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

 We decided that the Plan does not have to waive the copayment for a limited bilateral noninvasive physiologic studies of upper or lower extremity arteries (93922) rendered on September 23, 2021.  You asked the Plan to waive the copayment for a limited bilateral noninvasive physiologic studies of upper or lower extremity arteries. You say that you were called by the physician's office and were told there were some tests that were not done and were required by Medicare, and you needed to come back for these tests, which you did. You also say that if you had known you would have to pay for this test and it was not part of your annual physical, you would have refused it. 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 if you have had Part B for longer than 12 months, you can get an annual wellness visit to develop or update a personalized prevention plan based on your current health and risk factors. The Plan contract also says that this is covered once every 12 months. The Plan contract also says that this does not include laboratory tests, radiological diagnostic tests or non-radiological diagnostic tests, and additional cost share may apply to any lab or diagnostic testing performed during your visit. The Plan contract also says that enrollees must pay a $100 copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in a physician's office or at a free-standing facility (such as a radiology center or medical clinic).   You have been asked to pay a $100 copayment for a limited bilateral noninvasive physiologic study of upper or lower extremity arteries. A limited bilateral noninvasive physiologic study of upper or lower extremity arteries 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 limited bilateral noninvasive physiologic studies of upper or lower extremity arteries (93922) rendered on September 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a myocardial perfusion imaging spect test (78452) provided on May 27, 2021.  You asked the Plan to waive the copayment for the myocardial perfusion imaging spect test. You say that the services should be covered as you were not informed of the copayment beforehand. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.  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 $150 copayment for Outpatient diagnostic tests and therapeutic services and supplies.    You have been asked to pay a $150 copayment for the myocardial perfusion imaging spect test. SPECT tests fall 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 myocardial perfusion imaging spect test (78452) provided on May 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from October 6, 2021, to October 9, 2021.  You asked the Plan to waive the copayment for the inpatient hospital stay. You say that the services should be covered as you were advised to go to the emergency room. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided, since you were admitted into the hospital after your visit, the plan waived the $90 copayment for the emergency room and have only assessed the copayment for your inpatient stay.  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 $360 copayment per day for days 1-5 of Inpatient hospital care.   You have been asked to pay a $580 copayment for three days of inpatient hospital care, which is less than the $1,080 you would be charged for three days based on your contract with 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 copayment for an inpatient hospital stay provided from October 6, 2021, to October 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on January 19, 2021.  You asked the Plan to pay for the laboratory services. 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.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on January 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies (K05583), provided on September 4, 2021.  You asked the Plan to pay for the CGM supplies. You say that the items are medically necessary. The Plan denied your request. The Plan says the correct documentation was not provided.  The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.   The record does not contain a valid physician order, proof of delivery, or relevant medical records which support medical necessity for the supplies provided in this case. 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 the continuous glucose monitor (CGM) supplies (K05583), provided on September 4, 2021.
Appeal type: SNF
Decision: Favorable

 We decided that the Plan has to pre-approve the continuation of skilled nursing facility (SNF) care provided after February 19, 2022.  You asked the Plan to pre-approve the continuation of SNF care. You say that you continue to require SNF care. The Plan denied your request. The Plan says that SNF care no longer is medically reasonable and necessary.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 continuation of SNF care. Our reviewer says that the requested SNF care is medically reasonable and necessary. Our physician reviewer found the Plan has argued that the enrollee is no longer in need of SNF services because she can ambulate twenty-five feet. Records confirming this argument have not been submitted to the IRE for review.  The record indicates that records were provided to the health plan. As such, the documentation is found to be of insufficient quantity and quality to support the health plan's denial.  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 continuation of SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve the continuation of skilled nursing facility (SNF) care provided after February 19, 2022.   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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on October 11, 2021.  You asked the Plan to pay for the dental service. You say that the service should be covered. The Plan denied your request. The Plan says 1 emergency oral exam is covered per year. The Plan says that you previously received this service on July 22, 2021. The Plan also says that the frequency limit has been exceeded.  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 and limited oral evaluation is listed as covered, the frequency limit has been exceeded. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on October 11, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home health services provided from June 1, 2021, to June 21, 2021.  You asked the Plan to pay for the home health services. You say that the claim should be paid. The Plan denied your request. The Plan says the initial Request for Anticipated Payments (RAP) claim was not received within 5 calendar days from the start of care.  The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day periods and within 5 calendar days after the "from date" for each subsequent 30-day period of care, which is set at 0 percent at the beginning of every 30-day period.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home health services have not been met. Specifically, the initial Request for Anticipated Payments (RAP) claim was not received within 5 calendar days from the start of care, June 1, 2021. Therefore, we decided that the Plan does not have to pay for the home health services provided from June 1, 2021, to June 21, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the rest home visits (99336 x 2) provided on September 27, 2021 to October 18, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the evaluation and management services. You say that the services were medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained before the services were rendered to the enrollee.  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 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 rest home visits (99336 x 2) provided on September 27, 2021 to October 18, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Favorable

 We decided that the Plan has to pay for the outpatient surgery services provided on September 7, 2021.  You asked the Plan to pay for the outpatient surgery services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services were medically necessary; however, a corrected claim is needed for reprocessing.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. In this case, the Plan has denied payment stating the services would be approved if a corrected claim was sent for reprocessing. However, the Plan has provided no information on why the claim is not payable as submitted. The Plan has not provided any supporting evidence to deny payment for these services based on Medicare criteria. Therefore, we decided that the Plan has to pay for the outpatient surgery services provided on September 7, 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 the ambulance response and treatment, no transport, (A0998) provided on June 19, 2021.  You asked the Plan to pay for the ambulance service. You say that the paramedics assured you, you were not having a heart attack. You also say that you felt comfortable not going to the emergency room because of that. The Plan denied your request. The Plan says there was no transport provided on the date of service in this case. The Plan also says that since there was no transport provided, there is not a payable service.  The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.   The ambulance company did not provide transport services on June 19, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.      Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) provided on June 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the specialist office visit provided by a network provider on October 18, 2021.  You asked the Plan to waive the copayment for the specialist office visit. You say that you went to the office to get results from blood tests, and you should not have a copayment. The Plan denied your request. The Plan says you have been asked to pay 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 $40 copayment per visit for an in-network specialist.    You have been asked to pay a $40 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The medical record shows services were rendering during the office visit. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the specialist office visit provided by a network provider on October 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an office visit provided on June 2, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for an office visit. You say that you would like to appeal for the services provided. The Plan denied your request. The Plan says the provider is a non-participating provider, and the medical records do no reveal any medically urgent or emergent services.   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 office visit 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 pre-approve the electronic connection (E2311), expandable controller, (E2377), and harness (E2313).  You asked the Plan to pre-approve the electronic connection, expandable controller, and harness. You say that the items are medically necessary. The Plan denied your request. The Plan says the items are not medically necessary.  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 electronic connection, expandable controller, and harness. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found the patient does not need to control the power options through a joystick. The patient's upper extremity strength and function support that the patient can control any power options through their own switches.  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 electronic connection, expandable controller, and harness have not been met. Therefore, we decided that the Plan does not have to pre-approve the electronic connection (E2311), expandable controller, (E2377), and harness (E2313).
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) provided on December 22, 2020.  You asked the Plan to pay for the ambulance service. You say that you did not want to go to the hospital. The Plan denied your request. The Plan says there was no transport provided. The Plan also says since there was no transport provided, there is no payable service.  The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.   The ambulance company did not provide transport services on December 22, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) provided on December 22, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for psychotherapy services (90853) provided on September 1, 2021.  You asked the Plan to pay for psychotherapy services. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.  The Plan must follow Medicare rules. Medicare rules say that the CP will attempt to consult with the enrollee's attending or primary care physician.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of psychotherapy services have not been met. Specifically, the provided records do not document an attempt to consult with, nor a referral from, the enrollee's attending or primary care physician. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90853) provided on September 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the limited oral evaluation (D0140), bitewing x-rays (D0270), unspecified preventative procedure (D1999) and drugs dispensed in the office for home use (D9630) provided on October 13, 2021.  You asked the Plan to pay for the dental services. You say that these services were necessary after your tooth broke. The Plan denied your request. The Plan says the unspecified preventative procedure and medication dispensed in the office for home use are not covered services under your dental benefit. The bitewing x-rays and limited exam are covered services; however, they are denied in this instance because you have exceeded the frequency limitations for these services. One set of bitewing x-rays and one limited oral exam may be covered per plan year. You previously had bitewing x-rays provided in February 2021 and a limited exam in April 2021 which were covered by the Plan.  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. The Plan does not cover services or codes that are not listed as covered under the dental benefits chart in the contract. The Plan can cover one limited exam to evaluate a problem (D0140) per plan year. The Plan can cover one set of bitewing x-rays (D0270, D0272, D0273, D0274, D0277) per plan year.  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 or are requested in a frequency that exceeds what is covered by this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), bitewing x-rays (D0270), unspecified preventative procedure (D1999) and drugs dispensed in the office for home use (D9630) provided on October 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve second stage implant surgery represented by code D6011.  You asked the Plan to pre-approve second stage implant surgery. You say that you are disabled from serious health issues. You say that you urgently need the requested procedure to be done. You say that you were diagnosed with Lupus and stomach problems due to this and are unable to chew food the right way. The Plan denied your request. The Plan says the service being requested is not a covered benefit.  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 pre-approve second stage implant surgery represented by code D6011.