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

 We decided that the Plan does not have to pay for the office visit (99203) rendered by the out-of-network (OON) provider on June 10, 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 (99203) rendered by the out-of-network (OON) provider on June 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the domiciliary or rest home visit (99327) and brief emotional assessment services (96127) provided on June 2, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the domiciliary or rest home visit. You say that attached is the medical record which will show medical necessity for this claim. 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 (99327) and brief emotional assessment services (96127) provided on June 2, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for wound care supplies you received on June 9, 2021, and July 9, 2021.  You asked the Plan to waive the coinsurance for the wound care supplies. You say that you believe this provider charges more for these items when they bill insurance versus when you pay out of pocket. The Plan denied your request. The Plan says you were charged this coinsurance correctly.  This coinsurance is based on the allowed amount for these wound care supplies.  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 20% coinsurance for durable medical equipment and supplies.   You have been asked to pay 20% coinsurance for the wound care supplies. The wound care supplies fall within the durable medical equipment 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 coinsurance for wound care supplies you received on June 9, 2021, and July 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the gingivectomy or gingivoplasty (D4212) provided on December 15, 2020.  You asked the Plan to pay for the core buildup and gingivectomy or gingivoplasty and to pay more for the crown. You say that a Plan representative advised that the enrollee would be responsible for a 30% copayment for the services. You also say that the enrollee was given a treatment plan reflecting that cost, only to have the Plan cover a substantial amount less. The Plan denied your request. The Plan says gingivectomy or gingivoplasty and core buildup are not covered services. The Plan also says that the payment rate for the crown was processed according to the Plan's negotiated rate.  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, gingivectomy or gingivoplasty (D4212) is not among those covered under this benefit. The record shows that due to the misinformation that was provided by the Plan, the Plan has agreed to partially pay for the core buildup, including any pins when required (D2950), and to pay more for the crown (D2790). Therefore, we decided that the Plan does not have to pay for the gingivectomy or gingivoplasty (D4212) provided on December 15, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for outpatient mental health care provided from September 24, 2020, to October 8, 2020.  You asked the Plan to waive the copayments for outpatient mental health care. You say that you did not receive services at an outpatient hospital facility or under observation an disagree with the charges. 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 $40 copayment for outpatient mental health care provided by a specialist.  The record shows that you received outpatient mental health care provided by a specialist on September 24, 2020. Therefore, you are responsible to pay the $40 copayment.    The record shows that you received outpatient mental health care provided by a specialist on October 8, 2020. Therefore, you are responsible to pay the $40 copayment.    The total amount you owe is: $80.   You have been asked to pay the total copayment amount of $80 for outpatient mental health care. Outpatient mental health care falls within the outpatient mental health 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 copayments for outpatient mental health care provided from September 24, 2020, to October 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit coded 99213 provided on May 5, 2021.  You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.  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 99213 is office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter.   We find that CPT code 99213 is not supported in the medical record. Specifically, this code was billed with modifier -25 (separately identifiable Evaluation and Management (E/M) service). The documentation does not support a significant, separately identifiable E&M service above and beyond the other service provided. This means that modifier -25 is not supported by the documentation. Based on this information, we decided that Medicare rules for coverage of the office visit have not been met. Therefore, we decided that the Plan does not have to pay for the office visit coded 99213 provided on May 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids provided on June 25, 2021.

You asked the Plan to pay for the hearing aids. You say that this provider was supplying the same hearing aids at a cheaper price and had a licensed audiologist to repeat the tests for free. You say that the reimbursement is lower than the plan maximum benefit and you should be reimbursed the cost. The Plan denied your request. The Plan says this provider is not within the Plan's hearing network.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when they are received from a participating hearing aid supplier. 

We looked at this physician's review, the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Specifically, the hearing aids were not received from a participating supplier. Therefore, we decided that the Plan does not have to pay for the hearing aids provided on June 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from January 2, 2021 to January 7, 2021.

You asked the Plan to waive the copayment for inpatient hospital care. You say that you cannot afford the charges. 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 $350 copayment for inpatient hospital care. 

You have been asked to pay a $350 copayment for inpatient hospital care. Inpatient hospital care falls within the inpatient hospital 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 inpatient hospital care provided from January 2, 2021 to January 7, 2021.
Appeal type: Transportation
Decision: Favorable

 We decided that the Plan has to waive the coinsurance for the ambulance service, basic life support, non-emergency transport (A0428) and ground mileage, per statute mile (A0425) provided May 8, 2021.  You asked the Plan to waive the coinsurance for the ambulance service and ground mileage. You say that you should have no cost for the services. The Plan denied your request. The Plan says that the coinsurance was applied correctly.  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 for ground and air ambulance services regardless of the number of trips.   The Plan says you must pay 20% coinsurance for the ambulance service and ground mileage. Based on the Plan contract, however, you cannot be asked to pay more than a $0 copayment for the ambulance service and ground mileage. Therefore, we decided that the Plan has to waive the coinsurance for the ambulance service, basic life support, non-emergency transport (A0428) and ground mileage, per statute mile (A0425) provided May 8, 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 vestibular evoked myogenic potential (VEMP) testing coded as 92540, 92537, 92547, 92546, 92584, 92653, 92517 and 97750 provided June 24, 2021.  You asked the Plan to pay for the VEMP testing. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says there is insufficient evidence whether VEMP can accurately identify vestibular function.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the VEMP testing have not been met. Therefore, we decided that the Plan does not have to pay for the vestibular evoked myogenic potential (VEMP) testing coded as 92540, 92537, 92547, 92546, 92584, 92653, 92517 and 97750 provided June 24, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for an X-ray of the shoulder (73030) provided on July 27, 2021, by an out-of-network provider.  You asked the Plan to pay for an X-ray of the shoulder. You say that the requested service was 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 an X-ray of the shoulder (73030) provided on July 27, 2021, by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided on June 10, 2021.

You asked the Plan to waive the copayment for a CT scan. You say that you cannot afford the charges. 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 $195 copayment for CT scans. 

You have been asked to pay a $195 copayment for a CT scan. A CT scan 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 CT scan provided on June 10, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Praluent.

You asked the Plan to pre-approve Praluent. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.

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 Praluent.

Benefits for Praluent 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 waive the coinsurance for the Prolia injection you received on July 1, 2021.  You asked the Plan to waive the coinsurance for the Prolia injection. You say that you are on a fixed income and you thought that the Plan would pay more for this. The Plan denied your request. The Plan says you were charged this coinsurance correctly.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare Part B drugs.   You have been asked to pay 20% coinsurance for the Prolia injection. The Prolia injection falls within the Medicare Part B 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 Prolia injection you received on July 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system (E2300), an expandable controller (E2377), a harness for upgrade to expandable controller (E2313), electronic connection between wheelchair controller and two or more power seating system motors (E2311), quantum backup camera, and polyurethane liner 20x18.

You asked the Plan to pre-approve a power seat elevation system, an expandable controller, a harness for upgrade to expandable controller, electronic connection between wheelchair controller and two or more power seating system motors, quantum backup camera, and polyurethane liner 20x18. You say that the items are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that wheelchair accessories are covered when specific criteria are met. 

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 power seat elevation system, an expandable controller, a harness for upgrade to expandable controller, electronic connection between wheelchair controller and two or more power seating system motors, quantum backup camera, and polyurethane liner 20x18. Our reviewer says that the items are not medically necessary. Our physician reviewer found based on the medical records provided there is no documentation that the enrollee meets the coverage criteria detailed in the Local Coverage Article: Wheelchair Options/Accessories - Policy Article (A52504) for the requested additional accessories. The seat elevator and camera are statutorily non-covered as they are not primarily medical in nature. Records indicate the enrollee has 4/5 bilateral upper extremity strength with full range of motion and he is independent for feeding, thus indicating he has adequate upper extremity strength and function to control the wheelchair's power options with their own switches. The polyurethane liner is to protect the wheelchair from elements outside the home; durable medical equipment is only covered by Medicare for use in the home.

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 power seat elevation system, an expandable controller, a harness for upgrade to expandable controller, electronic connection between wheelchair controller and two or more power seating system motors, quantum backup camera, and polyurethane liner 20x18 have not been met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system (E2300), an expandable controller (E2377), a harness for upgrade to expandable controller (E2313), electronic connection between wheelchair controller and two or more power seating system motors (E2311), quantum backup camera, and polyurethane liner 20x18.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for inpatient hospital services and ground transportation services (A0425, A0427) rendered from June 15, 2021, to June 19, 2021.

You asked the Plan to waive the copayments for inpatient hospital services and ground transportation services. You say that you went to the urgent care and your oxygen level was so low they had to call an ambulance. You also say you thought that ride was covered. You also say you had to stay in the hospital until your oxygen consumption was down. You also say you are pretty sure this was the coronavirus (Covid 19) and should be covered. The Plan denied your request. The Plan says you were charged the correct cost sharing amount

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 copayment per day for day(s) 1-5 for Inpatient Hospital Care. Your contract with the Plan also clearly says that you must pay a $250 copayment for each one-way Medicare-covered ambulance trip. 

You have been asked to pay a $275 copayment per day for 4 days of inpatient hospital services, which is a total of $1,100 ($275 x 4 = $1,100). Inpatient hospital services fall within the Inpatient Hospital Care benefit category. You have also been asked to pay a $250 copayment for ground transportation services. Ground transportation 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 copayments for inpatient hospital services and ground transportation services (A0425, A0427) rendered from June 15, 2021, to June 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99203) rendered by the out-of-network (OON) provider on July 26, 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 (99203) rendered by the out-of-network (OON) provider on July 26, 2021.