is correct, because the documentation does not support a valid telemedicine service with the ordering physician.
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 orthotic items provided on May 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe surgical service provided on September 1, 2020.You asked the Plan to waive the copayment forthe surgical service. You say that you should not have a copayment.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 $125 copayment for outpatient surgery.You have been asked to pay a $125 copayment for the surgical service. The surgical service falls within the outpatient surgery 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 forthe surgical service provided on September 1, 2020.