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

We decided that the Plan does not have to pay for the urinalysis procedure (81001) provided on April 23, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the laboratory services. You say that the enrollee is in a nursing home facility and does not have an option on which lab service to use. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 urinalysis procedure (81001) provided on April 23, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for chiropractic visits you had from January 4, 2021, to May 17, 2021, and the emergency room (ER) visit you had on April 11, 2021.
You asked the Plan to waive the copayments for the chiropractic visits and the ER visit. You say that you pay too much in premiums to have copayments like this. The Plan denied your request. The Plan says you were charged these copayments 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 per visit for chiropractic services and a $120 copayment for emergency room visits. You have been asked to pay a $10 copayment per visit for the chiropractic visits and a $120 copayment for the
ER visit. This means that you have been asked to pay the correct amounts 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 chiropractic visits you had from January 4, 2021, to May 17, 2021, and the emergency room (ER) visit you had on April 11, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for skilled nursing facility (SNF) services you received
from March 17, 2021, to March 31, 2021.
You asked the Plan to waive the copayment for the SNF services. You say that you did not have a copayment
for the last SNF stay. The Plan denied your request. The Plan says that you were charged this copayment
correctly. The Plan says that the SNF stay you had from March 17, 2021, to March 31, 2021 constituted days
19-33, so the $184 copayment per day applies to days 21-33 until your maximum out-of-pocket amount was
reached.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that enrollees must pay a $0 copayment per day for days 1-20 and a $184
copayment per day for days 21-100 for skilled nursing facility services.
Records show that you had a SNF stay that lasted from January 5, 2021, through January 22, 2021, for a total
of 18 days. You were not charged a copayment for this stay because, according to your contract, you have a $0
copayment per day for days 1-20 for SNF services. You were admitted to a different SNF on March 17, 2021,
and remained there until March 31, 2021, for a total of 15 days. The Plan contends that because these two stays
were in the same benefit period that the copayments are essentially a continuation of your first SNF stay. The
Plan says that the second SNF stay constituted days 19-33. The Plan says you owe no copayment for days 19
and 20, but you do owe a copayment of $184 per day for days 21-33 (up until you hit your out-of-pocket
maximum.)
We do not agree with the Plan's assessment here. While we agree that under Medicare rules these two SNF
stays occurred in the same benefit period, the way that the Plan's Evidence of Coverage is worded, it clearly
indicates that the copayments for SNF services start over each time you are admitted to a SNF. In this case,
your second SNF stay was a completely different admission from the stay you had in January. The language of
the Evidence of Coverage explicitly states "for each Medicare-covered SNF stay, you are required to pay the
applicable cost sharing, starting with Day 1 each time you are admitted." Following this language, the stay
from March 17, 2021, to March 31, 2021 should have started a new cost sharing period because it was a new
admission. If this starts on Day 1 (as the contract says), that would mean that the stay from March 17, 2021, to
March 31, 2021, would constitute days 1 through 15. Your contract says that there is a $0 copayment per day
for days 1-20, so no copayment should apply to this stay. Therefore, we decided that the Plan has to waive the
copayment for skilled nursing facility (SNF) services you received from March 17, 2021, to March 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Regadenoson injection represented by code J2785 provided on May 18, 2021.
You asked the Plan to waive the coinsurance for the Regadenoson injection. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received a Part B injection on the date of service at issue in this appeal. The plan says that the correct coinsurance has applied per your contract with the Plan.
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 Medicare Part B prescription drugs. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received a Regadenoson
injection on May 18, 2021. The records show you received this injection through IV infusion. You have been asked to pay a 20% coinsurance for the Regadenoson injection, totaling $47.45. The Regadenoson injection 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 coinsurance for the Regadenoson injection represented by code J2785 provided on May 18, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on September 14, 2020.
You asked the Plan to pay for the genetic testing. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says it is unknown if the member's physician ordered the genetic testing.
The Plan must follow Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Specifically, the documentation submitted does not include a physician order or clinical information to verify the medical necessity of this testing. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on September 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the filling (D2393) for tooth # 5 provided on May 6, 2021.
You asked the Plan to pay for the dental service. You say that you think this is maintenance. You say that you cannot afford more insurance. You also say that you had the work done so that you would not have to have your tooth removed. The Plan denied your request. The Plan says the filling is not listed as a covered service.
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 filling is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the filling (D2393) for tooth # 5 provided on May 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the Etonogestrel implant system (J7307).
You asked the Plan to pay for the Etonogestrel implant system. You say that you need this item. The Plan denied your request. The Plan says this item is not covered by Medicare.
The Plan must follow Medicare rules. The rules say that items/services for the purposes of preventing conception (contraception) are not considered medically reasonable and necessary. Records show that the requested service is primarily for the purpose of contraception. The documentation does not show that this service is being requested to treat a specific illness/injury.
As such, the Medicare rules for coverage of this item/service have not been met. Therefore, we decided that the Plan does not have to pay for the Etonogestrel implant system (J7307).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on March 22,
2021.
You asked the Plan to waive the copayment for ambulance services. You say that you have a handbook stating
that any coronavirus related services are fully covered. 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 $200
copayment for ambulance services.
You have been asked to pay a $200 copayment for ambulance services. Ambulance services fall 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 ambulance services
provided on March 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) provided on
May 10, 2021.
You asked the Plan to pay for the complete series of intraoral x-rays. You say that the provider's office should
have informed you that you would have to pay out of pocket for these x-rays. You also say that you cannot
afford to pay for this. The Plan denied your request. The Plan says benefits for this service have been satisfied
and the frequency limitation has been exceeded. The Plan also says that you did not contact the Plan prior to
this date of service to verify benefits and provider eligibility.
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, full mouth or panoramic x-rays are
limited to one procedure code every five years. The record shows that you received a complete series of
intraoral x-rays (D0210) on July 30, 2018 and your full mouth or panoramic x-rays benefit has been exhausted.
Therefore, we decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210)
provided on May 10, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the transitional care management services (99496), advance care planning (99497), and hospice supervision (G0182), provided on February 5, 2021.
You asked the Plan to pay for the transitional care management services, advance care planning, and hospice supervision. You say that the services should be covered. The Plan denied your request. The Plan says Original Medicare is responsible for payment.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the transitional care management services (99496), advance care planning (99497), and hospice supervision (G0182), provided on February 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient rehabilitation facility (IRF)
admission and services provided January 27, 2021, to February 5, 2021.
You asked the Plan to waive the copayment for the IRF stay. You say that you were told the stay would be
covered. 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). The enrollee's contract with the Plan clearly says that enrollees
must pay a $325 copayment per day, days 1-6 for each Medicare covered hospital admission/stay.
The enrollee has been asked to pay a total of $1,950 ($325 copayment x 6 days = $1,950) for the IRF stay. This
inpatient stay falls within the Inpatient hospital care benefit category. This means that the enrollee has been
asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not
have to waive the copayment for the inpatient rehabilitation facility (IRF) admission and services provided
January 27, 2021, to February 5, 2021.
Your complaint about potentially being provided misinformation by a Plan representative 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 the pulmonary testing services provided on September 28, 2020.
You asked the Plan to pay for the pulmonary testing services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the member's physician has stated that there was no order of genetic testing for this member.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. We looked at your request, the file and Medicare rules. Based on this information we decided that Medicare criteria for coverage have not been met. Specifically, the documentation does not show that the requested testing was ordered due to any signs/symptoms of a medical condition. The documentation does not include any clinical information to verify why this testing was ordered or if it was medically necessary. Of note, the Plan has stated that the physician on the order was contacted and verified that no genetic testing had been ordered for this member. Therefore, we decided that the Plan does not have to pay for the pulmonary testing services provided on September 28, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the comprehensive cardiovascular panel provided on September 17,
2020.
You asked the Plan to pay for the cardiovascular panel. You say that you would like reconsideration based on
the records submitted. The Plan denied your request. The Plan says that it was unable to be verified if the
member's physician ordered this testing.
The Plan must follow Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory
tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the cardiovascular panel have been met. Specifically, the documentation submitted includes a
signed physician order. Therefore, we decided that the Plan has to pay for the comprehensive cardiovascular
panel provided on September 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on December 8, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the laboratory services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide 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 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 laboratory services provided on December 8, 2020 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Coflex device placement (22867).
You asked the Plan to pre-approve the procedure. You say that the services were medically necessary. The Plan denied your request. The Plan says this procedure is investigational and is not covered.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 the procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Coflex device is experimental. High failure rates have been reported with similar devices. 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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a Coflex device placement (22867).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services coded as 97110, 97140, G0283, 99072 provided on April 2, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the physical therapy services. You say that treatment in your office was directed by a participating provider, which is referred to as Plan directed care, and therefore, should be processed for reimbursement. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 physical therapy services coded as 97110, 97140, G0283, 99072 provided on April 2, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the facet joint injection procedure you had
at an outpatient hospital facility on March 19, 2021.
You asked the Plan to waive the copayment for the facet joint injection procedure. You say that you gained no
benefit from the procedure so you should not have to pay the copayment. 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 $350
copayment for surgery services at a hospital outpatient facility.
You have been asked to pay a $350 copayment for the facet joint injection procedure. The facet joint injection
procedure falls within the surgery services at a hospital outpatient facility benefit category. This copayment
applies regardless of the outcome of the surgery. 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 facet joint injection procedure you had at an outpatient hospital facility on March 19, 2021.