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

We decided that the Plan does not have to pay for the laboratory work provided on March 24, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the laboratory work. You say that the claim has not been paid in full or under the terms of the contract for the services. The Plan denied your request. The Plan says no prior authorization was obtained.
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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the services at issue were urgent or emergent. Therefore, we decided that the Plan does not have to pay for laboratory work provided on March 24, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the extremity study (93971) rendered by the out-of-network (OON) provider on June 14, 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 extremity study (93971) rendered by the out-of-network (OON) provider on June 14, 2021.
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 a urologist on July 13, 2021.
You asked the Plan to waive the copayment for the urology visit. You say that this visit was a follow-up from a procedure on July 1, 2021, so there should be no 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 $35 copayment for visits with a specialist.
The rules say that when you have surgery, certain postoperative visits during the post-operative period are included in the cost of the surgery. Depending on the surgery itself, that postoperative period can be 0 days, 10 days, or 90 days. In this case, the surgery you had (procedure code 52356) has a 0-day postoperative period. That means that any follow-up visits are separately payable and separate cost sharing applies. You have been asked to pay a $35 copayment for the urology visit. The urology visit falls within the visits with a specialist 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 office visit you had with a urologist on July 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group three power wheelchair and accessories for the 
enrollee. 
 
You asked the Plan to pre-approve the services. You say that the items in dispute are medically necessary. The 
Plan denied your request. The Plan says the medical necessity criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 services. Our reviewer says that the 
requested services are not medically reasonable or necessary.  
 
Our physician reviewer found there is no documentation from the enrollee's treating provider that this patient 
has a personal mobility deficit that impairs participation in mobility related activities of daily living such as 
toileting, feeding, grooming and bathing in customary locations within the home. There is no documentation 
that the mobility deficit cannot be helped by the use of a walker, cane, or manual wheelchair. There is no up to 
date face-to-face examination from the enrollee's medical provider is included in the available records 
documenting the necessity of the power mobility device or the accessories. The Standard Written Order is not 
dated or signed. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group three power wheelchair and accessories for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the office visit provided on June 15, 2021.
You asked the Plan to pay for the office visit. You say that lengthy discussions were necessary to pinpoint the problems you were experiencing. The Plan denied your request. The Plan says that routine services are not covered.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation when there is an expectation of improvement in function. The Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file, and Medicare rules. Your plan contract says that non-Medicare covered chiropractic services are covered for up to 8 visits. The case file does not show that 8 visits were already used prior to the date of service at issue. Based on this information, we decided that the Plan's rules for coverage have been met. Therefore, we decided that the Plan has to pay for the office visit provided on June 15, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an E0118 Roll-A-Bout Platform crutch.
You asked the Plan to pre-approve this item. You say that this platform crutch is medically necessary. The Plan denied your request. The Plan says this item is not covered by Medicare.
The Plan must follow Medicare rules. Medicare does not cover the Roll-A-Bout platform crutch. Therefore, we decided that the Plan does not have to pre-approve an E0118 Roll-A-Bout Platform crutch.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging of the spinal 
canal and contents (72141) rendered on July 10, 2021. 
 
You asked the Plan to waive the copayment for a magnetic resonance imaging of the spinal canal and contents. 
Your spouse says you were told by the provider that you owed $163.90 at the time of the visit, which you paid. 
Your spouse also said that you were told you did not owe any other amount, however, you received a bill from 
the provider in the amount of $86.68. Your spouse also said that you feel the provider should be taking care of 
the $86.68 because you were told you did not owe anything else. 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 $300 
copayment for Medicare-covered diagnostic radiology services (not including x-rays).  
 
You have been asked to pay a $250.58 copayment, which is less than the $300 copayment for a magnetic 
resonance imaging of the spinal canal and contents. A magnetic resonance imaging of the spinal canal and 
contents 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 magnetic resonance imaging of the spinal canal and 
contents (72141) rendered on July 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the orthopedic surgery visit you had on June 30, 2021.
You asked the Plan to waive the copayment for the orthopedic surgery visit. You say that this was a post-op visit from rotator cuff surgery. The Plan denied your request. The Plan says you were charged this copayment correctly. 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 $15 copayment for visits with a specialist. Medicare rules state that postoperative visits that are not related to the surgery itself are separately payable. We looked at the medical records from the visit you had on June 30, 2021. Although your surgery was for your rotator cuff, the notes from this visit show that you were evaluated for bilateral knee pain. This is not related to your rotator cuff surgery, so separate cost sharing can apply. You have been asked to pay a $15 copayment for the orthopedic surgery visit. The orthopedic surgery visit falls within the visits with a specialist. 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 orthopedic surgery visit you had on June 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for knee surgery on June 16, 2021.
You asked the Plan to waive the copayment for the knee surgery. You say that because you suffered atrial fibrillation after receiving anesthesia, your surgery had to be stopped. You don't think you should have to pay the copayment since the surgery did not occur. 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 $225 copayment for outpatient hospital services. You have been asked to pay a $225 copayment for the knee surgery. This copayment applies for each visit to an outpatient hospital facility, even if the surgery doesn't end up happening. 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 knee surgery on June 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ultrasonic osteogenesis stimulator (E0760).

You asked the Plan to pre-approve an ultrasonic osteogenesis stimulator. You say that this item is medically necessary. The Plan denied your request. The Plan says that your request is not medically necessary because your records show that you have a new fracture.

The Plan must follow Medicare rules. Medicare rules say that use of an ultrasonic osteogenesis stimulator for the treatment of a fresh fracture or delayed union will be denied as not medically necessary.

We looked at the file and Medicare rules. The file indicates the ultrasonic osteogenesis stimulator is being requested for treatment of a fresh fracture. Based on this information, we decided that Medicare rules for coverage of an ultrasonic osteogenesis stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve an ultrasonic osteogenesis stimulator (E0760).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81493) provided September 1, 2020.
You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan denied your request. The Plan says this service is not covered.
The Plan must follow Medicare rules. Medicare rules say that Corus CAD Assay is non-covered. We looked at the file and Medicare rules. The testing at issue is non-covered under Medicare rules. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (81493) provided September 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) services you received from May 7, 2021, to May 22, 2021.

You asked the Plan to waive the copayment for the SNF services. You say that you were not informed that there would be a copayment for this stay. You said that you were not charged a copayment for your previous stay. 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 $0 copayment for days 1-20, and a $184 copayment per day for days 21-57 for skilled nursing facility services. 

Records show that you were in the SNF from April 1, 2021, to April 17, 2021, for a total of 16 days. 

You were then readmitted to the SNF from May 7, 2021, to May 22, 2021, for a total of 15 days. Because there were fewer than 60 days between these two admissions, they are considered to be in the same benefit period. So, in total, you had 31 days of SNF services. You were not charged a copayment for the first 20 days or the day of discharge on May 22, 2021. For the remaining 10 days, you were charged a copayment of $184 per day, for a total of $1840.00. However, you only had $1748.22 remaining on your out-of-pocket maximum for the year when this claim processed, so that is all you are being charged. 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 skilled nursing facility (SNF) services you received from May 7, 2021, to May 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the dermatology visit you had on June 3, 2021.
You asked the Plan to waive the copayment for the dermatology visit. You say that this service should be paid because you were told by the Plan that a referral was not necessary. The Plan denied your request. The Plan says this claim has been reprocessed and the only thing you owe is your copayment. The Plan says that this copayment was charged 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 $35 copayment for specialist visits. You have been asked to pay a $35 copayment for the dermatology visit. The dermatology visit falls within the specialist 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 the dermatology visit you had on June 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the head you had on May 20, 2021.
You asked the Plan to waive the copayment for the CT scan. You say that you refuse to pay this bill because you have medical insurance for that reason. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for this service ($111.65) is less than your copayment obligation, you are responsible for the full allowed 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 $175 copayment for diagnostic radiology services at a freestanding radiology facility. You have been asked to pay a $175 copayment for the CT scan. The CT scan falls within the diagnostic radiology services at a freestanding radiology facility 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 computed tomography (CT) scan of the head you had on May 20, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the physical therapy (PT) visits (97110, 97530, 97140) you had on June 3, 2021, to June 14, 2021.
You asked the Plan to waive the copayments for the physical therapy visits. You say that you have never had to pay a copayment before, and you thought this was covered in full. The Plan denied your request. The Plan says you were charged these copayments correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 copayment per visit for physical therapy services. You have been asked to pay a $15 copayment per visit for three physical therapy visits, which total $45 ($15 copayment x 3 visits = $45). These copayments apply 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 copayments for the physical therapy (PT) visits (97110, 97530, 97140) you had on June 3, 2021, to June 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a dermatologist office visit provided on June 16, 2021.
You asked the Plan to waive the copayment for a dermatologist office visit. 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 at a specialist's office. You have been asked to pay a $45 copayment for a dermatologist office visit. A dermatologist 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 dermatologist office visit provided on June 16, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy treatment provided on July 23, 2021.

You asked the Plan to pay for physical therapy treatment. You say that the enrollee was referred by a participating provider and should be paid. The Plan denied your request. The Plan says the services were 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 requested provider in this case is not a network provider with the Plan. The record also shows that the referring provider is not a network provider with the Plan either. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for physical therapy treatment provided on July 23, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for ambulance services you received on April 13, 2021, and May 9, 2021.
You asked the Plan to waive the copayments for the ambulance services. You say that you are going through financial difficulties and you are on a fixed income. The Plan denied your request. The Plan says you were charged these copayments correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $125 copayment per trip for ambulance services. You have been asked to pay a $125 copayment per trip for the ambulance services. 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 ambulance services you received on April 13, 2021, and May 9, 2021