Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for outpatient mental health services (90797,
90834 and 90837) provided on October 7, 2019 through December 2, 2019.
You asked the Plan to reduce the copayment for the outpatient mental health services. You say that you would
like reconsideration because you were told these services would have a lower copayment. The Plan denied your
request. The Plan says there is a $90 copayment for outpatient mental health care when rendered by a
participating provider.
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 for Outpatient Mental Health Care provided in an outpatient hospital setting.
You have been asked to pay a $90 copayment for the outpatient mental health services. These services fall
within the Outpatient Mental Health 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 reduce the copayment
for outpatient mental health services (90797, 90834 and 90837) provided on October 7, 2019 through
December 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on June 24, 2019.
You asked the Plan to waive the copayment for an office visit. You say that only preventative services were rendered and you should not be responsible for 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 each visit with a primary care provider. You had an office visit on June 24, 2019. Due to the diagnostic codes on the claim, services provided went beyond preventative. Therefore, you are responsible to pay the $20 copayment. You have been asked to pay a $20 copayment for an office visit. An office visit falls 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 copayment for an office visit provided on June 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound repair services provided on September 3, 2019 billed with CPT code 12042.
You asked the Plan to pay for the wound repair services. You say that this was billed correctly and should be paid. The Plan denied your request. The Plan says the documentation does not support that an intermediate repair was performed.
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, the CPT Code Manual definition of code 12042 is Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 2.6 cm to 7.5 cm. 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 the wound repair services. Our reviewer says that the records does not support the billed services. Our physician reviewer found the medical records provided indicate that a "Simple" repair was performed, therefore the service billed cannot be verified and it is inappropriate to use CPT 12042 to bill for the service that was provided. 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 wound repair services have not been met. Therefore, we decided that the Plan does not have to pay for the wound repair services provided on September 3, 2019 billed with CPT code 12042.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora tetanus, diphtheria toxoids and a cellular pertussis vaccine (Tdap) vaccine (90715) provided on March 27, 2019.You asked the Plan to pay fora Tdap vaccine. You say that you were not aware how your vaccine coverage worked.The Plan denied your request. The Plan says coverage of this vaccine is the responsibility of your Part D plan.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a Tdap vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to a Tdap vaccine.Therefore, we decided that the Plan does not have to pay fora tetanus, diphtheria toxoids and a cellular pertussis vaccine (Tdap) vaccine (90715) provided on March 27, 2019.Benefits for a Tdap vaccine 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lower extremity MRI.
You asked the Plan to pre-approve the MRI. You say that you are in pain, cannot walk and your doctor suspects a tear. The Plan denied your request. The Plan says there is no documentation to suggest a ligament tear.
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 based on the information provided by the ordering physician, the request for an MRI of the lower extremity does not meet medical necessity criteria. Our physician reviewer found the record indicates that your osteoarthritis is stable, and the examination of the knee does not note any exam finding or maneuvers that are suggestive of ligament derangement. 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 a lower extremity MRI.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for sterile needles (A4215) and stimulation test leads (A4290) provided on November 6, 2019. You asked the Plan to pay for the supplies. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says these supplies are statutorily not covered. 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 A4215 and A4290 is not supported in the record. Specifically, the record indicates that these supplies were used during surgery. These supplies are statutorily not covered. Based on this information, we decided that Medicare rules for coverage of the supplies have not been met. Therefore, we decided that the Plan does not have to pay for sterile needles (A4215) and stimulation test leads (A4290) provided on November 6, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services (99308) provided on January 17, 2019.
You asked the Plan to pay for the outpatient mental health services. You say that the services were medically necessary. The Plan denied your request. The Plan says these services were not pre-authorized or emergent. There were network providers who could render the services at issue.
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 item/service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the outpatient mental health services (99308) provided on January 17, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided on October 29, 2019.
You asked the Plan to pay for the air ambulance service. You say that the air ambulance service was medically
necessary. The Plan denied your request. The Plan says the submitted information does not include clinical
notes, patient assessment, or glucose levels.
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your
medical condition is such that transportation by ground ambulance is not appropriate.
We looked at the file and Medicare rules. There is no documentation supporting medical necessity. Based on
this information, we decided that Medicare rules for coverage of the air ambulance service have not been met.
Therefore, we decided that the Plan does not have to pay for services provided on October 29, 2019.
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 September 10, 2019.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 forthe medical services provided to the enrollee by an out-of-network provider on September 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe tetanus, diphtheria, and acellular pertussis (Tdap) vaccine rendered to you on October 11, 2019.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 vaccine is not covered.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide these services. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to these services.Therefore, we decided that the Plan does not have to pay forthe tetanus, diphtheria, and acellular pertussis (Tdap) vaccine rendered to you on October 11, 2019.Benefits for these servicesmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for over the counter (OTC) items, medication co-payments and medical bill for Flex Benefit reimbursement for March 29, 2019 to November 6, 2019.You asked the Plan to pay forOTC items, medication co-payments and medical bill. You say that you were not advised that there was a deadline for sending in the receipts. You are 72 years old and unemployed and really need some of this money just to buy food.The Plan denied your request. The Plan says submitted after the filing limit and apple cider vinegar tablets, medical bill payments and medication co-payments are not covered under the Flex Benefits.The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items. However, the plan offers a Flex benefit that exceeds Medicare coverage. Forthat reason, the plan's coverage rules apply in this case. The Flex Benefit covers up to $400 annual for non-Medicare healthcare expenditures. Theclaim was submitted past the timely filing limit but theplan had agreed to reimburse $118.52 for covered Flex Benefit items as a one-time exception.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of OTC items, medication co-payments and medical bill have not been met.Therefore, we decided that the Plan does not have to pay forover the counter (OTC) items, medication co-payments and medical bill for Flex Benefit reimbursement for March 29, 2019 to November 6, 2019.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to charge a coinsurance for an office visit. We decided that the Plan does not have to waive the cost-sharing for an office visit. You asked the Plan to reduce the deductible for an office visit. You say that you have always paid $50 before.The Plan says that the correct deductible amount has been applied.We decided that the Planhas to charge a coinsurance foran office visit.The Plan follows Medicare rules. Medicare rules say that after your deductible is met you must pay a 30% coinsurance for an out-of-network office visit.We also decided that the Plandoes not have to waive the cost sharing amount for an office visit.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% coinsurance for an out-of-network office visit. The total amount you are being asked to pay is 33.66 ($112.19 (allowed amount) x 30% coinsurance = $33.66).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 foran office visit provided on November 21, 2019.You asked the Plan to waive the copayment foran office visit. You say that this was an annual wellness visit and you 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 $10 copayment for each primary care provider visit. The medical records show that you received services beyond an annual wellness visit on November 21, 2019. Therefore, you are responsible to pay the $10 copayment. You have been asked to pay a $10 copayment for an office visit. An officevisit falls 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 copayment foran office visit provided on November 21, 2019
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from November 25, 2019 to November 29, 2019. You asked the Plan to pay for this service. You say that this claim should be paid, and the enrollee had prior authorization. The Plan denied your request. The Plan says prior authorization was approved for rendered services; however, this practice is not in-network with the Plan. The claim forms do not have the appropriate home health data to process and pay the claim. The final claim must have the appropriate Type of Bill or 329 to process and pay the claim. The Plan states they accept a submission of a corrected claim to consider services for payment. 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. Medicare requires providers to submit claims with the appropriate codes and appropriate bill types. The claim submitted required a specific bill type for submission. This claim cannot be paid as billed. The Plan states a corrected claim would be accepted if submitted. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay for home health services provided to the enrollee from November 25, 2019 to November 29, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids purchased June 4, 2019.
You asked the Plan to pay for the hearing aids. You say that there is a $640 allowance and the claim was denied for maximum benefit exceeded but you did not use it. The Plan denied your request. The Plan says the maximum benefit limit has been exceeded.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only The plan pays up to $600 allowance for hearing aids every 3 years. The records show that the plan has paid the following amounts towards the $600 allowance for the hearing aid benefits: $147 paid on 10/14/2016, $343 paid on 109/18/17, and $73.50 paid on 03/23/18. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids purchased June 4, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve repeat RFA.You asked the Plan to pre-approve the repeat RFA. You say that the repeat RFA is medically necessary. The Plan denied your request. The Plan says thatthe member's pain relief did not last for six months.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review thecase file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the repeat RFA. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates the member had 90% pain relief for six months.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 repeat RFA have been met. Therefore, we decided that the Plan has to pre-approve repeat RFA.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric care beyond March 8, 2020.You asked the Plan to pre-approve the continued inpatient psychiatric care. You say that the enrollee should be allowed to receive continued care.The Plan denied your request. The Plan says the enrollee has stabilized and can be managed in outpatient setting.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 continued inpatient psychiatric care. Our reviewer says that the requested inpatient psychiatric services are not considered reasonable and necessary beyond the approved dates. Our physician reviewer found this 50-year-old male was admitted to the acute inpatient psychiatric hospitalization on March 1, 2020 with Major Depressive Disorder, Recurrent, Severe without Psychosis. Based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time beyond the dates in question as he was not showing any dangerousness to self or others, no auditory or visual hallucinations and no aggressive behaviors including aggression, describing his mood as "awesome". This patient was compliant with treatment. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as he did not have any suicidal or homicidal thoughts, delusions or hallucinations or aggressive behaviors. The health plan's denial of continued inpatient psychiatric services appears appropriate. This enrollee did not require inpatient mental health treatment beyond the dates in question as noted above as he was not a danger to himself or others and did not have any illusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve the patient's condition or for the purpose of diagnosis.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 continued inpatient psychiatric care have not been met.Therefore, we decided that the Plan does nothave to pre-approvecontinued inpatient psychiatric care beyond March 8, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe colonoscopy provided on September 10, 2019.You asked the Plan to waive the copayment forthe colonoscopy. You say that you were informed the colonoscopy would be fully covered. You say that you may have declined the procedure if you knew there would be additional costs.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 $100 copayment for Medicare-covered services provided in an ambulatory surgical center.You have been asked to pay a $100 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatientfacilities and ambulatory surgical centers" benefit category. The records show that polyps were removed, which makes this a surgical procedure. 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 colonoscopy provided on September 10, 2019.