Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a gynecologist office visit to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve an OON gynecologist office visit. You say that the requested provider can help you lose weight. The Plan denied your request. The Plan says the requested service is 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

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 a gynecologist office visit to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the automatic external defibrillator provided on October 21, 2020 by an OON provider.

You asked the Plan to pay for the automatic external defibrillator. The Plan denied your request. The Plan says this service was rendered by a non-participating provider. The Plan also says that the service was not approved in advance.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the automatic external defibrillator provided on October 21, 2020 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed.

You asked the Plan to pre-approve a total electric hospital bed (E0265). You say that a mechanical bed puts an
undue hardship on the caregiver and puts the enrollee at an unnecessary risk. The Plan denied your request. The
Plan says total electric hospital beds are not covered by Medicare or the Plan.

The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.

While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital
bed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the pneumatic walking boot provided on December 3, 2020.

You asked the Plan to waive the coinsurance for the pneumatic walking boot. You say that you were given a walking boot and no longer need it. You say you do not feel that you are responsible for this payment. The Plan denied your request. The Plan says you have been asked to pay 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 20% coinsurance upon written prescription from a network provider to a network durable medical equipment (DME) or Orthotics and Prosthetics (O&P) supplier in your primary care provider (PCP's) referral circle.

You have been asked to pay $43.10 which is 20% of the allowed amount for the pneumatic walking boot. The allowed amount is $215.50. ($215.50 x 20% = $43.10). The pneumatic walking boot falls within the "Prosthetic devices 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 the pneumatic walking boot provided on December 3, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the lodging services you had on November 4, 2020.

You asked the Plan to pay for the lodging. The Plan denied your request. The Plan says you are no longer part
of the transplant program.

The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee
Schedule indicates that the code in question is not valid for Medicare purposes.

We looked at the file and Medicare rules. As you were not part of the transplant program when the lodging
services were received, the Plan's supplemental benefit does not apply in this case. Code S9975 is assigned a
status indicator of "I" under the Physician Fee Schedule, which means that this code is not valid for Medicare
purposes. Medicare uses another code for reporting of, and payment for, these services. Based on this
information, we decided that Medicare rules for coverage of the lodging have not been met. Therefore, we
decided that the Plan does not have to pay for the lodging services you had on November 4, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the spine x-ray provided on November 18, 2020 by an out of
network (OON) provider.

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 services were rendered by an out-of-network provider without prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.

Therefore, we decided that the Plan does not have to pay for the spine x-ray provided on November 18, 2020
by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the CPAP device provided on October 8,
2020 and January 25, 2021.

You asked the Plan to waive the coinsurance for the CPAP device. You say that the CPAP machine should be
covered in full. The Plan denied your request. The Plan says you have been asked to pay 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 20%
coinsurance for covered items and related supplies.

You have been asked to pay $38 which is 20% of the allowed amount for the CPAP device on each date of
service. The allowed amount is $190. ($190 x 20% = $38). ($38 + $38 = $76). The CPAP device falls 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 the CPAP device provided on October 8, 2020 and January 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on December 8, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider on December 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on October 1, 2020.

You asked the Plan to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device. You say that the treatment was medically necessary and should be covered. The Plan denied your request. The Plan says the record does not support that the procedures were performed as billed.

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 HCPCS/CPT Code Manual definition of code 97016 is application of blood vessel compression or decompression device to 1 or more areas. The HCPCS/CPT Code Manual definition of code 97032 is application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes. The HCPCS/CPT Code Manual definition of code 97150 is therapeutic procedure(s), group (2 or more individuals). The HCPCS/CPT Code Manual definition of code 96372 is therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular. The HCPCS/CPT Code Manual definition of code J3490 is unclassified drug injection. The HCPCS/CPT Code Manual definition of code J3411 is injection, thiamine hcl, 100 mg. The HCPCS/CPT Code Manual definition of code J3415 is injection, pyridoxine hcl, 100 mg. 

We find that HCPCS/CPT codes 97016, 97032, and 97150 are not supported in the medical record. Specifically, the record does not support that a blood vessel compression device was applied. The manufacturer of the Sanexas device describes it as an electric cell signaling energy wave device, which does not meet the criteria to report CPT code 97016. The record also does not support that manual electrical stimulation was applied to any area for any amount of time. The record states that the Sanexas device was applied using standard programs. This does not support constant direct patient contact, which is required to report CPT code 97032. The record also does not support that therapeutic procedures in a group of 2 or more was performed. The record does not mention any therapeutic procedures, or the presence of any other patients receiving therapy at the same time; the criteria for reporting CPT code 97150 has not been met. 

Payment for HCPCS/CPT codes 96372, J3490, J3411, and J3415 are not supported. Specifically, the record does not contain documentation of the dosage and type of drug administered in each injection, which is required by Medicare for these services to be reimbursed. 

Based on this information, we decided that Medicare rules for coverage of the nutria-pharmaceutical injections and treatment with a Sanexas device have not been met. Therefore, we decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on October 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on September 28, 2020, by an OON
provider.

You asked the Plan to pay for office visit. You say that you were told by the provider that they did accept your
insurance. The Plan denied your request. The Plan says the denial of payment for this service is correct,
because this provider is out-of-network with the Plan and authorization was not obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for an office visit provided on September 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 office visit on provided on January 12, 2021.

You asked the Plan to waive the copayment for the office visit. You say that the provider did not perform ear wax removal at your appointment. The Plan denied your request. The Plan says it was determined that the medical records support that services were rendered, and that ear wax removal was performed.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). 

Review of the file show that you received the office services on January 12, 2021. You were asked to pay a $5 copayment for the office visit. Your 2021 EOC states that enrollees must pay a $5 copayment for medical care or surgery services in a Primary Care Physician's office. 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 office visit on provided on January 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the custom fabricated abutment (D6057) and the abutment
supported crown (D6058) for tooth # 30 provided on November 11, 2020.

You asked the Plan to pay for the dental services. You say that you understand that implants were not covered
in 2020. You say that crowns were though. You say that you should be reimbursed for the cost of a regular
crown. The Plan denied your request. The Plan says custom fabricated abutment is not listed as a covered
service. The Plan says that abutment supported crown is not listed as a covered service either.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
custom fabricated abutment (D6057) and the abutment supported crown (D6058) for tooth # 30 provided on
November 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the automatic external defibrillator provided on September 25, 2020 by an OON provider.

You asked the Plan to pay for the automatic external defibrillator. You say that you believe this service was authorized. The Plan denied your request. The Plan says there is not an approved referral or authorization on file.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the automatic external defibrillator provided on September 25, 2020 by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient hospital services provided on
January 28, 2021, at the outpatient department.

You asked the Plan to waive the copayment for outpatient hospital services. You say that you are appealing
your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the
claim was processed accordingly with your 2021 EOC benefits.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).

Review of the file show that you received outpatient hospital services on January 28, 2021. You were asked to
pay a $475 copayment for the services. Your 2021 EOC states that enrollees must pay a $475 copayment for
each Medicare-covered outpatient hospital visit. 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
outpatient hospital services provided on January 28, 2021, at the outpatient department.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided from
January 18, 2020, through January 20, 2020.

You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network 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 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 subsequent nursing facility care provided from January 18, 2020, through January 20, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for bladder function test (CPT code 51798) provided on January 28, 2021, by an in-network provider.

You asked the Plan to waive the copayment for the bladder function test. You say that this was for a post-operative visit to which the $15 copayment was waived. The Plan denied your request. The Plan says the claim was processed accordingly with your 2021 EOC benefits.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). 

Review of the file show that you received a bladder function test (CPT code 51798) on January 28, 2021, by an in-network provider. The rules say that a global surgical package includes certain services that are associated with the surgery performed. A global surgical package does not include diagnostic tests and procedures, including diagnostic radiological procedures. The Medicare-allowed amount for the bladder function test is less than the set $15 copayment; therefore, you have been asked to pay the lesser amount of $9.01 for the test. Your 2021 EOC states that enrollees must pay a $15 copayment for in-network Medicare-covered x-ray and ultrasounds. 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 bladder function test (CPT code 51798) provided on January 28, 2021, by an in-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the MRI provided on January 14, 2021.

You asked the Plan to waive the coinsurance for the MRI. You say that you pay a lot for insurance so you should not have coinsurance. The Plan denied your request. The Plan says you were charged the coinsurance 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 Outpatient Diagnostic tests. 

You have been asked to pay 20% coinsurance for the MRI. The MRI falls within the Outpatient Diagnostic Radiology 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 the MRI provided on January 14, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasounds provided on July 6, 2020.

You asked the Plan to waive the copayment for the ultrasounds. You say that your copayment for the procedure should be $20 and you should be reimbursed. 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 $125 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a free-standing facility.

You have been asked to pay a total of $238.14 for the ultrasounds.

The ultrasounds fall within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The ultrasounds are considered a diagnostic 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 ultrasounds provided on July 6, 2020.