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

 We decided that the Plan does not have to pre-approve lateral sacroiliac (SI) joint nerve blocks.  You asked the Plan to pre-approve the SI joint nerve blocks. You say that it is felt that this treatment should be allowed. The Plan denied your request. The Plan says this is an experimental procedure.  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 SI joint nerve blocks. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the patient had no relief from bilateral intra-articular SI joint blocks, and the physician wants to perform diagnostic lateral sacral branch blocks. This is not considered a medically reasonable treatment.  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 SI joint nerve blocks have not been met. Therefore, we decided that the Plan does not have to pre-approve lateral sacroiliac (SI) joint nerve blocks.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a psychiatric diagnostic evaluation with medical services (90792) rendered on July 29, 2021.  You asked the Plan to waive the copayment for a psychiatric diagnostic evaluation with medical services. You say that you do not recognize this bill at all. You also say that you had nothing done that day. 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 $20 copayment for each Medicare-covered individual visit for outpatient mental health care.     You have been asked to pay a $20 copayment for psychiatric diagnostic evaluation with medical services. Psychiatric diagnostic evaluations with medical services fall within the Outpatient mental health care benefit category. The records show that you had an outpatient mental health office visit on July 29, 2021. 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 psychiatric diagnostic evaluation with medical services (90792) rendered on July 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a specialist visit provided on July 14, 2021.  You asked the Plan to waive the copayment for a specialist visit. You say that this was a follow-up visit and you should not be charged a copayment. The Plan denied your request. The Plan says the claims were processed correctly, and you are being 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 $15 copayment for each specialist visit.   You had a specialist visit on July 14, 2021. Follow-up visits are subject to cost-sharing charges. Therefore, you are responsible to pay the $15 copayment.   You have been asked to pay a $15 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 specialist visit provided on July 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for a telephone medical discussion with a specialist provided on July 13, 2021.  You asked the Plan to waive the deductible for a telephone medical discussion with a specialist. You say that you were not aware that the phone call would warrant a copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $203 deductible which applies to physician/practitioner services, including doctor's office visits.   You had a telephone medical discussion with a specialist on July 13, 2021. The record shows that you had only paid $63.72 toward the $203 deductible prior to receiving the services. Therefore, you are responsible to pay the remaining deductible balance of $56.45.    The item or service you asked the Plan to waive the deductible for falls within the benefit category physician/practitioner services, including doctor's office visits. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $203 deductible which applies to physician/practitioner services, including doctor's office visits. This cost sharing is a contractual obligation that had not been met at the time a telephone medical discussion with a specialist was received on July 13, 2021. Therefore, we decided that the Plan does not have to waive the deductible for a telephone medical discussion with a specialist provided on July 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve diabetic shoes to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve diabetic shoes. You say that you want diabetic shoes that are not sneakers. The Plan denied your request. The Plan says there are diabetic shoes available to you from in network providers.  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 diabetic shoes to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a limited oral evaluation (D0140), a panoramic radiographic image (D0330) and a tooth extraction (D7140) provided on February 26, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for a limited oral evaluation, a panoramic radiographic image, and a tooth extraction. You say that you have had work done on your teeth in the past and you have dealt with infections. You are requesting reconsideration for payment on this claim. The Plan denied your request. The Plan says the services at issue are not a covered benefit with your Plan.  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 a limited oral evaluation (D0140), a panoramic radiographic image (D0330) and a tooth extraction (D7140) provided on February 26, 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 a spinal cord stimulator with 32 electrodes.  You asked the Plan to pre-approve the extra electrodes. You say that this is medically necessary. The Plan denied your request. The Plan says only two leads or sixteen contacts (eight per side) are allowed.  The Plan must follow Medicare rules. The rules say that Medicare will reimburse for placement of a maximum of 2 leads or 16 contacts.  The requested amount of electrodes for this request exceeds the limits set by the Medicare guidelines. Based on this information, we decided that Medicare rules for coverage of the extra electrodes have not been met. Therefore, we decided that the Plan does not have to pre-approve a spinal cord stimulator with 32 electrodes.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for lab services you received on April 17, 2021, with an out-of-network provider.  You asked the Plan to waive the coinsurance for the out-of-network lab services. You say that you went to the walk-in clinic because it was near your home. You said that you thought your insurance would pay for it. The Plan denied your request. The Plan says you were charged this coinsurance correctly.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 50% coinsurance for out-of-network lab services.   You have been asked to pay 50% coinsurance for the out-of-network 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 coinsurance for lab services you received on April 17, 2021, with an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve binaural hearing aids.  You asked the Plan to pre-approve binaural hearing aids. You say that your right ear can't hear anything, and your left ear is getting worse. The Plan denied your request. The Plan says the Centers for Medicare & Medicaid Services guidelines, require that in order to have had binaural hearing aids in the past 5 years, severe vision problems, or needed binaural hearing aids for work or school. The member does not meet those requirements at the present time.  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 binaural hearing aids. Our reviewer says that the requested binaural hearing aids are not considered medically reasonable and necessary in this case. Our physician reviewer found that the provided records did not clearly reveal you having severe vision problems, need binaural aids for work or school, and no prior use of binaural hearing aids to meet criteria. A single hearing aid for the right ear was approved, however, there was insufficient support made for the request for binaural hearing aids.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of binaural hearing aids have not been met. Therefore, we decided that the Plan does not have to pre-approve binaural hearing aids.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the dermatology visit you had on July 30, 2021.  You asked the Plan to waive the copayment for the dermatology visit. You say that you were told that the office would not charge you for changing a band-aid. The Plan denied your request. The Plan says you were charged this copayment correctly.  The Plan says that because the allowed amount for this service ($21.83) is less than your copayment obligation, you are responsible for the full allowed 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 $40 copayment for visits with a specialist.   You have been asked to pay a $40 copayment for the dermatology visit. This copayment applies regardless of the extent of services you receive at the specialist's office. 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 dermatology visit you had on July 30, 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 have documented skilled nursing needs. You do not have documented skilled therapy needs. There is no evidence of a clear, acute decline in function. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of your condition. Your care needs, as a practical matter, can be provided 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 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for treatment of root canal obstruction (D3331) provided by an out-of-network provider on June 22, 2021.  You asked the Plan to pay for treatment of root canal obstruction. You say that you were not aware that this provider was out-of-network. The Plan denied your request. The Plan says the rendering dentist is out-of-network; therefore, these services have been correctly denied.  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 treatment of root canal obstruction when provided by an in-network provider. Prior authorization must be obtained to receive care from an out-of-network provider.    We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of treatment of root canal obstruction have not been met. Therefore, we decided that the Plan does not have to pay for treatment of root canal obstruction (D3331) provided by an out-of-network provider on June 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory testing provided on May 12, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for laboratory testing. You say that you are appealing with medical records showing this was medically necessary. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this provider is out-of-network with the Plan and authorization was not obtained.   Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan 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 laboratory testing provided on May 12, 2021 by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for ambulance services you received on June 3, 2021.  You asked the Plan to waive the copayment for the ambulance services. You say that you had to be transferred to a different facility because the one you were at couldn't accommodate you for your procedure.  You stated that it was not your fault that you had to be transferred, so you shouldn't have to pay this 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 $230 copayment per trip for ambulance services.   You have been asked to pay a $230 copayment per trip for the ambulance services. This copayment applies regardless of the reason for the transport. 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 ambulance services you received on June 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory testing provided on March 23, 2021.  You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because records were not received to show that this testing was recommended or that the enrollee's treating physician intended to order this testing.  The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the Plan sufficient information to determine whether payment is due for a claim.   We looked at the file and Medicare rules. You did not submit lab result records for this testing. The Plan made attempts to obtain these records, but they were not submitted. Without records of the lab results, you have not furnished sufficient information to determine whether payment is due for the codes billed on this claim. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on March 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray exam of the lumbar spine (72100), the arthrocentesis, aspiration and/or injection, of a major joint or bursa; without ultrasound guidance (20610), and the triamcinolone acetonide injection (J3301) rendered by the out-of-network (OON) provider on July 2, 2021.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the x-ray exam of the lumbar spine (72100), the arthrocentesis, aspiration and/or injection, of a major joint or bursa; without ultrasound guidance (20610), and the triamcinolone acetonide injection (J3301) rendered by the out-of-network (OON) provider on July 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for endodontic therapy, molar tooth (D3330) provided by an out-of-network provider on June 16, 2021.

You asked the Plan to pay for endodontic therapy. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says the rendering dentist is out-of-network; therefore, these services have been correctly denied.

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 endodontic therapy, molar tooth (D3330) provided by an out-of-network provider on June 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the cystoscopy procedure you had at an ambulatory surgical center on June 23, 2021.  You asked the Plan to waive the copayment for the cystoscopy procedure. You say that you cannot afford this copayment.  You said that you were not expecting it because it was not listed on your ID card. 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 $250 copayment for ambulatory surgical center services.   You have been asked to pay a $250 copayment for the cystoscopy procedure. The cystoscopy procedure falls within the ambulatory surgical center 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 cystoscopy procedure you had at an ambulatory surgical center on June 23, 2021.