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

 We decided that the Plan does not have to waive the copayment for cataract surgery provided on October 28, 2021.  You asked the Plan to waive the copayment for the cataract surgery. You say that you phoned a month prior to the surgery and was told it should be $30 total. You say that you did not expect the additional $150 and this should be reviewed. The Plan denied your request. The Plan says the copayment applied 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 $150 copayment for in-network, Medicare-covered outpatient hospital surgery services.     You have been asked to pay a $150 copayment for the cataract surgery. The cataract surgery 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 cataract surgery provided on October 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the surgical extraction (D7210) provided on September 2, 2021.  You asked the Plan to pay for the surgical extraction. The Plan denied your request. The Plan says this service is not covered.  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 pay for the surgical extraction (D7210) provided on September 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the dermatology office visit provided on August 16, 2021, by an OON provider.  You asked the Plan to pay for the dermatology office visit. You say that the service denied due to no referral which would not have occurred if the enrollee had stayed under Medicare. 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 service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the dermatology office visit provided on August 16, 2021, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for outpatient surgery services for botulinum toxin A injections rendered from June 21, 2021, to September 13, 2021.  You asked the Plan to waive the copayments for outpatient surgery services for botulinum toxin A injections. You say that you were charged for an operating room and there is no operating room involved. 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 covered services include but are not limited to certain drugs and biologicals that you cannot give yourself. Your contract with the Plan also says that enrollees must pay a $275 copayment for each Medicare-covered visit to an ambulatory surgical center or an outpatient hospital facility.    You have been asked to pay a $275 copayment for each outpatient surgery service for a botulinum toxin A injection, which is a total of $550 ($275 copayment x 2 visits = $550). Outpatient surgery services for botulinum toxin A injections fall within the Outpatient Hospital Services 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 outpatient surgery services for botulinum toxin A injections rendered from June 21, 2021, to September 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve sacroplasty for your broken sacral bone (CPT code 0201T), for the enrollee.  You asked the Plan to pre-approve the services. You say that the services are necessary The Plan denied your request. The Plan says there are not enough studies to show sacroplasty is safe and effective to treat broken sacral bone.  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 items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found sacroplasty is experimental. More research is needed to show safety and efficacy for the treatment of sacral insufficiency fractures.    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 sacroplasty for your broken sacral bone (CPT code 0201T), for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Prostatic arterial embolization (PAE) services.  You asked the Plan to pre-approve PAE services. You say that this is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this procedure is considered experimental/investigational for the enrollee's condition.  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 PAE services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found PAE is considered an experimental technique to treat symptomatic benign prostatic hyperplasia. Very limited studies have demonstrated possible short-term safety and efficacy. The most recent American Urological Association guidelines do not recommend this procedure outside of a clinical trial 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 PAE services have not been met. Therefore, we decided that the Plan does not have to pre-approve Prostatic arterial embolization (PAE) services.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the routine disposable supplies (A0398), ground mileage (A0425), and advanced life support (A0433) provided on May 23, 2021.  You asked the Plan to pay for the routine disposable supplies. You say that the enrollee's hospice care ended on May 22, 2021 and you could not bill them for this date of service. The Plan denied your request. The Plan says this request is not a covered benefit because ambulance supplies are included in the payment rate for the ambulance transport.    The Plan must follow Medicare rules. Medicare rules say that an ambulance must have customary patient care equipment and first aid supplies, including reusable devices and equipment such as backboards, neckboards, inflatable legs, and arm splints. These are all considered part of the general ambulance service and payment for them is included in the payment rate for the transport.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the routine disposable supplies have not been met. Therefore, we decided that the Plan does not have to pay for the routine disposable supplies (A0398), ground mileage (A0425), and advanced life support (A0433) provided on May 23, 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 by a participating provider on May 2, 2021, to August 26, 2021.  You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you do not agree with these copayments. The Plan denied your request. The Plan says the correct copayments have 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 $325 copayment per admission for inpatient hospital care.   You have been asked to pay a $325 copayment per admission for an inpatient hospital stay. The total amount you are being asked to pay is $650 ($325 x 2 admissions = $650). The correct copayments have been applied to the two inpatient admissions that were provided. An inpatient hospital stay falls within the inpatient hospital care 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 inpatient hospital stay provided by a participating provider on May 2, 2021, to August 26, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the physical therapy (97161), provided on September 22, 2021.  You asked the Plan to waive the copayment for the physical therapy. You say that you should not have to pay a copay. The Plan denied your request. The Plan says the cost share was applied correctly.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copay for outpatient rehabilitation services.   You have been asked to pay a $35 copay for the physical therapy. This service falls within the outpatient rehabilitation services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the physical therapy (97161), provided on September 22, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pay for the acupuncture services provided May 4, 2021 to May 10, 2021.  You asked the Plan to pay for the acupuncture services. You say that you were told you can submit your copays for wellness reimbursement. You are upset because every time you call you get wrong answers. The Plan denied your request. The Plan says that the claim was processed correctly applying the applicable cost share.  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 servicing provider is an in-network provider. The Plan has not provided an EOB (Explanation of Benefits) showing that any payment was made for the dates of service at issue. The Plan has not provided records to show that the acupuncture services were not for chronic low back pain. The Plan has not provided any information to substantiate their reason to deny payment. Therefore, we decided that the Plan has to pay for the acupuncture services provided May 4, 2021 to May 10, 2021.   If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the wheelchair back cushion (E2311), wheelchair seat cushion (E2601), commode chair (E0163), anti-tipping device (E0971), and heel loop/holder (E0951), provided on June 2, 2021 by an out-of-network (OON) provider.  

You asked the Plan to pay for the wheelchair back cushion, wheelchair seat cushion, commode chair, anti-tipping device, and heel loop/holder. You say that the items should be covered. The Plan denied your request. The Plan says no prior authorization was obtained for these items.  

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 wheelchair back cushion (E2311), wheelchair seat cushion (E2601), commode chair (E0163), anti-tipping device (E0971), and heel loop/holder (E0951), provided on June 2, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the x-ray you had at an outpatient hospital facility on September 24, 2021.  

You asked the Plan to waive the copayment for the x-ray. You say that you had this x-ray in an office, so there should not be a copayment. The Plan denied your request. The Plan says you were charged this copayment correctly.  

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copayment for diagnostic tests at an outpatient hospital facility.   

You have been asked to pay a $90 copayment for the x-ray. We have confirmed that the provider who provided this x-ray is registered with Medicare and the Plan as an outpatient hospital facility, not as an office.  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 x-ray you had at an outpatient hospital facility on September 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for x-rays provided by a chiropractor on September 14, 2021.  You asked the Plan to pay for x-rays. You say that you would like the Plan to reconsider the x-rays. The Plan denied your request. The Plan says this service is not a covered benefit.  The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.   The records show that the service at issue is not manual manipulation of the spine. The x-rays are not a covered benefit of Medicare or the Plan because they were provided by a chiropractor. Therefore, we decided that the Plan does not have to pay for x-rays provided by a chiropractor on September 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve computed tomography scan of the chest (71250).  You asked the Plan to pre-approve the diagnostic service. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says the records do not support that the requested CT scan is medically necessary.  The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically 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 diagnostic service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found There was no indication for getting a CT for screening purposes or to follow-up on recent worsening of dyspnea which was clearly a result of stopping asthma medication and a flare of her allergies. Lung exam and other findings did not suggest pathology in the lungs that required any imaging. Therefore, CT will be considered not medically necessary.   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 diagnostic service have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography scan of the chest (71250).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  

You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically necessary.  

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  

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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  Our physician reviewer found based on the documentation provided the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to provide additional payment for the unspecified preventive procedure, by report (D1999),  extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140),  limited oral evaluation - problem focused (D0140),  intraoral - periapical first radiographic image  (D0220),  comprehensive oral evaluation - new or established patient (D0150),  panoramic radiographic image  (D0330), and  prophylaxis - adult (D1110) provided March 9, 2021, and March 25, 2021, by an out-of-network (OON) provider.  You asked the Plan to provide additional payment for the unspecified preventative procedures, tooth extraction, limited oral exam, intraoral x-ray, comprehensive oral exam, panoramic x-ray and dental cleaning. You say that you would like the Plan to pay for the remaining cost. The Plan denied your request. The Plan says the unspecified preventative procedures and tooth extraction are not covered under your benefits. The remaining services have processed correctly according to your OON benefits.  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 covers the limited oral exam, intraoral x-ray, comprehensive oral exam, panoramic x-ray and dental cleaning up to a certain amount when provided out-of-network. You might be billed for charges above what the Plan pays.   We looked at the file, and Medicare rules. In this case the Plan has provided documentation showing that the full allowed amount has been covered for the limited oral exam, intraoral x-ray, comprehensive oral exam, panoramic x-ray and dental cleaning. You are responsible for the difference between the allowed amount and the total cost billed by the OON provider. Though the Plan offers dental benefits in excess of Medicare coverage, the unspecified preventative procedure and tooth extraction are not among those covered services. Therefore, we decided that the Plan does not have to provide additional payment for the unspecified preventive procedure, by report (D1999),  extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140),  limited oral evaluation - problem focused (D0140),  intraoral - periapical first radiographic image  (D0220),  comprehensive oral evaluation - new or established patient (D0150),  panoramic radiographic image  (D0330), and  prophylaxis - adult (D1110) provided March 9, 2021, and March 25, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the porcelain fused to predominantly base metal crown (D2751) provided on September 13, 2021.  You asked the Plan to waive the copayment for the crown. You say that you were not advised that there would be responsible for a $125 payment for this service. The Plan denied your request. The Plan says the cost share was assessed correctly according to your benefits.  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 $125 copayment for covered porcelain/ stainless steel crowns. Therefore, we decided that the Plan does not have to waive the copayment for the porcelain fused to predominantly base metal crown (D2751) provided on September 13, 2021.