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

We decided that the Plan does not have to waive the coinsurance for durable medical equipment provided by a participating provider on September 14, 2020, to December 14, 2020.
You asked the Plan to waive the coinsurance for durable medical equipment. You say that you never had a charge for this before. The Plan denied your request. The Plan says the correct coinsurance has been 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 20% coinsurance for durable medical equipment. You have been asked to pay a 20% coinsurance of the allowed amount for durable medical equipment. The total allowed amount is $199.14. The total amount you are being asked to pay is $39.84 ($199.14 x 20% = $39.84). Durable medical equipment falls within the durable medical equipment 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 durable medical equipment provided by a participating provider on September 14, 2020, to December 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a facet fusion to be provided at the out-of-network facility.
You asked the Plan to pre-approve the facet fusion to be provided at the out-of-network facility. You say that this surgery must be provided at the out-of-network facility due to them having the necessary equipment. The Plan denied your request. The Plan says this surgery can be provided at an in-network facility.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a facet fusion to be provided at the out-of-network facility.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on
November 3, 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 on November 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that you are not able to stand in the shower. The Plan denied your request. The Plan says the shower chair is a non-covered item.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for robotic-assisted surgery (S2900) provided July 21, 2020.
You asked the Plan to pay for robotic-assisted surgery. You say that the records provided should support the necessity of the service in dispute. The Plan denied your request. The Plan says the claim was billed with an invalid procedure code.
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 S2900 is surgical techniques requiring use of robotic surgical system (list separately in addition to code for primary procedure). We find that CPT code S2900 is not supported in the medical record. Specifically, CPT code S2900 has a status code of "I" which is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of robotic-assisted surgery have not been met. Therefore, we decided that the Plan does not have to pay for robotic-assisted surgery (S2900) provided July 21, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entyvio.
You asked the Plan to pre-approve Entyvio. You say that this is medically necessary. The Plan denied your
request. The Plan says step therapy requirements have not been met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve Entyvio. Our reviewer says that the
criteria for coverage of Entyvio have not been met. Our physician reviewer found the Plan requires a trial of
Remicade or Inflectra and Stelara before they will approve the requested drug, Entyvio. Based on the medical
records provided, the patient has not tried and failed the required drugs and there is no indication that the
required drugs would likely be less effective or have adverse effects.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Entyvio have not been met. Therefore, we decided that the Plan does not have
to pre-approve Entyvio.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99072) provided October 6, 2020.
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says the billed code is 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. We find that CPT code 99072 is not supported in the medical record. Specifically, CPT code 99072 is a bundled-only procedure and not separately payable. Based on this information, we decided that Medicare rules for coverage of the physician services have not been met. Therefore, we decided that the Plan does not have to pay for physician services (99072) provided October 6, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ground mileage and ambulance service provided on
September 19, 2020.
You asked the Plan to pay for the ground mileage and ambulance service. The Plan denied your request. The
Plan says Original Medicare would be responsible for payment of all Medicare covered services related or
unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Original Medicare is responsible for payment for services until the first day of the month after the
hospice election has been revoked or terminated.
The enrollee ended Medicare Hospice benefits on September 10, 2020. The services in question were provided
before the end of that month. Therefore, we decided that the Plan does not have to pay for the ground mileage
and ambulance service provided on September 19, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical pathology services provided on January 7, 2021.
You asked the Plan to pay for the surgical pathology services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they 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 surgical pathology services. 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 surgical pathology services provided on
January 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen and pelvis, with contrast (74177).
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says this service is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 this service. Our reviewer says that this service is not medically necessary. Our physician reviewer found that the enrollee has endobronchial small cell lung cancer that was diagnosed in August 2020. He has been receiving CT scans every three months. The last CT scan was in February 2021. At issue is whether a CT scan of the abdomen and pelvis for the enrollee is a covered service under Medicare rules. The rules indicate that CT scans are covered if there is literature to support its use for the patient's condition and the scan is reasonable and necessary for the patient. The provided medical records indicate that the enrollee was seen on February 21, 2021. At that time, a CT scan was planned for three months. Three months has not yet passed. The requested test at this time is not medically reasonable or necessary. Therefore, the requested service cannot be recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen and pelvis, with contrast (74177).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction services received on November 19, 2020.
You asked the Plan to pay for the eye refraction 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 a covered benefit.
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. The Plan covers certain vision services. We looked at the file and the Plan's rules. While the Plan does cover certain vision services, eye refractions are not covered by the Plan. Based on this information, we decided that the Plan's rules for coverage of the eye refraction services have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction services received on November 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids, digital, binaural (V5261) provided
November 4, 2020.
You asked the Plan to pay for the hearing aids. You say that the hearing aids should be covered by the Plan up
to $2,500. The Plan denied your request. The Plan says the hearing aids were provided by a non-contract
provider without prior authorization and therefore are not covered.
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 when they are purchased through the Plan's hearing provider and prior authorization is
obtained prior to services.
We looked at the file and the Plan's rules. The enrollee was provided hearing aids by a non-contract provider.
Prior authorization was not obtained prior to receiving the services. 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 the hearing aids, digital, binaural (V5261) provided November 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99232) provided August 27, 2020 to August 31, 2020.
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim did not include a valid diagnosis code.
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 99232 is not supported in the medical record. Specifically, the diagnosis code billed, N18.30, was not effective yet on the dates of service at issue. This diagnosis code was not effective until October 1, 2020. Based on this information, we decided that Medicare rules for coverage of the physician services have not been met. Therefore, we decided that the Plan does not have to pay for physician services (99232) provided August 27, 2020 to August 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for specialist visits and does not have to
waive the coinsurance for a Medicare Part B drug provided from September 30, 2020, to October 20, 2020.
You asked the Plan to waive the copayments for specialist visits and to waive the coinsurance for a Medicare
Part B drug. You say that you feel that the charges are unfair. 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 $45
copayment for specialist visits. Your contract with the Plan also clearly says that you must pay 20%
coinsurance for Medicare Part B prescription drugs.
You received a specialist visit on September 30, 2020. Therefore, you are responsible to pay the $45
copayment.
You received a specialist visit on October 20, 2020. Therefore, you are responsible to pay the $45 copayment.
You received a Medicare Part B drug on October 20, 2020. The allowed amount is $5.32 and 20% of that is
$1.06.
The total amount you owe is: $91.06.
You have been asked to pay the total amount of $91.06 for specialist visits and a Medicare Part B drug.
Specialist visits fall within the physician/practitioner services, including doctor's office visits benefit category.
A Medicare Part B drug falls within the Medicare Part B prescription drugs 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 copayments for specialist visits and does not have to waive the coinsurance for a
Medicare Part B drug provided from September 30, 2020, to October 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic testing strips provided on August 28, 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 diabetic testing strips provided on August 28, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit provided by an out-of-network provider on November 3, 2020.
You asked the Plan to pay for the home visit. You say that the physician depends on the hospital staff to verify eligibility and obtain proper authorization. You say that the physician provided medically necessary services and should be reimbursed. The Plan denied your request. The Plan says prior authorization was required but 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 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 home visit provided by an out-of-network provider on November 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full amount for the fillings for teeth # 7, 8, and 9 provided on December 28, 2020.
You asked the Plan to pay the full amount for the dental services. You say that your plan should pay 100% for 2 fillings per year. You say that your plan should pay a total of $352 to the provider for the 2 fillings that you received. The Plan denied your request. The Plan says extractions are listed as a covered service. The Plan also says that there is a 50% coinsurance for extractions that you receive in network
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 fillings are listed as a covered service, there is a 5% coinsurance for fillings that you receive from an in network dentist.
Additionally, the frequency limit has been exceeded. The record shows that the Plan paid the 50% coinsurance for the fillings for teeth # 7 and 8 that you received on the date of service in this case. Therefore, we decided that the Plan does not have to pay the full amount for the fillings for teeth # 7, 8, and 9 provided on December 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for fluoroscopic guidance (77001) ultrasonic guidance for needle
placement (76937) provided July 1, 2019.
You asked the Plan to pay for the diagnostic services. You say that please reconsider claim with attached
records. This service was medically needed. Your physician performed the professional service in good faith,
and you request processing for payment. The Plan denied your request. The Plan says the claim was filed past
the timely filing limitation.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010,
must be filed no later than one calendar year after the date of service.
The record shows that a claim for the diagnostic services was not filed until December 29, 2020. This means
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we
decided that the Plan does not have to pay for fluoroscopic guidance (77001) ultrasonic guidance for needle
placement (76937) provided July 1, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to hold you harmless for inpatient hospital care provided from December 9, 2020, to December 11, 2020.
You asked the Plan to hold you harmless for inpatient care. You say that you had very tight chest pain and had to be taken to the emergency room. The Plan denied your request. The Plan says that you did not need to be treated at the inpatient level of care, because your care could have been managed at a lower level such as outpatient.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. You were admitted to the hospital as an inpatient by an in-network hospital facility. The file does not show that the Plan provided prior notice that inpatient care would not be covered. Under Medicare rules, this means inpatient care is considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for inpatient hospital care provided from December 9, 2020, to December 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the blood glucose strips provided by an out-of-network provider on September 23, 2020.
You asked the Plan to pay for the blood glucose strips. You say that purchasing online is half the cost of the pharmacy prices. You say that you want to be reimbursed for what you spent. The Plan denied your request. The Plan says care and supplies must be received from in-network providers.
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 blood glucose strips provided by an out-of-network provider on September 23, 2020.