Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and services provided from February 16, 2021, to February 21, 2021.  You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you cannot afford this bill. The Plan denied your request. The Plan says this claim was processed correctly, and your copayment was assessed in accordance with your contract.  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 $290 copayment for each of the first five days of an inpatient hospital stay.    You have been asked to pay a $1,450 copayment for the five-day inpatient stay ($290 x 5 = $1,450). 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 inpatient hospital admission and services provided from February 16, 2021, to February 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150), intraoral - complete series of radiographic images (D0210), and prophylaxis - adult (D1110) provided October 7, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the comprehensive oral exam, complete series of intraoral x-rays and dental cleaning. You say that you were provided inaccurate information about coverage and could not be expected to know services would not be covered. The Plan denied your request. The Plan says these services are not covered because they were provided OON.  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. The Plan covers the comprehensive oral exam, complete series of intraoral x-rays and dental cleaning when the services are provided by a dentist who participates in the Plan's dental vendor network.   We looked at the file and Medicare rules. The provider who rendered these services is not a participating dentist with the Plan's dental vendor network. Based on this information, we decided that the Plan's rules for coverage of the comprehensive oral exam, complete series of intraoral x-rays and dental cleaning have not been met. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150), intraoral - complete series of radiographic images (D0210), and prophylaxis - adult (D1110) provided October 7, 2021, by an out-of-network (OON) provider.   Your complaint about confusing or contradictory information about the network status of this provider is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for drug testing (G0482) provided on August 3, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for drug testing. You say that this was medically necessary. The Plan denied your request. The Plan says this was not authorized or ordered by a network physician.  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 drug testing (G0482) provided on August 3, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the chest x-ray services coded 71046 provided on September 21, 2021.  You asked the Plan to pay for the chest x-ray services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are a duplicate.  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 71046 is radiologic examination, chest; 2 views.    We find that CPT code 71046 is not supported in the medical record. Specifically, the documentation shows that this claim was previously processed and paid by the Plan. The documentation did not include additional information that additional views were provided. Based on this information, we decided that Medicare rules for coverage of the chest x-ray services have not been met. Therefore, we decided that the Plan does not have to pay for the chest x-ray services coded 71046 provided on September 21, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for physical therapy services provided on September 16, 2020.  You asked the Plan to waive the copayment for the physical therapy services. You say that you could not complete the session due to your medical condition. 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 $20 copayment for each physical therapy visit.     You have been asked to pay a $20 copayment for the physical therapy services. The physical therapy services fall within the Outpatient Rehabilitation 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 physical therapy services provided on September 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that your records show that you do not require daily physician management and you do not require specialized nursing services that are only available in an LTACH.  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 reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. You were admitted with a soft tissue infection of the hand and found to have osteomyelitis. The record indicates that you have been discharged home to receive antibiotic therapy. The medical record does not indicate that you require acute care services that you are not currently receiving but that would be available at the LTACH facility. Our physician reviewer found that your condition does not meet Medicare criteria for LTACH services.  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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) and wrist hand orthosis (L3916) provided on April 5, 2021.  You asked the Plan to pay for the durable medical equipment. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says documentation required for payment is missing.  The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.   The record does not contain a valid proof of delivery. In this case, there is no documentation provided that shows the equipment was delivered to the enrollee. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) and wrist hand orthosis (L3916) provided on April 5, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Butrans patches for the enrollee.  You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.    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 Butrans patches for the enrollee.   Benefits for this 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: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pay for the skilled nursing facility (SNF) services provided May 11, 2021 to June 27, 2021.  You asked the Plan to pay for the SNF services. You say that you feel that the Plan should cover for the SNF services. The Plan denied your request. The Plan says that the inpatient services are not covered for this procedure.  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 rules say that Medicare plans must tell an enrollee that the Plan will stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before the last covered day. This notice must include a description of the enrollee's right to an appeal.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. 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. In this case specific records or information was required to substantiate the plans denial. The required information was missing from the original file. The file does not show that a valid NOMNC was delivered but the limited information provided from the appellant shows a SNF payment may have been approved by the Plan for dates May 11, 2021 to 5/27/21 as their request indicates payment for dates 5/28/2021 to 06/26/2021. There were no medical records included for this case file. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request Therefore, we decided that the Plan has to pay for the skilled nursing facility (SNF) services provided May 11, 2021 to June 27, 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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Monoferric (J1437).  You asked the Plan to pre-approve Monoferric. You say that Monorferric is medically necessary. The Plan denied your request. The Plan says Infed and Venofer must be tried before alternatives can be considered.  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 Monoferric. Our reviewer says that Monoferric is not medically necessary. Our physician reviewer found the record shows no trial of the plan preferred drugs or any reason they would be unsafe or ineffective for the enrollee.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Monoferric have not been met. Therefore, we decided that the Plan does not have to pre-approve Monoferric (J1437).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Shingles (Shingrix) vaccine received on July 28, 2021.  You asked the Plan to pay for the Shingles vaccine. You say that you were not told what this service would cost. The Plan denied your request. The Plan says the services received is not a covered benefit.  In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Shingles vaccine. The Plan follows the same rules.   Records do not show that you have been injured or directly exposed to any illness related to the Shingles vaccine. Therefore, we decided that the Plan does not have to pay for the Shingles (Shingrix) vaccine received on July 28, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the speech/hearing therapy (92507) provided from July 15, 2021, to July 27, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the speech/hearing therapy. You say that the services provided were medically necessary and you would like this claim to be reconsidered for payment. The Plan denied your request. The Plan says the non-participating provider did not follow the Plan's rules to request authorization for OON 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 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 speech/hearing therapy (92507) provided from July 15, 2021, to July 27, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for office visit services provided to the enrollee on February 25, 2021.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says there is no referring provider involved in 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 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 office visit services provided to the enrollee on February 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the 5 additional chiropractic visits (98941, 97110, 97014, 97026).  You asked the Plan to pre-approve the chiropractic visits. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says according to the medical record, the enrollee does not have a diagnosis of subluxation.  The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.   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 chiropractic visits Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that 5 additional chiropractic visits are medically reasonable and necessary for the enrollee in this case.  The medical documentation in the case file does not support a diagnosis of subluxation of the spine for which manual manipulation of the spine is needed to correct.  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 chiropractic visits have not been met. Therefore, we decided that the Plan does not have to pre-approve the 5 additional chiropractic visits (98941, 97110, 97014, 97026).
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the magnetic resonance angiography (MRA) imaging of the brain interpretation provided on September 9, 2021.  You asked the Plan to pay for the MRA interpretation as billed. You say that this was medically necessary imaging, and both codes should be covered. The Plan denied your request. The Plan says the Column 2 code was not billed with a required modifier to allow for payment.  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, we have confirmed that code 70544 is a column II code in relation to column I code 70551. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the magnetic resonance angiography (MRA) imaging of the brain interpretation provided on September 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and segmental pneumatic appliance (E0673).    You asked the Plan to pay for a pneumatic compression device and appliance. You say that you are not contracted with the facility or the prescribing physician and do not receive payment from either provider. You do not have access to patients' medical records. The Plan denied your request. The Plan says pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.  The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  We looked at the file and Medicare rules. In this case, the enrollee used the equipment in the facility during and/or after surgery. Payment for this service would have been included under the facility claim. Payment for this service is the responsibility of the facility or hospital that provided the surgery. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675) and segmental pneumatic appliance (E0673).
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ambulance service, advanced life support, emergency transport, level 1 (A0427), and ground mileage (A0425) provided June 15, 2021.  You asked the Plan to waive the copayment for the emergency ambulance services and ground mileage. You say that the provider is balance billing you. The Plan denied your request. The Plan says the copayment was 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 $250 copayment for Ambulance services. The Plan additionally states that they have contacted the out-of-network provider to explain that the Plan has only assessed a $250 copayment.   You have been asked to pay a $250 copayment for the emergency ambulance services and ground mileage. The emergency ambulance services, and ground mileage falls within the Ambulance services benefit category. This means that the Plan has asked you 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 service, advanced life support, emergency transport, level 1 (A0427), and ground mileage (A0425) provided June 15, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ambulance response and treatment, no transport (A0998) provided April 12, 2021.  You asked the Plan to waive the copayment for the ambulance response and treatment. You say that the enrollee received a large bill for the very minor services provided. The Plan denied your request.  The Plan says the Plan is covering ambulance services with no transport as an enhanced benefit and the copayment was 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 $300 copayment for ambulance services.   You have been asked to pay a $225 copayment for the ambulance response and treatment. The ambulance response and treatment are being covered within the Ambulance services benefit category. This means that you have been asked to pay less than or equal to 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 response and treatment, no transport (A0998) provided April 12, 2021.