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

 We decided that the Plan does not have to pay for the medical services provided on April 2, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the medical services. You say that you believe you are an in-network provider. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered. The Plan has confirmed that you are not a network provider with the enrollee's specific plan.  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 medical services provided on April 2, 2021, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Favorable

 We decided that the Plan has to pay for the emergency air ambulance transport.  You asked the Plan to pay for the emergency air ambulance transport. You say that this enrollee's auto insurance benefits have been exhausted. The Plan denied your request. The Plan says that this claim denied because the primary payor's Explanation of Benefits (EOB) and statement of benefits exhaustion is needed.  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 substantiated its denial of this claim. In its original denial, the Plan says that because they are the secondary insurer, they needed the EOB and the proof of benefits exhaustion.  This information is in the file and confirms that the enrollee exhausted their auto insurance benefits.  The Plan has provided no other explanation or support for their denial   It is the Plan's burden to prove why its decision to deny payment is correct, and they have failed to do so. Therefore, we decided that the Plan has to pay for the emergency air ambulance transport.   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 x-ray services coded 73502 provided on July 9, 2021.  You asked the Plan to pay for the x-ray services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately payable.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 73502 for the x-ray services is a column II code to column I code 73523.  This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray services coded 73502 provided on July 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the pneumatic compression device coded E0675 and related accessory (E0673) provided to the enrollee on June 15, 2021.  You asked the Plan to pay for the pneumatic compression device and accessory. You say that You say that this device is medically necessary and should be covered. This device was appropriate to prevent deep vein thrombosis. The Plan denied your request. The Plan says this item is not covered.  The Plan must follow Medicare rules. Medicare rules say that pneumatic compression devices coded with E0675 are non-covered. Because this item is statutorily non-covered, any related accessories are also non-covered.  This decision is not a determination of medical necessity or whether or not the item is experimental/investigational.  Rather, this determination is purely an administrative denial based on the explicit wording of the applicable local coverage determination.    Based on this information, we decided that Medicare rules for coverage of the pneumatic compression device and accessory have not been met. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device coded E0675 and related accessory (E0673) provided to the enrollee on June 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the rest home visit provided on June 8, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the OON services. You say that the assisted living facility is responsible to obtain prior authorization. The Plan denied your request. The Plan says the services were not urgent, emergent, or authorized prior to 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 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 rest home visit provided on June 8, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for anesthesia services provided on December 28, 2020.  You asked the Plan to pay for the anesthesia services. You say that you do not understand why the Plan is refusing to pay for this. The Plan denied your request. The Plan says this claim needs to first go to your primary insurance company.  Once they have processed the claim, it should then be resubmitted.  The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.  The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has contacted the provider and advised them of the primary insurance information and told them to submit claims to the primary insurer. In addition, the Plan contacted you directly and advised you that this claim needed to first go to your primary insurance company. As the secondary insurer, the Plan cannot be held responsible for the anesthesia services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for anesthesia services provided on December 28, 2020.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a 60-day supply of Doxycycline Hyclate 50 MG capsule provided by an out-of-network pharmacy on July 29, 2021.  You asked the Plan to waive the copayment for Doxycycline Hyclate. You say that you were charged $49.14 for a prescription. You asked why it was not covered. The Plan denied your request. The Plan says the cost-share was applied correctly. The Plan's Tier 4 copayment for a 60-day supply of medication is $190, but since the claim submitted by the pharmacy indicated a lower charge, you were charged the lesser amount instead of the $190 copayment.     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 $95 copayment for Tier 4 (Non-Preferred Drugs) up to a 30-day supply when provided by an out-of-network pharmacy.   You have been asked to pay a $49.14 copayment for Doxycycline Hyclate, which falls within the Tier 4 (Non-Preferred Drugs) benefit category. Doxycycline Hyclate is listed as a Tier 4 drug on page 17 of the Plan's 2021 Drug Formulary, which is a list of drugs covered by the Plan. Furthermore, page 169 of the Plan's 2021 Provider Directory indicates the specific pharmacy location you went to is not an in-network pharmacy. Therefore, the out-of-network cost-sharing on page 152 of the EOC applies. Under your benefit, a 60-day supply would require a $190 copayment ($95 for a 30-day supply ? 2 (to equal 60 days) = $190).   Since you are being asked to pay less than the required copayment, 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 60-day supply of Doxycycline Hyclate 50 MG capsule provided by an out-of-network pharmacy on July 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit provided on June 10, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for these services. You say that you never go to a specialist without a referral. 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 requested provider in this case is not a network provider with the Plan. The referring provider 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 provided on June 10, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for pathology services provided on September 24, 2020 by an out-of-network (OON) provider.  You asked the Plan to pay for the OON pathology services. You say that these services were medically necessary. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.  The Plan says that the referring provider is also out-of-network with the Plan.    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 pathology services provided on September 24, 2020 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99202) provided on July 15, 2021.  You asked the Plan to pay for the office visit. You say that you believed these services would be covered. The Plan denied your request. The Plan says the only chiropractic services the Plan covers is the manual manipulation of the spine.  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. Therefore, we decided that the Plan does not have to pay for the office visit (99202) provided on July 15, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy (45378) rendered on July 26, 2021.  You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that you were told this was a routine colonoscopy and you feel it should be billed as such. You also say then it will be covered in full under your benefits for a routine colorectal screening. The Plan denied your request. The Plan says you were charged the correct amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $395 copayment per visit for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.   You have been asked to pay a $395 copayment for a diagnostic colonoscopy. Since this service was a diagnostic colonoscopy, the cost share associated with the diagnostic colonoscopy will apply. Diagnostic colonoscopies fall 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 a diagnostic colonoscopy (45378) rendered on July 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on February 10, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on February 10, 2021 by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the psychiatric evaluation provided on April 15, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the OON services. You say that you were told this was a par provider. The Plan denied your request. The Plan says a participating provider was not used.  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 OON services. Therefore, we decided that the Plan does not have to pay for the psychiatric evaluation provided on April 15, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home visit provided on June 21, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for these services. You say that you rely on the facility to obtain authorization. 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 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 home visit provided on June 21, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the physician office visit you had on July 14, 2021.  You asked the Plan to waive the copayment for the physician office visit. You say that you thought that this visit would be covered in full. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that although you were also seen for your annual wellness visit (for which you were not charged a copayment), you doctor also treated you for hypercholesterolemia.  This is an additional service beyond the annual wellness visit, so the physician services copayment applies.  The rules say that a Cost plan must disclose in writing all benefits available under the Plan. The health plan contract says that enrollees must pay a $10 copayment for physician services.  You have been asked to pay a $10 copayment for the physician office visit. 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 physician office visit you had on July 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the wrist-hand brace provided on June 9, 2021.  You asked the Plan to waive the coinsurance for the wrist-hand brace. You say that you were told that this would be covered with a $0 cost share. The Plan denied your request. The Plan says this coinsurance was charged 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). The enrollee's contract with the Plan clearly says that enrollees must pay 20% coinsurance for prosthetic devices (including braces).   The enrollee has been asked to pay 20% coinsurance for the wrist-hand brace. The wrist-hand brace falls within the prosthetic devices 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 coinsurance for the wrist-hand brace provided on June 9, 2021.
Appeal type: Imaging
Decision: Favorable

 We decided that the Plan has to pay for the computed tomography received on August 3, 2021.  You asked the Plan to pay for the computed tomography. You say that you feel this service should be covered. The Plan denied your request. The Plan says that the services received are not a covered benefit.  Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules.  You received the computed tomography by a contract provider. The file does not show that the Plan provided notice that the computed tomography would not be covered. Under Medicare rules, this means the computed tomography is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the computed tomography received on August 3, 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 copayment for lab services you received on June 2, 2021.  You asked the Plan to waive the copayment for the lab services. You say that these lab services were part of your annual visit, so there should be no 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 $10 copayment for lab services.   We looked at the medical records from this visit.  The medical records show that you had an annual wellness exam.  According to your contract and Medicare rules, the annual wellness exam includes services to develop or update a personalized prevention plan based on your current health and risk factors.  It does not include lab services.  Therefore, separate cost sharing for the lab services can apply. You have been asked to pay a $10 copayment for the lab services. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for lab services you received on June 2, 2021.