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

We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on April 27, 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 (99214) rendered by the out-of-network (OON) provider on April 27, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a continuous positive airway pressure (CPAP) device and
humidifier.
You asked the Plan to pre-approve a CPAP device and humidifier. You say that your CPAP has been recalled
and that you require a replacement. The Plan denied your request. The Plan says that the services are not
covered.
The Plan must follow Medicare rules. Medicare rules say that the MAO is responsible for maintaining
continuity of care for its enrollee by ensuring uninterrupted access to the medically necessary covered DME
item, including when the item needs to be repaired or replaced. If necessary, the plan must purchase or rent a
replacement item for the beneficiary to use.
We looked at the file and Medicare rules. The case file shows that the enrollee's existing CPAP machine was
recalled by the manufacturer. The records show that the enrollee's provider has determined that continued used
of this recalled machine is not safe. The Plan has not demonstrated that they have ensured access to a usable
CPAP for the enrollee.
The rules also say that more extensive maintenance which, based on the manufacturers' recommendations, is to
be performed by authorized technicians, is covered as repairs for medically necessary equipment which a
beneficiary owns. This might include, for example, breaking down sealed components and performing tests
which require specialized testing equipment not available to the beneficiary. In this case, the file shows that the
manufacturer has issued a recall on the enrollee's current device that the enrollee is not able to correct on their
own. Therefore, we decided that the Plan has to pre-approve a continuous positive airway pressure (CPAP)
device and humidifier.
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: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the computed tomography (CT) scan provided on July 28, 2021.  You asked the Plan to waive the coinsurance for the CT scan. You say that you thought this test was previously approved. 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 20% coinsurance for each diagnostic radiology and complex imaging service.   You have been asked to pay $36.42, which is 20% of the allowed amount for the CT scan ($182.09 allowed amount x 20% coinsurance = $36.42). The 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 coinsurance for the computed tomography (CT) scan provided on July 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve non-lycra compression pantyhose.  You asked the Plan to pre-approve non-lycra compression pantyhose. You say that the enrollee needs these to treat the painful varicocities in her legs. The Plan denied your request. The Plan says the denial of authorization for these items is correct, because these do not serve a primarily medical purpose and are not covered by Medicare.  The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.    The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve non-lycra compression pantyhose.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a SNF stay provided from May 1, 2021, to May 20, 2021.
You asked the Plan to waive the copayment for a SNF stay. You say that you disagree with the charges because you were not aware of the copayment and cannot afford it. 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 $0 copayment for days 1-20 and a $184 copayment for days 21-36 for SNF care. You had a SNF stay from April 19, 2021, to May 20, 2021. You are not being charged a copayment for days 1-
20 (April 19, 2021, to May 8, 2021). You are responsible to pay a $184 copayment for days 21-31 (May 9,
2021, to May 19, 2021. The total amount you owe is: $184 (copayment) x 11 (SNF days) = $2,024.
You have been asked to pay the total copayment amount of $2,024 for a SNF stay. A SNF stay falls within the
SNF 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 a SNF stay provided from
May 1, 2021, to May 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the Remicade infusions you received on March 31, 2021, and May 26, 2021.  You asked the Plan to waive the coinsurance for the Remicade infusions. You say that you have never had to pay more than $8.95 for any drug before. 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 Remicade infusions. the Remicade infusions fall within the Medicare Part B drugs benefit category. This cost sharing applies regardless of what you may have paid in the past. 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 Remicade infusions you received on March 31, 2021, and May 26, 2021.
Appeal type: Drugs
Decision: Favorable

 We decided that the Plan has to pay for four units of zoledronic acid (J3489) provided on May 21, 2021.  You asked the Plan to pay for the zoledronic acid. You say that you would like reconsideration because there is no frequency limit listed for Zometa and the maximum units allowed per administration is 5 units. The Plan denied your request. The Plan says that the recommended regimen is a 5 mg infusion once a year.  The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary.   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 the zoledronic acid. Our reviewer says that zoledronic acid (zometa) is supported by major drug compendia for the treatment of bone loss associated with androgen deprivation therapy. Our physician reviewer found dosing is either  5 mg once every 12 months or 4 mg once every 6 to 12 months. Therefore, 4 units of J3489 is reasonable and medically necessary.  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 zoledronic acid have not been met. Therefore, we decided that the Plan has to pay for four units of zoledronic acid (J3489) provided on May 21, 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergency transportation, wheelchair van services provided on July 22, 2021.
You asked the Plan to pay for the non-emergency transportation, wheelchair van services. You say that you came out of the hospital and the van was there to take you to Greenfields. You say that you did not know about SafeRide. The Plan denied your request. The Plan says this service is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport services. The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided that the Plan does not have to pay for non-emergency transportation, wheelchair van services provided on
July 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the cost sharing for the outpatient arthroplasty procedure you had on June 15, 2021, and the physical therapy session you had at an outpatient hospital facility on June 16, 2021.  You asked the Plan to waive the cost sharing for the outpatient arthroplasty surgery and the physical therapy session. You say that you have never received a bill like this before for surgery and you shouldn't be responsible. The Plan denied your request. The Plan says you were charged this cost sharing 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 outpatient surgery and a $40 copayment for physical therapy visits.   You have been asked to pay 20% coinsurance for the outpatient arthroplasty surgery and a $40 copayment for the physical therapy session. 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 cost sharing for the outpatient arthroplasty procedure you had on June 15, 2021, and the physical therapy session you had at an outpatient hospital facility on June 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an X-ray provided on July 12, 2021.
You asked the Plan to waive the deductible for an X-ray. You say that you did not have a choice in the provider because the physician wanted immediate results. 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. Your contract with the Plan says that there is a $750 deductible which applies to X-rays. You received an X-ray on July 12, 2021. The record shows that you only paid $0 toward the $750 deductible prior to receiving the services. Therefore, you are responsible to pay the allowed amount of $65.07. The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which applies to outpatient diagnostic tests and therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time
an X-ray was received on July 12, 2021. Therefore, we decided that the Plan does not have to waive the deductible for an X-ray provided on July 12, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound care services provided on August 18, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the wound care 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 wound care services provided on August 18, 2021 by an out-of-network (OON) provider
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve SNF care. You say that this provider confirmed having a contract with the Plan and is willing to accept the enrollee. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and the enrollee can be treated at an in-network skilled nursing facility (SNF).  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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.  The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care to be provided by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital services provided on May 18, 2021.
You asked the Plan to pay for hospital services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on May 13, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for hospital services provided on May 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services (99053) provided on May 3, 2021.
You asked the Plan to pay for code 99053. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. Code 99053 has a status code of "B" under the Medicare Physicians
Fee Schedule Database (MPFSDB) and no separate payment is made for this code under the fee schedule as payment is bundled into the payment for the services to which this code is incident to. Therefore, we decided that the Plan does not have to pay for the medical services (99053) provided on May 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit with a specialist (99214)
rendered on July 22, 2021.
You asked the Plan to waive the copayment for an office visit with a specialist. You say that you did not see the
doctor, however, the nurse practitioner came in and told you that you cannot have an injection on your knee
due to the fact you had a knee replacement. You also say that you explained to her that your ankle was red and
swollen and the nurse responded that the doctor did not have time to look at your leg. You also say that you do
not feel that you are responsible for this payment because the doctor did not put anything in your knee. 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 $25
copayment for each in-person specialist visit.
You have been asked to pay a $25 copayment for an office visit with a specialist. The record shows that
although you were not seen by the doctor, you were seen at his office by the nurse practitioner. 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 with a specialist (99214) rendered on July 22, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network
(OON) provider on June 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 (99214) rendered by the out-of-network (OON) provider on June 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the myocardial perfusion imaging you received on July 2, 2021.
You asked the Plan to waive the copayment for the myocardial perfusion imaging. You say that this was all part of a stress test, which you consider to be under the 'cardiovascular screenings' heading. You state that this should have a $0 copayment. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan stated that it has reduced your copayment to $45 for this service.
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 diagnostic procedures and tests. You have been asked to pay a $45 copayment for the myocardial perfusion imaging. The myocardial perfusion imaging falls within the diagnostic procedures and tests benefit category. Your Evidence of Coverage states
that the only services covered with zero cost sharing under the 'Cardiovascular Disease Testing' benefit are
blood tests. The myocardial perfusion imaging is not a blood test and is not cardiovascular disease testing for
which there is no cost sharing. 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 myocardial perfusion
imaging you received on July 2, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the esophagogastroduodenoscopy (EGD) you had at an ambulatory surgery center on August 2, 2021.  You asked the Plan to waive the copayment for the EGD. You say that you feel as though this is a preventive service, so there should not be 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 $350 copayment for outpatient surgery and services at an ambulatory surgery center.   You have been asked to pay a $350 copayment for the EGD. This copayment applies regardless of the reason for this service. 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 esophagogastroduodenoscopy (EGD) you had at an ambulatory surgery center on August 2, 2021.