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

We decided that the Plan does not have to waive the copayment for the measurement of estradiol levels
rendered on July 6, 2021.
You asked the Plan to waive the copayment for lab services. You say that you had a telehealth visit on July 2,
2021, wherein labs were ordered. You say it was impossible to get the lab work done on the same day as the
office visit because it was telehealth. You stated in the past when you have had an office visit with labs, a
copayment was never charged. The Plan denied your request. The Plan says the lab services were rendered on
July 6, 2021, and further specified that your copayment for lab testing is charged per day. This indicates the
claim was processed 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 $10
copayment for Medicare-covered laboratory tests that are not FIT tests.
You have been asked to pay a $10 copayment for lab services. Lab services fall within the Outpatient
Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive
the copayment for the measurement of estradiol levels rendered on July 6, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the medical services you received from a network provider on January 29, 2021.

You asked the Plan to pay for the medical services. You say that you thought your spouse had removed you from your other insurance. The Plan denied your request. The Plan says that it needs Explanations of Benefits (EOBs) from your primary insurer before it will process this claim.

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 not met its obligation with regards to coordination of benefits. Specifically, the Plan has done none of the three options listed above. They have not sent the bill to the primary insurer. The Plan has not directed this network provider to send the bill to the primary insurer. Lastly, the Plan has not paid for the services and submitted a request for reimbursement to the primary insurer. The Plan has done none of the things that would have satisfied their burden to coordinate benefits. The Plan appears to have attempted to get the EOBs, but it's not clear from whom. In addition, all of the Plan's attempts occurred within the 4 days just prior to the Plan sending the case to us. So, even if the Plan had received the EOBs, there would have been no time for them to make it into the case file that the Plan submitted. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the medical services have been met. Therefore, we decided that the Plan has to pay for the medical services you received from a network provider on January 29, 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 out of network physician services provided to the enrollee from June 16, 2021, to June 18, 2021.
You asked the Plan to pay for these services. 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 physician services provided to the enrollee from June 16, 2021, to June 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture services coded as 97810 and 97811 provided on May 19, 2021 to July 22, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the acupuncture services. You say that your previous acupuncturist (in-network) never submitted for pre-authorization to continue your treatments. Therefore, you sought care so as not to interrupt your 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 acupuncture services coded as 97810 and 97811 provided on May 19, 2021 to July 22, 2021 by an out-of-network (OON) provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost sharing for the sagittal-coronal control lumbar spinal
orthosis (back brace) you received from an out-of-network provider on January 29, 2021.
You asked the Plan to reduce the cost sharing for the back brace. You say that you can find this item on the
open market for much cheaper, so you think you are being overcharged. The Plan denied your request. The
Plan says you were charged this cost sharing 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 25%
coinsurance for prosthetics and supplies after your $1300 deductible is met.
The Plan is required to pay, and the provider is required to accept, Medicare-allowed amount for items and
services provided. In this case, the back brace you received (code L0637) has a Medicare-allowed amount of
$1373.96. The Plan has calculated this allowed amount correctly. According to the case file documentation,
you had $464.66 remaining on your deductible when you received this item. That leaves a balance of $909.30.
This means that the coinsurance can apply to this remaining amount of $909.30. The applicable coinsurance for
out-of-network prosthetics is 25%, so your coinsurance responsibility is $227.33. This coinsurance, added to
your remaining deductible makes your total cost sharing obligation $691.98. This is the exact amount you have
been charged. The back brace you received falls into the prosthetics and supplies benefit category, so the
correct coinsurance was assessed. 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 reduce the cost sharing for the sagittal-coronal
control lumbar spinal orthosis (back brace) you received from an out-of-network provider on January 29, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90834) provided on April 26, 2021.
You asked the Plan to pay for psychotherapy services. You say that the medically necessary services at issue were provided to the enrollee in good faith. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. Medicare rules say that CP will attempt to consult with the enrollee's attending or primary care physician. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of psychotherapy services have not been met. Specifically, the provided records do not document an attempt to consult with, nor a referral from, the enrollee's attending or primary care physician. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90834) provided on April 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network chiropractic services provided from May 4,
2021, to May 21, 2021.
You asked the Plan to pay for these services. You say that you were told these services would be covered. The
Plan denied your request. The Plan says you did not have a referral or 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 contract also states a referral is required.
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. You did not have a referral for these services. 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 chiropractic services provided from May 4, 2021, to May 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for CTA scans of the chest and of the abdomen and pelvis provided on July 1, 2021, by an out-of-network provider.
You asked the Plan to pay for CTA scans. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for out-of-network care 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 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 CTA scans of the chest and of the abdomen and pelvis provided on July 1, 2021, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumococcal vaccine administration rendered on March 9, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not billed correctly.

The Plan must follow Medicare rules. The rules say that the administration of the pneumococcal vaccine should be billed with procedure code G0009. 

We looked at the file and Medicare rules. The file shows that the services were billed with code 90471 and not the required G0009 code. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the pneumococcal vaccine administration rendered on March 9, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve home infusion therapy, chemotherapy infusion (S9329) and home infusion therapy, continuous (twenty-four hours or more) chemotherapy infusion (S9330).  You asked the Plan to pre-approve home infusion therapy, chemotherapy infusion and home infusion therapy, continuous (twenty-four hours or more) chemotherapy infusion. You say that the services are necessary. The Plan denied your request. The Plan says codes S9329 and S9330 has a status indicator of "I", which indicates that this service is not valid for Medicare purposes. Therefore, coverage criteria have not been met.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Procedures should be reported with the Current Procedural Terminology (CPT) code that describes the services performed.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home infusion therapy, chemotherapy infusion and home infusion therapy, continuous (twenty-four hours or more) chemotherapy infusion have not been met.      Therefore, we decided that the Plan does not have to pre-approve home infusion therapy, chemotherapy infusion (S9329) and home infusion therapy, continuous (twenty-four hours or more) chemotherapy infusion (S9330).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the
chest you had on April 15, 2021.
You asked the Plan to waive the copayment for the CT scan. You say that you were never told that there would
be cost sharing for this service. 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 $150
copayment for CT scans.
You have been asked to pay a $150 copayment for the CT scan. 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 computed tomography (CT) scan of the chest you had on April 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient psychiatric hospital admission and services provided May 27, 2020, to June 1, 2020.
You asked the Plan to waive the copayment for the inpatient psychiatric hospital services. You say that you shouldn't be responsible for the cost of the services. The Plan denied your request. The Plan says the copayment was applied correctly. Your additional concerns are being handled separately as a grievance.
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 $395 copayment for each day for days 1 to 4 each time that you are admitted for inpatient mental health care. You have been asked to pay a total of $1,580 ($395 copayment x 4 days = $1,580) for the inpatient psychiatric
hospital services. The inpatient psychiatric hospital services fall within the Inpatient mental health 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 the inpatient psychiatric hospital admission and services provided May 27, 2020, to June 1, 2020
Appeal type: Drugs
Decision: Partially Favorable

 We decided that the Plan has to pre-approve two levels bilateral of epidural steroid injection. We decided that the Plan does not have to pre-approve one level bilateral transforaminal epidural injection.   You asked the Plan to pre-approve two levels bilateral of epidural steroid injection. You say that the services are necessary. The Plan says that based on the documentation provided, coverage criteria have not been met.  We decided that the Plan has to pre-approve one level bilateral transforaminal epidural injection.   The Plan follows Medicare rules. Medicare rules say that epidural steroid injections are covered when specific criteria are met.   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 one level bilateral transforaminal epidural injection. Our reviewer says that the services are medically necessary. Our physician reviewer found this exceeds the utilization criteria of the LCD. Only one level bilaterally is medically reasonable and 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 one level bilateral transforaminal epidural injection have been met. Therefore, we decided that the Plan has to pre-approve one level bilateral transforaminal epidural injection.   We also decided that the Plan does not have to pre-approve one level bilateral transforaminal epidural injection.  The Plan follows Medicare rules. Medicare rules say that epidural steroid injections are covered when specific criteria are met.   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 one level bilateral transforaminal epidural injection. Our reviewer says that the services are not medically necessary. Our physician reviewer found this exceeds the utilization criteria of the LCD. Only one level bilaterally is medically reasonable and 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 one level bilateral transforaminal epidural injection have not been met. Therefore, we decided that the Plan does not have to pre-approve one level bilateral transforaminal epidural 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the transport of portable x-ray equipment rendered on June
28, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services were not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of
service (POS) code.
We looked at the file and Medicare rules. The file shows that the services were performed in a nursing facility
and not billed with the required 32 POS code. Therefore, we decided that the Plan does not have to pay for the
transport of portable x-ray equipment rendered on June 28, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an eye exam (92250, 99203) rendered on January 27, 2021.
You asked the Plan to waive the copayment for an eye exam. You say that you went in for a routine eye exam and thought there was a $0 copayment. You also say that you called in for a routine eye exam and the provider office informed you there was no copayment. You also say you do not believe you owe the $35 copayment. 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 you must pay a $35 copayment for per visit for Medicare-covered exams to diagnose and treat diseases of the eye, including an annual glaucoma screening for members at high risk.
You have been asked to pay a $35 copayment for an eye exam. Eye exams fall within the Vision Care benefit category. The records show the diagnosis and treatment for diabetes. 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 eye exam (92250, 99203) rendered on January 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided on April 2, 2021.

You asked the Plan to pay for these services. You say that you feel the Plan should provide coverage for these services. The Plan denied your request. The Plan says you 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 physician services provided on April 2, 2021.