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

 We decided that the Plan does not have to waive the copayment for an epidural injection provided on August 11, 2021.  

You asked the Plan to waive the copayment for the injection. You say that you feel that there may be a coding error since you were not charged for your first injection. 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 $300 copayment for outpatient surgery or procedures at an outpatient hospital facility or ambulatory surgical center.    

You have been asked to pay a $300 copayment for the injection. Please note that epidural injections are considered surgical procedures. The injection 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 an epidural injection provided on August 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a dynamic adjustable wrist extension/flexion device to be provided by an out-of-network (OON) provider.  

You asked the Plan to pre-approve a dynamic adjustable wrist extension/flexion device to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not been met.  

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 a dynamic adjustable wrist extension/flexion device to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a total electric hospital bed.  

You asked the Plan to pre-approve a total electric hospital bed. You say that the item is necessary. The Plan denied your request. The Plan says the requested item is not a covered benefit.  

The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.   

While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), and bitewing x-rays (D0274) provided on September 16, 2021.  

You asked the Plan to pay for the dental services. You say that you were not aware that this dentist was out of network. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that services received out of network are not covered. The Plan also says that you were given names of in network providers that could provide these 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, dental services received out of network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), and bitewing x-rays (D0274) provided on September 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office or other outpatient visit (99203) provided on August 17, 2021, by an OON provider.  

You asked the Plan to pay for the office or other outpatient visit. You say that you were not aware that you would be charged by the provider in question for this office visit. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON provider.  

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 office or other outpatient visit (99203) provided on August 17, 2021, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay more for the periodic oral evaluation (D0120), bitewing x-rays (D0274), and prophylaxis (D1110) provided on June 1, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay more for the periodic oral evaluation, bitewing x-rays, and prophylaxis. You say that when you contacted the Plan you were assured that this treating provider, who you have been going to for over 30 years, was in-network. The Plan denied your request. The Plan says these services were performed by a non-participating provider. You are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for the services. The Plan also says that you were advised that this treating provider was OON when you contacted the Plan prior to receiving these 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, you are responsible for a 50% coinsurance of the allowed amount for the periodic oral exam, bitewing x-rays, and prophylaxis, plus the difference between the billed amounts and allowed amounts because these services were received OON. Therefore, we decided that the Plan does not have to pay more for the periodic oral evaluation (D0120), bitewing x-rays (D0274), and prophylaxis (D1110) provided on June 1, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient hospital care provided from June 22, 2021, to June 30, 2021.

  You asked the Plan to pay for the inpatient care. You say that the enrollee was not stable for discharge during this period. You say that the enrollee required a level of care higher than what a skilled nursing facility could provide. You also say that these services should be covered. The Plan denied your request. The Plan says the enrollee's benefit of 90 days and the reserve benefit of 60 days have both been exhausted prior to the dates of service in this case.  

The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.     

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the inpatient care have not been met. Specifically, the file shows that the inpatient hospital care benefit has been exhausted. The record shows that the enrollee had used 43 of the 90 total allowed days from January 7, 2021, to March 6, 2021. The record also shows that the Plan paid for inpatient care provided from March 6, 2021, to June 21, 2021 (107 days), thus exhausting the number of allowed days per inpatient benefit period. Therefore, we decided that the Plan does not have to pay for the inpatient hospital care provided from June 22, 2021, to June 30, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 We decided that the Plan has to pay for a lumbar spinal orthosis (L0650) provided to the enrollee on April 22, 2021.  

You asked the Plan to pay for the services. You say that this was medically necessary for the enrollee, and the tracking shows proof of delivery. The Plan denied your request. The Plan says that the shipping information shows that the label for the item was created, but the package did not enter the system.  

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 case file indicates that the tracking number for the orthosis was 9405536108992852299239. The United States Postal Service (USPS) tracking system shows that the shipping label for this item was created, but the package was never received by USPS for delivery. However, USPS only keeps tracking information for packages for 120 days. It is more than 120 days after the delivery at issue in this case. There is a possibility that USPS has re-used the tracking number for this item, and the number might not track to the orthosis at issue in this case. The provider has sent an invoice and a tracking document with the tracking number on both documents that shows that the package was delivered to the enrollee's address. They have satisfied the proof of delivery requirements in this case, and the plan's denial has not been substantiated.   

Additionally, the plan has not provided any citations showing that the date of service must be the date that the item was shipped. The rules say that the supplier may use the shipping date as the date of service, but doesn't specify that they must use this date. The rules further state that the date that the beneficiary received the item shall be the date of service on the claim. Therefore, we decided that the Plan has to pay for a lumbar spinal orthosis (L0650) provided to the enrollee on April 22, 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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for the laboratory services and ultrasound provided on April 9, 2021.  You asked the Plan to waive the copayments for the laboratory services and ultrasound. You say that only one copayment should apply for multiple services on the same day. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $10 copayment for each laboratory service.   The enrollee's contract with the Plan also clearly says that enrollees must pay a $175 copayment for diagnostic radiology services in an outpatient facility. Multiple radiology services at the same location on the same day will result in one copayment.  The enrollee has been asked to pay a $10 copayment for each laboratory service. You have also been asked to pay $54.05 for the ultrasound, which is less than the $175 copayment for diagnostic radiology services. The laboratory services and ultrasound fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the laboratory services and ultrasound provided on April 9, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.  You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 you do not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. You are at a high functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. You do not require skilled nursing or skilled therapy on a daily basis or as a practical matter in a SNF.  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 skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an x-ray exam provided on August 14, 2021.  

You asked the Plan to waive the copayment for the x-ray exam. You say that you were told by the provider it would be covered. The Plan denied your request. The Plan says the proper copayment has been applied.  

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 for x-rays in a Specialist's Office.     

You have been asked to pay a $40 copayment for the x-ray exam. The x-ray exam in a Specialist's Office 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 an x-ray exam provided on August 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit services provided on July 22, 2021 by an out-of-network (OON) provider.  

You asked the Plan to pay for the office visit services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.  

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the office visit services provided on July 22, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve surgery and hospital services related to a clinical trial.  

You asked the Plan to pre-approve the medical services. You say that this is medically necessary. The Plan denied your request. The Plan says services related to a clinical trial are covered by Original Medicare.  

The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services.  

In this case, you asked the Plan to pre-approve the medical services as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-approve surgery and hospital services related to a clinical trial.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for domiciliary or rest home visits (99336, 96127, 99407) provided on August 4, 2021, to August 18, 2021, by an out-of-network (OON) provider.  

You asked the Plan to pay for domiciliary or rest home visits. You say that these services were medically necessary and requested by the facility. The Plan denied your request. The Plan says these services were not authorized.  

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 domiciliary or rest home visits (99336, 96127, 99407) provided on August 4, 2021, to August 18, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the therapeutic continuous glucose monitor provided on August 18, 2021.  

You asked the Plan to pay for the therapeutic continuous glucose monitor. You say that you would like this claim reprocessed for payment. The Plan denied your request. The Plan says payment is not allowed because the service was related to a prohibited telemarketing contact.    

The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances.  

We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the past 15 months. Based on this information, we decided that Medicare rules for coverage of the therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic continuous glucose monitor provided on August 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a diagnostic bone scan on August 31, 2021.  

You asked the Plan to waive the copayment for a diagnostic bone scan. You say that you have never paid a copayment for this scan. The Plan denied your request. The Plan says the appropriate copayment was applied.  

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 in-network Specialty Scans and Other Services such as Diagnostic Bone Scans.     

You have been asked to pay a $106.22 copayment which is less than the required $175 for a diagnostic bone scan. A diagnostic bone scan falls within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a diagnostic bone scan on August 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve application of a skin substitute (Flower AmnioPatch).  

You asked the Plan to pre-approve the services. You say that claims were previously paid for this same issue. The Plan denied your request. The Plan says the records show that the wound is less than 1.0 square centimeters in size.  

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee had a medial left plantar ulcer measuring 0.4 x 0.4 x 0.3cm post-debridement. The enrollee does not have a documented skin deficit at least 1.0 square centimeter (cm) in size.  

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 application of a skin substitute (Flower AmnioPatch).