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

We decided that the Plan does not have to waive the copayment for arthroplasty provided from March 31, 2021, to April 1, 2021.
You asked the Plan to waive the copayment for arthroplasty. You say that you should not be responsible for the charges because you were waiting to be approved for a rehabilitation stay. 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 $295 copayment for outpatient surgery, including services provided at hospital outpatient facilities. You received arthroplasty at an outpatient hospital facility on March 31, 2021, to April 1, 2021. Arthroplasty is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $295 copayment. You have been asked to pay a $295 copayment for arthroplasty. Arthroplasty falls within the outpatient
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for arthroplasty provided from March 31, 2021, to April 1, 2021
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided by an out-of-network provider on April 6, 2021.
You asked the Plan to pay for physical therapy services. You say that the individual provider and referring provider are participating providers with Medicare. You say that the services were medically necessary, and the services should be approved for payment. The Plan denied your request. The Plan says prior authorization for out-of-network services was not 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. Therefore, we decided that the Plan does not have to pay for physical therapy services provided by an out-of-network provider on April 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on August 21, 2020.
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 should be submitted to the enrollee's primary insurer.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed you, the provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the office visit until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the office visit provided on August 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (80307, G0483) provided on December 21, 2020.
You asked the Plan to pay for the drug testing services. You say that you would like reconsideration because physicians send specimens to you and you do not have access to physician's notes and reports. The Plan denied your request. The Plan says the submitted claim form indicates the laboratory specimen was obtained in a laboratory; however, the submitted medial documentation and/or claim history indicates that the specimen was obtained in an office setting.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT codes 80307, G0483 are not supported in the medical record. Specifically, this claim was billed with a laboratory place of service code while the record indicates that the member's face-to-face service was rendered in an office setting. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing services (80307, G0483) provided on December 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for specialist services, hearing services, and a nasal function study provided from February 16, 2021, to March 9, 2021.
You asked the Plan to waive the copayments for specialist services, hearing services, and a nasal function study. You say that you asked several times if you would owe a copayment and were told that you would not. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for specialist services. Your contract with the Plan also clearly says that you must pay a $50 copayment for hearing services. Your contract with the Plan also clearly says that you must pay a $75 copayment for diagnostic procedures and tests. You received specialist services on February 16, 2021. Therefore, you are responsible to pay the $50 copayment. You received hearing services on February 16, 2021. Therefore, you are responsible to pay the $50 copayment. You received specialist services on March 9, 2021. Therefore, you are responsible to pay the $50 copayment. You received a nasal function study on March 9, 2021. Therefore, you are responsible to pay the $75 copayment. The total amount you owe is: $225.
You have been asked to pay the total copayment amount of $225 for specialist services, hearing services, and a nasal function study. Specialist services fall within the physician/practitioner services, including doctor's office visits benefit category. Hearing services fall within the hearing services benefit category. A nasal function study 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 copayments for specialist services, hearing services, and a nasal function study provided from February 16, 2021, to March 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided from April 2, 2021, to May 28, 2021.
You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that the drugs are important for your quality of life and 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 20% coinsurance for Medicare Part B prescription drugs. You received Medicare Part B drugs on April 2, 2021. The total allowed amount is $15,225.30 an 20% of that is $2,926.32.
You received Medicare Part B drugs on April 30, 2021. The total allowed amount is $15,225.30 an 20% of that is $2,926.32. You received Medicare Part B drugs on May 28, 2021. Therefore, you are responsible to pay $607.36, which is less than the 20% coinsurance amount. The total amount you owe is: $6,460. You have been asked to pay the total coinsurance amount of $6,460 for Medicare Part B drugs. Medicare Part B drugs fall within the Medicare Part B prescription 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 Medicare Part B drugs provided from April 2, 2021, to May 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on March 10, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
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 laboratory testing 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 March 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services (98941) provided on January 6, 2021 to March 9, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the chiropractic services. You say that you fell in January and started going to this provider because you were told it would help and it has. He is not in network but you like his treatments. 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 chiropractic services (98941) provided on January 6, 2021 to March 9, 2021 by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy re-evaluation provided on April 15, 2021.
You asked the Plan to pay for the physical therapy re-evaluation. The Plan denied your request. The Plan says CPT code 97164 has an MUE value of 1 but 2 units were billed.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT code 97164 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the physical therapy re-evaluation have not been met. Therefore, we decided that the Plan does not have to pay for the physical therapy re-evaluation provided on April 15, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services you received on April 27, 2021.
You asked the Plan to waive the copayment for the ambulance services. You say that according to the 2021 Medicare booklet, you should only have to pay 20% of the cost for this transport. You say that you are being charged 80% of the cost. 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 $200 copayment for ambulance services. You have been asked to pay a $200 copayment for the ambulance services. Your Evidence of Coverage clearly states that you pay a $200 copayment for ambulance services. The 20% coinsurance you quoted in your appeal letter applies to individuals who have Original Medicare. You do not have Original Medicare- you have a Medicare Advantage plan. Medicare Advantage plans are permitted to set their own cost sharing amounts for
medical 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 copayment for ambulance services you received on April 27, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided by an out-of-network provider on April 1, 2021.
You asked the Plan to pay for physical therapy services. You say that the individual provider and referring provider are participating providers with Medicare. You say that the services were medically necessary, and the services should be approved for payment. The Plan denied your request. The Plan says prior authorization for out-of-network services was not 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. Therefore, we decided that the Plan does not have to pay for physical therapy services provided by an out-of-network provider on April 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network services provided to the enrollee on December 1, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for 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 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 out of network services provided to the enrollee on December 1, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued SNF care.
You asked the Plan to pre-approve SNF care. You say that the requested SNF care is a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for SNF care have not been met.
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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that there is no documentation that the enrollee requires skilled nursing services. The enrollee does require skilled therapy services; however, daily skilled services are not required. As a practical matter, based on the medical records provided, the enrollee does not require services on an inpatient basis only in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued SNF care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on July 30, 2020 by an outof-
network (OON) provider.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 laboratory services provided on July 30, 2020
by an out-of-network (OON) provider
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic carpal tunnel injections coded 20526 provided on March 2, 2021.
You asked the Plan to pay for the therapeutic carpal tunnel injections. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT code 20526 is 1 The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the therapeutic carpal tunnel injections have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic carpal tunnel injections coded 20526 provided on March 2, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the requested drug is subject to step therapy.
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 pre-approve the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found based on the medical records provided, the enrollee has not tried and failed the plan's required drug - Retacrit. There is no indication that the plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. 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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Aranesp for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided on March 1, 2021, and March 4, 2021.
You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you disagree with the charges because you were told you would not owe anything for the services. 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 20% coinsurance for Medicare Part B prescription drugs. You received Medicare Part B drugs on March 1, 2021. The total allowed amount is $5 and 20% of that is $1.
You received Medicare Part B drugs on March 4, 2021. The total allowed amount is $2,622.18 and 20% of that is $524.44. The total amount you owe is: $525.44. You have been asked to pay the total coinsurance amount of $525.44 for Medicare Part B drugs. Medicare Part B drugs fall within the Medicare Part B prescription 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 Medicare Part B drugs provided on March 1, 2021, and March 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve disposable pads.
You asked the Plan to pre-approve disposable pads. You say that the items are necessary. The Plan denied your request. The Plan says the requested items are non-reusable and are hygienic items. Therefore, coverage criteria have not been met.
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 disposable pads.