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

We decided that the Plan does not have to waive the copayment for the ER visit provided on January 6, 2020.
You asked the Plan to waive the copayment for the ER visit. You say that you were never seen by a physician and services were not rendered. You say that insurance shouldn't pay and you shouldn't have a copayment. 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 $90 copayment per visit. You have been asked to pay a $90 copayment for the ER visit. The ER visit falls within the "Emergency care" benefit category. The records show that you were triaged in the ER and laboratory tests were ordered. 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 January 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forcomprehensive eye exam (92004) provided November 5, 2019.You asked the Plan to pay forthe vision services. You say that you went to this provider for a second opinion but was not informed that this visit would not be covered and had to be payed out of pocket. You cannot afford to pay the bill which is over $200.The Plan denied your request. The Plan says this service exceeds the benefit frequency limitation of once a year.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. ThePlan covers eye exams only once per year. The record shows that this service was already rendered on May 22, 2019.We looked at the file and the Plan's rules. The plan covers routine eye exams (including refraction) once a year. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met.Therefore, we decided that the Plan does not have to pay forcomprehensive eye exam (92004) provided November 5, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9500) provided on December 27, 2019 through December 31, 2019.
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code S9500 has a status code of I which is not valid for Medicare purposes.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code S9500 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code S9500 has a status code of I. This means that CPT code S9500 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9500) provided on December 27, 2019 through December 31, 2019.
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 December 27, 2019.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 providersavailable 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 December 27, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Psychological Testing Services.You asked the Plan to pre-approve Psychological Testing Services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are not medically necessary.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 Psychological Testing Services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found you were diagnosed with chronic pain and depression. Based on review of the records provided, it was noted that your provider is asking for evaluation through a Beck Depression scale. This can be performed throughout the evaluation without formal psychological testing during your evaluation/visit. Based on review the records provided your requirement of psychological testing is unfounded for the treatment of chronic pain as the testing that is asked for above can be rendered throughout the evaluation. Therefore, you do not meet criteria for the requested testing.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Psychological Testing Services have not been met.Therefore, we decided that the Plan does not have to pre-approve Psychological Testing Services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dextrose in water.You asked the Plan to pre-approve Dextrose in water. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested drug is not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approve Dextrose in water.Benefits for Dextrose in water may be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transport accessories for a power chair (K0108).
You asked the Plan to pre-approve the transport accessories for a power chair. You say that the accessories are medically necessary. The Plan denied your request. The Plan says the transit options are for use outside the home, and are not medical devices.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve transport accessories for a power chair (K0108).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gastric sleeve bariatric surgery procedure.You asked the Plan to pre-approve gastric sleeve bariatric surgery procedure. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are not medically necessary.Medicare rules say that bariatric surgery is only covered when the enrollee's BMI is greater than 35 kg/m2.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 gastric sleeve bariatric surgery procedure. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found you are 5 feet 7 inches tall and weighs 201 pounds, giving you a body mass index (BMI) of 31.49 kg/m2. The documentation does not support that you have a BMI that is greater than 35 kg/m2. Therefore, you do not meet criteria for the requested 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 gastric sleeve bariatric surgery procedure have not been met.Therefore, we decided that the Plan does not have to pre-approve gastric sleeve bariatric surgery procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe prophylaxis and periodic oral evaluation provided on December 20, 2019.You asked the Plan to pay forthe prophylaxis and periodic oral evaluation. You say that you did not know that your coverage was not in effect until January 1, 2020.The Plan denied your request. The Plan says your request is not medically necessary because these services are not covered under Medicare and the EOC does not provide a benefit for these services.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teethor the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pay forthe prophylaxis and periodic oral evaluation provided on December 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the denture repair (D5511) provided on February 13, 2020.
You asked the Plan to pay for the dental service. You say that your upper denture broke. You also say that you cannot afford to pay for them to be repaired. The Plan denied your request. The Plan says denture repair is not a covered service.
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, denture repair is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the denture repair (D5511) provided on February 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copay forthe specialist office visit provided on October 12, 2019.You asked the Plan to waive the copay forthe office visit. You say that you were not aware of the specialist copay charges.The Plan denied your request. The Plan says the copay is a contractual obligation, and was appropriately 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 $45 copay for each specialist visit. You have been asked to pay a $45 copay for the office visit. The visit falls within the physician services 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 copay forthe specialist office visit provided on October 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the Inogen G5 Portable Oxygen Concentrator Package purchased on November 27, 2019.
You asked the Plan to reimburse you for the portable oxygen concentrator (POC). You say that to improve your quality of life you need a POC that can plug into a vehicle and be used when traveling. The Plan denied your request. The Plan says you did not have prior authorization for the POC from an out of network provider.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare rules say that only rented oxygen equipment is eligible for coverage. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Purchased oxygen equipment is statutorily non-covered by Medicare. Therefore, we decided that the Plan does not have to reimburse you for the Inogen G5 Portable Oxygen Concentrator Package purchased on November 27, 2019.
Appeal type: Imaging
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 February 11, 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 networkproviders 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 February 11, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services provided to the enrollee by an out-of-network provider on December 10, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not authorized.The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan.The services at issue in this appeal were not provided in an emergency or urgent care situation. These services were not provided by the Plan or through arrangements with them.Therefore, we decided that the Plan does not have to pay forthe services provided to the enrollee by an out-of-network provider on December 10, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay forgenetic testing services provided to the enrollee on June 8, 2018.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthis was routine care and 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 involvingemergencies, 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 notpre-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 Plandoes not haveto pay forgenetic testing services provided to the enrollee on June 8, 2018
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate for the periodontal scaling and root planing (D4342 x 2), the gingival irrigation (D4921 x 2), and the drug administration (D9630) provided on January 27, 2020 by out of network provider.
You asked the Plan to pay the in network rate for the periodontal scaling and root planing, gingival irrigation, and drug administration. You say that the provider is in network. The Plan denied your request. The Plan says the periodontal scaling and root planing, gingival irrigation, and drug administration are not listed as covered services.
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 periodontal scaling and root planing, gingival irrigation, and drug administration are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay the in network rate for the periodontal scaling and root planing (D4342 x 2), the gingival irrigation (D4921 x 2), and the drug administration (D9630) provided on January 27, 2020 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forvision care provided on January 22, 2020.You asked the Plan to waive the copayment forvision care. You say that you are being charged a $50 copayment.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 copayment for vision care. You have been asked to pay a $10 copayment for vision care. Vision care falls within the vision 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 copayment forvision care provided on January 22, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on December 4, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was not billed correctly.
The Plan must follow Medicare rules. The rules say that a claim for a referred laboratory service that does not contain the modifier 90 is returned as unprocessable if the claim can otherwise be identified as being for a referred service. We looked at the file and Medicare rules. The file shows that the provider submitted a claim for procedure code 88360 with modifier 90. 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 laboratory services rendered on December 4, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the inpatient rehabilitation services provided from November 28, 2019, to December 4, 2019.
You asked the Plan to waive the copay for the inpatient services. The Plan denied your request.
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 $295 copay per day for days 1-6 for inpatient hospital care. You have been asked to pay a $295 copay per day for days 1-6 for the inpatient services. However, as a courtesy the Plan has agreed to waive the copay for day 6. This means that you are only responsible for $1475, which is days 1-5 of the inpatient care. The services fall 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 further waive the copay for the inpatient rehabilitation services provided from November 28, 2019, to December 4, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on November 18, 2019.
You asked the Plan to waive the copayment for laboratory services. You say that you previously had no copayment for laboratory services at the same facility. 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 $45 copayment for lab services at an in-network outpatient hospital. You have been asked to pay a $45 copayment for the laboratory services. Laboratory services 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 services provided on November 18, 2019.
Please note, the Explanation of Benefits issued to you may contain inaccurate information about this claim. Please contact the health plan to receive a corrected Explanation of Benefits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing services provided on January 16, 2020.You asked the Plan to pay forthe drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records stating exactly what tests are to be performed.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician orderor lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met.Therefore, we decided that the Plan does not have to pay forthe drug testing services provided on January 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran office visit and physical therapy provided by a chiropractor from January 2, 2020 to January 30, 2020.You asked the Plan to pay foroffice visit and physical therapy. You say that these services help manage your pain level and perform activities of daily living.The Plan denied your request. The Plan says the denial of payment for these services is correct, because these services are not covered by Medicare or the Plan when performed by a chiropractor.The Plan must follow Medicare rules. The rules say that theonly 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 foran office visit and physical therapy provided by a chiropractor from January 2, 2020 to January 30, 2020.