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

 We decided that the Plan does not have to waive the copayments for hyperbaric oxygen chamber services provided from May 3, 2021, to May 28, 2021. We also decided that the Plan does not have to waive the copayment for inpatient hospital services provided from May 21, 2021, to May 25, 2021.  You asked the Plan to waive the copayments for the hyperbaric oxygen chamber services and inpatient hospital services. You say that you were informed that you met your maximum out-of-pocket expenses and would like the charges verified. 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 $260 copayment for surgery or other services provided to you at an ambulatory surgical center or outpatient hospital.  Your contract with the Plan also clearly says that you must pay $285 per day for days 1-6 and $0 per day after day 6 for each inpatient stay.  Service Copayment per EOC Actual Charges Hyperbaric Oxygen Chamber - May 28, 2021 $260 $260 Inpatient Care - May 21, 2021, to May 25, 2021 $285/day $1,140 (4 days) Hyperbaric Oxygen Chamber - May 3, 2021 $260 $260 Hyperbaric Oxygen Chamber - May 4, 2021 $260 $260 Hyperbaric Oxygen Chamber - May 5, 2021 $260 $260 Hyperbaric Oxygen Chamber - May 6, 2021 $260 $260 Hyperbaric Oxygen Chamber - May 7, 2021 $260 $179.67 (max met) Total:  $2,619.67  You have been asked to pay $2619.67 for the hyperbaric oxygen chamber services and inpatient hospital services. The hyperbaric oxygen chamber services fall within the Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. The inpatient hospital services fall within the Inpatient Hospital Care benefit category. Please note that your maximum out-of-pocket (MOOP) expenses were met when the claim for May 7, 2021, was processed. The remaining claims were paid in full by the Plan. 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 copayments for hyperbaric oxygen chamber services provided from May 3, 2021, to May 28, 2021. We also decided that the Plan does not have to waive the copayment for inpatient hospital services provided from May 21, 2021, to May 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the destruction by neurolytic agent (64624).  You asked the Plan to pre-approve the destruction by neurolytic agent (64624). You say that the member experienced 80% improve in her pain that lasted over 4 months with the previous radiofrequency ablation. You say that authorization for this treatment option should be provided. The Plan denied your request. The Plan says radiofrequency ablation is considered experimental.  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 destruction by neurolytic agent (64624). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case.  Our physician reviewer found that genicular nerve blocks and genicular nerve radiofrequency ablation are considered investigational and not medically necessary for the treatment of chronic knee pain.  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 destruction by neurolytic agent (64624) have not been met. Therefore, we decided that the Plan does not have to pre-approve the destruction by neurolytic agent (64624).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an emergency response system (S5161).  

You asked the Plan to pre-approve an emergency response system. You say that this is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.  

The Plan must follow Medicare rules. Medicare rules say that personal emergency response systems are not covered. However, the Plan offers personal emergency systems as a supplemental benefit. These are covered when there is a relevant diagnosis.   

We looked at the file and Medicare rules. The medical records submitted do not include evidence of such things that would be relevant for a personal emergency response system including things such as history of falls, unsteady gait or balance disorder. Based on this information, we decided that Medicare rules for coverage of an emergency response system have not been met. Therefore, we decided that the Plan does not have to pre-approve an emergency response system (S5161).
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the electroencephalogram (95813), somatosensory testing (95927 and 95938) and intraoperative neuromonitoring services (95940) provided on February 5, 2021.  You asked the Plan to pay for the intraoperative neuromonitoring services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says these services have not been billed with the appropriate modifier.    The Plan must follow Medicare rules. Medicare rules say that all items and non-physician services furnished to inpatients must be furnished directly by the hospital or billed through the hospital under arrangements.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the intraoperative neuromonitoring services have not been met. Specifically, the record indicates that the member was registered inpatient on the billed date of service. Payment for these services is included in the payment to the facility and is the responsibility of the facility to any vendor. Therefore, we decided that the Plan does not have to pay for the electroencephalogram (95813), somatosensory testing (95927 and 95938) and intraoperative neuromonitoring services (95940) provided on February 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for continuous positive airway pressure (CPAP) device provided on July 30, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for a CPAP device. You say that your PCP directed you to purchase the CPAP device from the non-participating provider. The Plan denied your request. The Plan says a conversation with the enrollee's PCP it was stated the enrollee was not referred to an online provider and the PCP only wrote the prescription for a replacement CPAP device that was needed.  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 continuous positive airway pressure (CPAP) device provided on July 30, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the filling (D2391) for tooth # 5 provided on November 3, 2021.  You asked the Plan to pay for the filling. You say that this was an emergency. You also say that your filling fell out and exposed a cavity. The Plan denied your request. The Plan says 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 (D2391) for tooth # 5 provided on November 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the periodontal maintenance (D4910), gingival irrigation (D4921), and unspecified preventive service (D1999) provided on June 28, 2021.  You asked the Plan to pay for the dental services. You say that you require periodontal maintenance 3 time a year. You say that you are trying to hold on to your remaining teeth. You also say that these services should be covered. The Plan denied your request. The Plan says periodontal maintenance is not listed as a covered service. The Plan says that gingival irrigation is not listed as a covered service. The Plan also says that unspecified preventive service is not listed as a covered service either.  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 dental services you received are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910), gingival irrigation (D4921), and unspecified preventive service (D1999) provided on June 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a therapeutic facet joint injection.  You asked the Plan to pre-approve a therapeutic facet joint injection. You say that this is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met.  The Plan follows Medicare rules. Medicare rules say that therapeutic facet joint injections are subject to the coverage criteria listed in the Medicare rules section.   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 a therapeutic facet joint injection. Our reviewer says that the requested injection services are not medically reasonable and necessary. Our physician reviewer found that the record indicates that the enrollee has lumbar back pain with radiculopathy.  The record indicates that the enrollee underwent radiofrequency ablation in May 2021 with persistent 75% pain relief. The record does not include documentation of why the patient is not a candidate for repeat radiofrequency ablation.  The elements of the coverage criteria are not satisfied. The requested service is not recommended.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a therapeutic facet joint injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic facet joint injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99213) rendered by the OON provider on September 9, 2021.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without 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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99213) rendered by the OON provider on September 9, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on November 2, 2021.  

You asked the Plan to waive the copayment for the ER visit. You say that you were unable to see your PCP without an appointment and you cannot afford the charges. 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 $90 copayment for each emergency room visit.   

You have been asked to pay a $90 copayment for the ER visit. The ER visit falls within the Emergency Care 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 an emergency room (ER) visit provided on November 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for specialist visits provided on August 5, 2021, and August 26, 2021.  You asked the Plan to waive the copayments for specialist visits. You say that these were follow-up visits and you were told that you would not owe a copayment. 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 $50 copayment for specialist visits.   You received specialist visits on August 5, 2021, and August 26, 2021. Follow-up visits are subject to cost-sharing charges. Therefore, you are responsible to pay a $50 copayment per each visit. The total amount you owe is: $50 (copayment) x 2 (specialist visits) = $100.   You have been asked to pay the total copayment amount of $100 for specialist visits. Specialist visits fall within the physician/practitioner services, including doctor's office visits 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 copayments for specialist visits provided on August 5, 2021, and August 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265).  

You asked the Plan to pre-approve a total electric hospital bed. You say that a total electric bed will be medically beneficial. The Plan denied your request. The Plan says this is not covered under any normal circumstances.  

The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.   

While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed (E0265).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a specialist office visit provided on August 13, 2021.  You asked the Plan to waive the copayment for the specialist office visit. You say that you feel that the office visit should be part of the colonoscopy procedure and not a separate charge. 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 $45 copayment for services obtained from a specialist.   You have been asked to pay a $45 copayment for the specialist office visit. The specialist office visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits benefit category.   This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a specialist office visit provided on August 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on September 30, 2021.  You asked the Plan to pay for the problem focused limited oral evaluation. You say that you would like this service to be covered. The Plan denied your request. The Plan says this claim processed appropriately. The Plan also says that you signed an agreement with the provider acknowledging that you would be responsible for all charges, whether or not paid by the insurance and for all services rendered on your behalf.    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 problem focused limited oral evaluation (D0140) provided on September 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a Freestyle Libre continuous glucose monitor sensor (K0553) provided on February 28, 2021.  

You asked the Plan to pay for a Freestyle Libre sensor. You say that the item at issue was a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for durable medical equipment have not been met.  

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the information in the patient's medical record adequately supports the medical necessity for the item.  

The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. Specifically, the provided medical records do not discuss the item at issue. 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 a Freestyle Libre continuous glucose monitor sensor (K0553) provided on February 28, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that IRF admission is medically necessary. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found IRF care is not medically necessary based on your lack of medical complexity, rehabilitation nursing needs, and your high functional level. While you may benefit from physical and/or occupational therapy, your rehabilitation needs can be safely met in a lower intensity setting such as skilled nursing facility.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a transthoracic echocardiography (TTE) with doppler provided on August 31, 2021.  

You asked the Plan to waive the copayment for the TTE with doppler. You say that you feel that your copayment should only be $45 since that is what is on your ID card. 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 $160 copayment for radiological diagnostic services, not including X-rays.  

You have been asked to pay a $160 copayment for the TTE with doppler. Please note that the specialist copayment listed on your ID card refers to specialist office visits and does not include procedures. The TTE with doppler falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a transthoracic echocardiography (TTE) with doppler provided on August 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a hip injection provided on May 12, 2021.  You asked the Plan to waive the copayment for the injection. You say that you were not informed that the procedure was considered outpatient surgery and would not have had it done if you knew the cost. 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 $275 copayment for outpatient services at hospital facilities.   You have been asked to pay $234.56, which is less than the $275 copayment for the injection. The injection falls within the Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category.    This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a hip injection provided on May 12, 2021.