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

We decided that the Plan does not have to waive the copayment for the telehealth visit you had with your primary care physician on May 26, 2021.

You asked the Plan to waive the copayment for the telehealth visit. You say that you have never had to pay a copayment before. The Plan denied your request. The Plan says you were charged this copayment 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 $10 copayment for telehealth visits with your primary care provider. 

You have been asked to pay a $10 copayment for the telehealth 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 the telehealth visit you had with your primary care physician on May 26, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the therapeutic ultrasound services you received from your physical therapist on March 12, 2021.

You asked the Plan to waive the coinsurance for the therapeutic ultrasound services. You say that you did not receive therapeutic ultrasound services. The Plan denied your request. The Plan says you were charged this 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 15% coinsurance for physical therapy services. 

You have been asked to pay 15% coinsurance for the therapeutic ultrasound services. The medical records from this date of service clearly indicate that you received therapeutic ultrasound services that lasted 12 minutes.

The records also state that this ultrasound was done to the cervical area to reduce tightness. The therapeutic ultrasound services falls within the physical therapy services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the therapeutic ultrasound services you received from your physical therapist on March 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the cystourethroscopy procedure you had at an outpatient hospital facility on April 26, 2021.

You asked the Plan to waive the copayment for the cystourethroscopy procedure. You say that this procedure should be considered a diagnostic test, not an outpatient surgery. The Plan denied your request. The Plan says you were charged this copayment 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 $250 copayment for outpatient surgery. 

You have been asked to pay a $250 copayment for the cystourethroscopy procedure. Medicare considers the procedure code billed (52000) to be a surgical service, not a diagnostic test. That is why the cystourethroscopy procedure falls within the outpatient surgery 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 the cystourethroscopy procedure you had at an outpatient hospital facility on April 26, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network medical services provided to the enrollee on January 19, 2021.

You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.

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 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 out of network medical services provided to the enrollee on January 19, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on May 3, 2021.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.

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 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 out of network physician services provided to the enrollee on May 3, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network home health care provided from September 8, 2020 to September 29, 2020.

You asked the Plan to pay for out of network providers. You say that you would like the Plan to reconsider their denial as these services were necessary. The Plan denied your request. The Plan says you did not have a referral from your physician or prior authorization from the Plan for these services.

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 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 out of network home health care provided from September 8, 2020 to September 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided on May 6, 2021.

You asked the Plan to pay for this service. You say that this service should be covered by the Plan. The Plan denied your request. The Plan says you did not have prior authorization for out of network care.

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 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 out of network physician services provided on May 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network services provided to the enrollee on May 19, 2021.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have 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 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 out of network services provided to the enrollee on May 19, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the electronic analysis of a neurostimulator you received on May 3, 2021.
You asked the Plan to waive the copayment for the electronic analysis service. You say that the cost of this analysis should be part of the office visit copayment. You said that your Evidence of Coverage does not clearly define that additional cost sharing would be owed for this service. The Plan denied your request. The Plan says you were charged this copayment 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 $20 copayment for non-radiological diagnostic services.
You have been asked to pay a $20 copayment for the electronic analysis service. The electronic analysis service is considered a non-radiological diagnostic service because it is done to ensure that your neurostimulator is functioning as expected. 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 electronic analysis of a neurostimulator you received on May 3, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes (CPT code 99406), federally qualified health center (FQHC) visit, established patient; a medically-necessary, face-to-face encounter (one-on-one) between an established patient and a FQHC practitioner during which time one or more FQHC services are rendered and includes a typical bundle of Medicare-covered services that would be furnished per diem to a patient receiving a FQHC visit (CPT code G0467) and the office visit (CPT code 99214) provided to the enrollee on April 23, 2021

You asked the Plan to pay for the services. You say that the enrollee was seen in your office for an office visit and there is not charge for a drug on the claim. The Plan denied your request. The Plan says that they did not make a decision within the sixty (60) day timeframe. The Plan states there was an error that was corrected.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.

Review of the records show the enrollee did not receive a drug during this visit. The medical records verify that the services billed were provided. The Plan's denial states, "charges for this drug have already been paid to a different provider." The denial is not valid because the claim this provider submitted did not include a drug. Therefore, the claim needs to reprocessed for payment. Therefore, we decided that the Plan has to pay for smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes (CPT code 99406), federally qualified health center (FQHC) visit, established patient; a medically-necessary, face-to-face encounter (one-on-one) between an established patient and a FQHC practitioner during which time one or more FQHC services are rendered and includes a typical bundle of Medicare-covered services that would be furnished per diem to a patient receiving a FQHC visit (CPT code G0467) and the office visit (CPT code 99214) provided to the enrollee on April 23, 2021.

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 Plan does not have to pay for out of network physician services provided on November 1, 2020.

You asked the Plan to pay for these services. You say that you believe the Plan should pay for these services. The Plan denied your request. The Plan says you did not have prior authorization for out of network care.

The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan. The services at issue in this appeal were not provided in an emergency or urgent care situation. These services were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not have to pay for out of network physician services provided on November 1, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on May 4, 2021.

You asked the Plan to waive the copayment for the ambulance transport. You say that $325 copayment for ambulance transport is too high. The Plan denied your request. The Plan says you were 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 $325 copayment for per trip for ambulance services. 

You have been asked to pay a $325 copayment for the ambulance transport. The ambulance transport falls within the Ambulance Services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance transport provided on May 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Actemra injector pens.
You asked the Plan to pre-approve self-administered drug. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Actemra injector pens.
Benefits for self-administered drug 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically reasonable and necessary. 
The Plan denied your request. The Plan says rules for SNF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found admission to a SNF is not reasonable and not 
necessary as she has no skilled nursing needs and does not need skilled therapies on a daily basis in an inpatient 
setting with the above functional status per physical therapy & occupational therapy evaluations. In this case, 
the documentation does not support the need for an admission to a SNF. The enrollee's rehab needs can be met 
at a lower intensity level such as in the alternate level of care facility when medically ready with services as 
needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for the dental services provided on February 23, 2021 and March 30, 2021. 
We decided that the Plan does not have to pay for the dental services provided on December 14, 2020.  
 
You asked the Plan to pay for the dental services. You say that the claims were denied for the same doctor that 
was approved for January 9, 2020. You say that the Plan should approve the dental claims with this provider 
who has been your provider for many years. The Plan says that the provider is not part of the Medicare 
program. 
 
We decided that the Plan has to pay for the dental services provided on February 23, 2021 and March 
30, 2021.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The records show you enrolled in a new plan as of January 1, 2021. The Plan did 
not submit the correct 2021 Evidence of Coverage. Without the correct Evidence of Coverage, we cannot 
determine if the coverage for dental services clearly excludes providers that have opted out of Medicare. 
Therefore, we decided that the Plan has to pay for the dental services provided on February 23, 2021 and 
March 30, 2021. 
 
We also decided that the Plan does not have to pay for the dental services provided on December 14, 
2020. 
 
The 2020 Evidence of Coverage clearly says dental services cannot be provided by a provider who has opted 
out of Medicare. Therefore, we decided that the Plan does not have to pay for the dental services provided on 
December 14, 2020. 
 
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on June 1, 2021.

You asked the Plan to pay for laboratory services. You say that the medical records support the service. The Plan denied your request. The Plan says this provider is out of network with the Plan and prior 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 laboratory services provided on June 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation services. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says you do 
not meet the requirements for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that facet joint interventions are only covered under 
certain medical indications.

We looked at the file and Medicare rules. The records show that you previously received radiofrequency 
ablation services on December 26, 2021, and January 12, 2021. For each covered spinal region, no more than 
two radiofrequency sessions will be reimbursed per rolling 12 months. Based on this information, we decided 
that Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve radiofrequency ablation services.