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

We decided that the Plan does not have to waive the copayment for an office visit (99214) provided on June 9, 2021.
You asked the Plan to waive the copayment for an office visit. You say that this should be covered as a preventative service. The Plan denied your request. The Plan says this processed 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 out-of-network office visits. You have been asked to pay a $10 copayment for an office 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 an office visit (99214) provided on June 9, 2021.
Your complaint about your vaccine administration not being covered as billed is not a valid appeal for medical coverage. After looking at all of the information in this case, we found that you do not owe any money for the vaccine administration. Since you owe no money, there is no need for a coverage decision. If the provider is billing you for charges beyond any applicable cost-sharing amounts, please contact the Plan directly
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the dental exam you had on June 8, 2021.

You asked the Plan to waive the copayment for the dental exam. You say that the dentist lied to you and told you that you did not have a 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 $25 copayment per visit for preventive dental services. 

You have been asked to pay a $25 copayment per visit for the dental exam. The dental exam falls within the preventive dental 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 dental exam you had on June 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) provided on May
26, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the domiciliary or rest home visit. You say that the assisted living facility is
responsible to obtain prior authorization for all of their patients, which should also cover for the medical
treatments provided by the doctor. 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 domiciliary or rest home visit (99336)
provided on May 26, 2021 by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on April 24, 2021.  You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you would like these services to be covered because they were medically necessary. The Plan denied your request. The Plan says this service is not covered.  The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.   The ambulance company did not provide transport services on April 24, 2021. The record shows that you declined transportation services. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on April 24, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered on December 18, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services were not billed correctly.
The Plan must follow Medicare rules. The rules say that in addition to reporting a visit line using the G codes,
HHAs must report an additional line item with the same revenue code and date of service, reporting one of the
three Q codes (Q5001, Q5002, and Q5009).
We looked at the file and Medicare rules. The file shows that the services were not billed with one of the
required G codes. Based on this information, we decided that Medicare rules for coverage of these services
have not been met. Therefore, we decided that the Plan does not have to pay for the home health services
rendered on December 18, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on
May 24, 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 must 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 24, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for lab services billed with code 88361 provided on June 17, 2021.
You asked the Plan to pay for the lab services. You say that these services were medically necessary and
ordered by the patient's doctor to rule out Barrett's esophagus. The Plan denied your request. The Plan says that
the medical necessity criteria of Local Coverage Article A57611 have not been met.
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 Plan based its denial rationale solely on criteria listed in Local Coverage
Article A57611. However, the enrollee in this case resides in Pennsylvania. This lab is located in New York.
This Local Coverage Article is only applicable in the following jurisdictions: California, American Samoa,
Guan, Hawaii, Northern Mariana Islands, and Nevada. So, this policy is neither applicable nor controlling in
this case. The Plan has failed to bring forth any other argument or support for their position of non-covered in
this case. The burden is on the Plan to prove that their denial is appropriate, and they have failed to do so.
Therefore, we decided that the Plan has to pay for lab services billed with code 88361 provided on June 17,
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from
June 15, 2021, through June 16, 2021.
You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says the
primary procedure is typically done in the outpatient setting, not in an inpatient hospital setting.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
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 pay for acute inpatient hospital care. Our reviewer
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our
physician reviewer found that the record does not show that at the time of inpatient admission the admitting
physician reasonably expected that the enrollee's necessary hospital care (including earlier emergency
department and/or observation care) would span two midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the
Plan does not have to pay for the acute inpatient hospital care provided from June 15, 2021, through
June 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures (D0431), drugs or medicaments dispensed in the office for home use (D9630), enamel microabrasion (D9970) and localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth (D4381) provided June 25, 2021, and July 22, 2021.  You asked the Plan to pay for the adjunctive pre-diagnostic test, drugs dispensed for home use, enamel microabrasion and localized delivery of antimicrobial agents. You say that you feel you were overcharged for the services. The Plan denied your request. The Plan says these services are not covered under your benefits.  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 adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures (D0431), drugs or medicaments dispensed in the office for home use (D9630), enamel microabrasion (D9970) and localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth (D4381) provided June 25, 2021, and July 22, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to hold you harmless for the nerve conduction study you had on August 2, 2021.
You asked the Plan to hold you harmless for the nerve conduction study. You say that this was not a cosmetic
procedure. The Plan denied your request. The Plan says that the nerve conduction study you received is
investigational when used for polyneuropathy rather than carpal tunnel, and it is not covered.
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 the nerve conduction study by a contract provider. The file does not show that the Plan
provided notice that the nerve conduction study would not be covered. Under Medicare rules, this means the
nerve conduction study is considered approved by the Plan. Therefore, we decided that the Plan has to hold you
harmless for the nerve conduction study you had on August 2, 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 that the Plan does not have to pay for the outpatient office visit (99203) chiropractic manipulative treatment (98941) provided on May 6, 2021 to July 19, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the chiropractic services. You say that at the onset of treatment the enrollee gave you her Medicare insurance card which you billed. Medicare informed you they were not the primary carrier. The treatment rendered was reasonable and necessary. 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 outpatient office visit (99203) chiropractic manipulative treatment (98941) provided on May 6, 2021 to July 19, 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 office visit you had with an otolaryngologist on February 18, 2021.
You asked the Plan to waive the copayment for the otolaryngology visit. You say that you went to the office for a hearing aid examination. You spoke with one doctor and then had an audiology test with another doctor. You think you should only have to pay one copayment because both doctors were in the same office. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that the medical records prove that you had services with two different doctors on this date, so two separate copayments apply.
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 services with a specialist. Records show that on this date of service, you had a hearing test with one doctor, and an office visit with a different otolaryngologist. You have been asked to pay a $10 copayment for the otolaryngology visit. Your copayment is due each time you see a specialist. Since you saw two different specialists on this date, two
copayments can apply. 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 office visit you had with an otolaryngologist on February 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on June 11, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. 

In this case, the MUE for CPT code 27096 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services rendered on June 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Shingles vaccine you received on August 17, 2021.
You asked the Plan to pay for the Shingles vaccine. You say that the doctor's office should have billed Part D for this. You said that you do have a Part D policy but wanted to try to appeal this first. The Plan denied your request. The Plan says this vaccine is not covered under your medical benefits. The Plan says that you contacted them multiple times to ask if this vaccine is covered, and you were told each time that it is only potentially covered under your Part D benefits.
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 vaccine you received on August 17, 2021.
Benefits for the Shingles vaccine 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: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee
July 27, 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 must 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 July 27, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had
from April 6, 2021, to April 7, 2021.

You asked the Plan to waive the copayment for the ER visit. You say that you are not responsible for this bill
because you were admitted through the ER to the hospital. 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 an $80
copayment for emergency room services.

You have been asked to pay an $80 copayment for the ER visit. The ER copayment is only waived if you are
admitted to the hospital as an inpatient within 48 hours. The records show that you were not admitted as an
inpatient. Instead, you were kept in observation (which is not an admission and is considered an outpatient
status). This means that the ER copayment applied correctly. 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 emergency room (ER) visit you had from April 6, 2021, to April 7, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90837) provided on July 2, 2021, by an out-of-network provider.

You asked the Plan to pay for psychotherapy services. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for out-of-network care have not been met.

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 psychotherapy services (90837) provided on July 2, 2021, by an out-of-network provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90837) provided on July 13, 2021, by an out-of-network provider.

You asked the Plan to pay for psychotherapy services. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for out-of-network care have not been met.

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 psychotherapy services (90837) provided on July 13, 2021, by an out-of-network provider.