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

We decided that the Plan does not have to waive the copayment for the laboratory work provided on December
3, 2019.
You asked the Plan to waive the copayment for the laboratory work. You say that you are entitled to one free
physical per year. The Plan denied your request. The Plan says you have been charged 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 a $10
copayment for Medicare-covered laboratory tests.
You have been asked to pay a $10 copayment for the laboratory work. The laboratory work falls within the
"Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows the
laboratory work is considered a separate service from the annual physical.
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 laboratory work provided on December 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided from September 6, 2019 through September 13, 2019.
You asked the Plan to pay for home infusion therapy. You say that on the CMS website, this is a valid code. You say if this is not a valid code you want a valid code in which to receive payments for the service. The Plan denied your request. The Plan says Medicare guidance says procedure code S9328 has a status code of "I". Medicare guidance says status code "I = 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. In this case, the CPT Code Manual definition of code S9328 is listed in the current Physician Fee Schedule however it does not price the requested HCPCS Code. We find that CPT code S9328 is not supported in the medical record. Specifically, Medicare states that this code is for private payor use. It is not valid and not payable by Medicare. Based on this information, we decided that Medicare rules for coverage of home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) provided  from September 6, 2019 through September 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 30, 2019 by out of
network provider.
You asked the Plan to pay for physician services. You say that you would like these services reviewed and
approved for payment. The Plan denied your request. The Plan says the referring provider is
out-of-network. The Plan says is also out-of-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the medical services provided on August 30, 2019
by out of network provider.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to hold you harmless for a back brace (L0642, A9270) provided to the enrollee on August 16, 2019.
You asked the Plan to hold you harmless for the orthosis. You say that the back brace should be covered and is necessary for pain relief. The Plan denied your request. The Plan says that this is a non-covered benefit.
The Plan must follow Medicare rules. The rules say that a Cost plan must cover items or services if an enrollee: 1. Received the items or services under the direction or authorization of a plan physician; 2. Correctly identifies himself or herself as a member of that plan to the contract provider before receiving the items or services; and 3. Has not been informed that he or she is liable for the cost of such items or services. You were referred for the orthosis by a contract provider with the Plan. The file does not show that you failed to correctly identify yourself as a member of the Plan before receiving the orthoses. The file does not show that the Plan provided notice that the orthoses would not be covered. Therefore, we decided that the Plan has to hold you harmless for a back brace (L0642, A9270) provided to the enrollee on August 16, 2019.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic mammogram provided on November 25, 2019.
You asked the Plan to waive the copayment for a diagnostic mammogram. You say that you were not informed that you would owe a copayment for diagnostic services. 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 $40 copayment for each basic imaging service. You have been asked to pay a $40 copayment for a diagnostic mammogram. A diagnostic mammogram falls 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 a diagnostic mammogram provided on November 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride varnish and inhalation of
nitrous oxide/analgesia, anxiolysis provided on August 14, 2019.
You asked the Plan to pay for the topical application of fluoride varnish and inhalation of nitrous
oxide/analgesia, anxiolysis. You say that you called member services and were told that you have 100%
coverage for routine dental checkups. You also say that you inquired if the Dr. was in-network with your
plan. The Plan denied your request. The Plan says these services are not covered benefits under your dental
plan.
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
topical application of fluoride varnish and inhalation of nitrous oxide/analgesia, anxiolysis provided on August
14, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for gradient compression stockings purchased on August 5,
2019.
You asked the Plan to pay for the gradient compression stockings. You say that you are requesting
reconsideration of the denial. The Plan denied your request. The Plan says if you go to a provider who is not
eligible to participate in Medicare, you will be responsible for the full cost of the services you receive.
Medicare rules say that no provider or supplier shall receive payment for services furnished to a Medicare
beneficiary unless the provider and supplier enroll in the Medicare program.
The requested provider in this case is not a Medicare provider and does not participation in Medicare. 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 gradient compression stockings purchased on August 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided on July 16, 2019.
You asked the Plan to pay for the lumbar-sacral orthosis. You say that the items were medically necessary. The Plan denied your request. The Plan says the records do not support the items billed.
The Plan must follow Medicare rules. Medicare rules say that the patient's medical record must contain sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered. We looked at the file and Medicare rules. The records include a delivery ticket and order form. The Medical records provided do not include any details of discussion with the provider regarding the need for the orthosis. Based on this information, we decided that Medicare rules for coverage of the lumbar-sacral orthosis have not been met. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided on July 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aid services for a conformity evaluation used in
hearing items provided on July 22, 2019.
You asked the Plan to pay for the hearing aid services. The Plan denied your request. The Plan says hearing aid
services are covered when received from a provider.
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 or related hearing services when received from a  provider.
We looked at the file and the Plan's rules. The file shows that is not a provider.
Based on this information, we decided that the Plan's rules for coverage of the hearing aid services have not
been met. Therefore, we decided that the Plan does not have to pay for the hearing aid services for a conformity
evaluation used in hearing items provided on July 22, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services for the enrollee.
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the enrollee does not have multiple medical conditions that need complex medical management with daily doctor visits.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our physician reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) for lower extremity cellulitis related to chronic thigh wounds. The enrollee received wound care, antibiotics and transient hemodialysis. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99202) provided on August 21, 2019 by out of network provider,
You asked the Plan to pay for an office visit. You say that the service should be paid for by the plan because before receiving the service you were advised that this provider was PAR. You say you were referred to this provider from the plan. The Plan denied your request. The Plan says the claim was denied for lack of authorization for a non-par provider. The plan also says that the information received did not show that you required emergent or urgently needed care, did not show that you required kidney dialysis services when you were temporarily outside of the plan's service area, did not show that there are no providers in the plan who can provide the service you needed, and did not show that you contacted the plan and were informed that the provider Dermatology was not participating with the plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for an office visit (99202) provided on August 21, 2019
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the physician services provided on June 13, 2019.
You asked the Plan to pay for the physician services. You say that you had your procedure performed at the out-of-network facility as they were the nearest facility to you that could perform the procedure. The Plan agreed with you and overturned their denial for dates of service June 14, 2019 and June 15, 2019; however did not overturn their denial for the June 13, 2019 date of service. The Plan denied your request. The Plan says that they provided a one-time discretionary overturn due to a misunderstanding that the facility was an in-network provider for dates of service June 14, 2019 and June 15, 2019. The Plan states you were referred, a participating provider and the out-of-network facility was the only hospital in the area to perform your procedure.
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 referred for the physician services by a contract provider. The file does not show that the Plan provided notice that the physician services would not be covered. Under Medicare rules, this means the physician services is considered approved by the Plan. Furthermore, the Plan's correspondence to you states that the out-of-network provider was the only hospital in the area to perform your procedure. Therefore, we decided that the Plan has to pay for the physician services provided on June 13, 2019.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies, extra-large adult diapers (A4520).
You asked the Plan to pre-approve the incontinence supplies. You say that you are appealing for coverage under the over the counter benefit because you need size 3XL adult diapers because you had a stroke and is unable to get out of bed to go to the bathroom. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items that incontinence supplies are not covered because they are hygienic items that are non-reusable. However, the plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The plan's benefit is limited to approved over the counter medications and items available from the plan's over the counter list. The benefit limits size ranges from SM-XL. The requested 3XL size cannot be provided. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies, extra-large adult diapers (A4520).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction of erupted tooth requiring removal of bone and/or sectioning of tooth and extraction of erupted tooth or exposed root provided on August 15, 2019.
You asked the Plan to pay for the extractions. You say that before you got your teeth pulled you called the Plan and they told you that they would pay for half of the bill. The Plan denied your request. The Plan says your wife called the Plan prior to these services being rendered and she was advised that services are only covered when they are rendered by an in-network provider. The Plan also says that this provider is out-of-network with your plan.
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, your contract clearly states that you are responsible for 100% of the extractions when they are received out-of-network. The record shows that you saw an out-of-network provider, so the Plan does not have to pay the in-network benefit rates for the extractions. Therefore, we decided that the Plan does not have to pay for the extraction of erupted tooth requiring removal of bone and/or sectioning of tooth and extraction of erupted tooth or exposed root provided on August 15, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to hold you harmless for a periodic comprehensive medicine evaluation provided by on April 15, 2019.
You asked the Plan to be held harmless for preventive evaluation. You say that this visit was different from your prior visit on March 28, 2019, and both examinations are fully covered by your insurance policy. The Plan denied your request. The Plan says that the denial of payment for this service is correct, because the Annual Wellness Visit is only covered once every 12 months.
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 provided preventive evaluation. The Doctor is a contract provider. The file does not show that the Plan provided notice that preventive evaluation would not be covered. The code billed for this service is not the same code used to identify the Medicare Annual Wellness Visit. Therefore, the documentation does not support that you exceeded the benefit limitation for Medicare-covered Annual Wellness Visits. Under Medicare rules, this means preventive evaluation is considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for a periodic comprehensive medicine evaluation provided on April 15, 2019.
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 pre-approve office services.
You asked the Plan to pre-approve office services. You say that this doctor has been continuing the enrollee's
conservative treatment plan, and other approaches tried in the past were not beneficial. The Plan denied your
request. The Plan says the denial of authorization for these services is correct, because this provider is out-of-network
with the Plan and the enrollee can be treated by an in-network neurologist.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan
providers available to meet the enrollees' needs. The enrollee's contract with the Plan says that, with few
exceptions, enrollees must use contract providers for care.
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 office services. Our reviewer says that
the enrollee does not meet the Medicare criteria for continuity of care with out-of-network provider. Our physician reviewer found the enrollee is not currently receiving any active treatment and/or medical
management of her condition that makes it medically necessary for the enrollee to continue care. There is nothing unique about the enrollee's condition that would make it medically necessary
to continue care.
The Plan has shown that they have in-network neurology specialists who have the qualifications and expertise
necessary to meet medical standards of care for treatment of the enrollee's condition. The enrollee's care can be
safely transferred to an in-network neurology specialist at this time.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of office services have not been met. Therefore, we decided that the Plan does not
have to pre-approve office services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to hold you harmless for the arthrocentesis and the Orthovisc injection provided on September 14, 2018 minus any cost share amount.
You asked the Plan to pay for the arthrocentesis and the Orthovisc injection. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the services received are not a covered benefit.
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 referred for the arthrocentesis and the Orthovisc injection by the physician. The physician is a contract provider. The file does not show that the Plan provided notice that the arthrocentesis and the Orthovisc injection would not be covered. Under Medicare rules, this means the arthrocentesis and the Orthovisc injection is considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for the arthrocentesis and the Orthovisc injection provided on September 14, 2018 minus any cost share amounts.
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.