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

We decided that the Plan does not have to waive the cost-sharing for office visits and a venipuncture (a blood draw for lab testing) provided from January 14, 2021, to June 10, 2021.
You asked the Plan to waive the cost-sharing for office visits and blood draw. You say that you have seen this provider since 2018 and have always been in her network, and you were unaware that this provider was out-of-
network. The Plan denied your request. The Plan says the cost-sharing amounts you are being charged are correct.
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 $1,000 deductible for office visits and 40% coinsurance for blood draw provided by an out-of-network provider within the state of Alabama. At the time these claims were processed, $43.55 of the $1,000 deductible had been met. The allowed amounts of the office visits total $609.48, resulting in a deductible amount of $609.48. The allowed amount of the blood draw is $3.00, resulting in a coinsurance amount of $1.20. Your total cost-sharing responsibility is therefore $610.68. You have been asked to pay $1,000 deductible for office visits and 40% coinsurance for blood draw. Office visits and blood draw fall within the "Physician/Practitioner Services, Including Doctor's Office Visits" and "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit categories. 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 office visits and a venipuncture (a blood draw for lab testing) provided from January 14, 2021, to June 10, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment for the parathyroidectomy or exploration of a
parathyroid (60500) provided from April 16, 2021, through April 17, 2021.
You asked the Plan to adjust the copayment. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to
the service 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 $175
copayment for each Medicare-covered outpatient hospital facilities visit.
You have been asked to pay a $175 copayment for the Medicare-covered outpatient hospital surgery provided.
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 adjust the copayment for the parathyroidectomy or exploration of a parathyroid
(60500) provided from April 16, 2021, through April 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a crown (D2740) provided on January 18, 2021.

You asked the Plan to pay for a crown. You say that the service at issue should be covered. The Plan denied
your request. The Plan says you are responsible for services provided by privately contracted providers. The
Plan will not reimburse for charges incurred by Medicare Opt Out providers.

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.

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of a crown have not been met. Specifically, services were provided by an Opt Out provider. The Plan
does not cover dental services when provided by an Opt Out provider. Therefore, we decided that the Plan does
not have to pay for a crown (D2740) provided on January 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office or other outpatient visit (99204) to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the office or other outpatient visit. You say that care from an OON provider is medically necessary. The Plan denied your request. The Plan says they have in-network providers available to provide the care the enrollee needs.
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 the office or other outpatient visit (99204) to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for pathology services you received on April 30, 2021.
You asked the Plan to waive the coinsurance for the pathology services. You say that your plan has no coinsurance. 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 10% coinsurance for pathology services. You have been asked to pay 10% coinsurance for the pathology 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 coinsurance for pathology services you received on April 30, 2021.
Appeal type: Drugs
Decision: Partially Favorable

We decided that the Plan has to waive the cost for the intravenous infusions. We decided that the Plan does not have to waive the cost for the vedolizumab injection.
You asked the Plan to waive the cost for the vedolizumab injection and intravenous infusions. You say that there is another claim processed with no charge for any coinsurance. You say that you are frustrated with the bill and won't pay for it. The Plan says that the coinsurance applied correctly.
We decided that the Plan has to waive the cost for the intravenous infusions.
The records show the billing provider is a hospital. The intravenous infusions are considered physician services provided by an outpatient hospital not a Part B drug. The Cost Sharing guide says that you pay $0 for outpatient hospital services. Therefore, we decided that the Plan has to waive the cost for the intravenous infusions provided.
We also decided that the Plan does not have to waive the cost for the vedolizumab injection.
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% of the cost of Part B Drugs. The allowed amount for the vedolizumab injection is $6,104.40 (20% x $6,104.40 = $1,220.88). Therefore, we decided that the Plan does not have to waive the cost for the vedolizumab injection.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory service (83036), office visit (99203), and the annual wellness visit (G0439) rendered by the out-of-network (OON) provider on December 7, 2020.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue.
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the laboratory service (83036), office visit (99203), and the annual wellness visit (G0439) rendered by the out-of-network (OON) provider on December 7, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the direct skilled nursing services of a registered nurse (rn) in the home health or hospice setting, each 15 minutes represented by code G0299 provided from April 6, 2021 to April 8, 2021.

You asked the Plan to pay for code G0299. 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. Home health care services must be billed on a UB-04 form per Medicare guidelines. The case file shows the home health services were submitted incorrectly. Therefore, we decided that the Plan does not have to pay for the direct skilled nursing services of a registered nurse (rn) in the home health or hospice setting, each 15 minutes represented by code G0299 provided from April 6, 2021 to April 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction (D7140) provided on April 12, 2021 by an OON provider.
You asked the Plan to pay for the extraction. You say that the facility that was recommended to you was not able to see you for two months. You also say that you were in excruciating pain, needed to be seen as soon as possible, and this provider was able to see you within one week. The Plan denied your request. The Plan says this service was rendered by a provider who is not in the Plan's network. The Plan also says that you must use network providers to receive dental services.
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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the extraction (D7140) provided on April 12, 2021 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for services provided on April 7, 2021.
You asked the Plan to waive the cost share for Myocardial perfusion imaging (78452), Cardiovascular stress test (93015), Technetium tc-99m sestamibi, diagnostic (A9500), and Injection, regadenoson (j2785). You say that the test was ordered by your physician so you should not be charged beyond the $40 copayment. The Plan denied your request. The Plan says you were charged the cost share 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 cost shar for these services. You have been asked to pay the cost share of $379.10 for Myocardial perfusion imaging (78452), Cardiovascular stress test (93015), Technetium tc-99m sestamibi, diagnostic (A9500), and Injection, regadenoson (j2785). 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 share for services provided on April 7, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for a catheter insertion (51702) provided on March 16, 2021.
You asked the Plan to pay for a catheter insertion. You say that this is supported by the records. The Plan denied your request. The Plan says that this is not separately payable from 76775.
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. The Plan's denial states that this cannot be paid separately from 76775. However, 76775 was not billed on the claim for 51702, and additional documentation showing it was billed on a separate claim has not been submitted. Therefore, we decided that the Plan has to pay for a catheter insertion (51702) provided on March 16, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation (90791) rendered by the out-of-network (OON) provider on February 16, 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 psychiatric diagnostic evaluation (90791) rendered by the out-of-network (OON) provider on February 16, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81206, 81295, 81292, 81298) provided February 9, 2021.

You asked the Plan to pay for genetic testing. You say that the services were medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that this service is covered for enrollees with either recurrent, relapsed, refractory, metastatic, or advanced stages III or IV cancer.

We looked at the file and Medicare rules. The enrollee had cancer in 2003, and the record shows negative biopsies since. The enrollee does not have a current cancer diagnosis. 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 (81206, 81295, 81292, 81298) provided February 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a genicular nerve block.

You asked the Plan to pre-approve the requested services. You say that this procedure was very successful for the enrollee years ago. The Plan denied your request. The Plan says the requested service is deemed investigational or experimental.

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 requested services. Our physician reviewer found that the enrollee has been diagnosed with osteophytosis of the bilateral knees. She has had knee injections without success. Genicular nerve blocks and genicular nerve radiofrequency ablation are considered investigational and not medically necessary for the treatment of chronic knee pain.

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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a genicular nerve block.
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 January 30, 2021.
You asked the Plan to pay for physical therapy services. You say that you are requesting retro authorization and reprocessing of the claim 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 January 30, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the direct skilled nursing services of a registered nurse (rn) in the home health or hospice setting, each 15 minutes represented by code G0299 provided from May 3, 2021 to May 5, 2021.

You asked the Plan to pay for code G0299. 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 must follow Medicare rules. Medicare rules say that providers must report services correctly.

We looked at the file and Medicare rules. Home health care services must be billed on a UB-04 form per Medicare guidelines. The case file shows the home health services were submitted incorrectly. Therefore, we decided that the Plan does not have to pay for the direct skilled nursing services of a registered nurse (rn) in the home health or hospice setting, each 15 minutes represented by code G0299 provided from May 3, 2021 to May 5, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on March 7, 2021.
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you fell and hit your head, and someone called the emergency medical service for you. You also say that you chose to return to the hotel to rest because you were told there would be a 4 hour wait if you were transported to the hospital. The Plan denied your request. The Plan says the Medicare ambulance benefit is a transport benefit. The Plan also says that if no transport occurs, there is no Medicare covered services.
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 March 7, 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 with no transport (A0998) provided on March 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator.
You asked the Plan to pre-approve a portable ventilator. You say that a portable ventilator is medically necessary. The Plan denied your request. The Plan says that you do not meet criteria for coverage.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a portable ventilator. Our reviewer says that a portable ventilator is not medically reasonable and necessary. You were diagnosed and treated for asthma, obesity, obstructive sleep apnea, bronchopulmonary dysplasia requiring BiPAP. The records show acute respiratory acidosis. No supportive evidence was provided to show chronic hypercarbia. There is no evidence that you have a neuromuscular disorder, thoracic restrictive disorder, or COPD with chronic respiratory failure to justify use of a home ventilator unit. There was no documentation of having tried and
failed BiPAP with average volume-assured pressure support (AVAPS). Our physician reviewer found that your condition does not meet Medicare criteria for a portable ventilator. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a portable ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on June 4, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the subsequent nursing facility care. You say that you were granted privileges to treat and provider necessary medical 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 the subsequent nursing facility care provided on June 4, 2021 by an out-of-network (OON) provider.