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

We decided that the Plan does not have to waive the copayment for the closed treatment of a humeral shaft fracture provided in an outpatient hospital facility on August 22, 2019.
You asked the Plan to waive the copayment for the closed treatment of a humeral shaft fracture. You say that you did not receive an outpatient surgical procedure. 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 $200 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You received the closed treatment of a humeral shaft fracture on August 22, 2019. The closed treatment of humeral shaft fracture is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $200 copayment. You have been asked to pay a $200 copayment for the closed treatment of a humeral shaft fracture. The closed treatment of a humeral shaft fracture 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 the closed treatment of a humeral shaft fracture provided in an outpatient hospital facility on August 22, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided to the enrollee on July 6, 2019. You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says this is not a covered service. The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for the lab services provided to the enrollee on July 6, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for nonemergency transportation commercial flight provided on October 30, 2018.
You asked the Plan to pay for nonemergency transportation commercial flight. You say that you are requesting reimbursement of services rendered. The Plan denied your request. The Plan says the service is not a covered benefit under the plan.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of nonemergency transportation commercial flight have not been met. The service is not a covered benefit under Medicare or the plan. Therefore, we decided that the Plan does not have to pay for nonemergency transportation commercial flight provided on October 30, 2018.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora diagnostic mammogram provided on January 2, 2020.You asked the Plan to waive the copayment fora diagnostic mammogram. You say that you suffered from left breast pain and this was a routine mammogram.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 $10 copayment for diagnostic procedures and tests. The medical records show that you received a diagnostic mammogram on January 2, 2020 due to left breast pain and a lump. Therefore, you are responsible to pay the $10 copayment. You have been asked to pay a $10 copayment for a diagnostic mammogram. A diagnostic mammogram falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment fora diagnostic mammogram provided on January 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided to the enrollee on October
17, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says there is no
evidence of an established relationship between the enrollee and the ordering physician.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the
medical record, his or her intent that the test be performed.
We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering
physician's intent that the tests be performed. Based on this information, we decided that Medicare rules for
coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to
pay for the drug testing services provided to the enrollee on October 17, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approve the Freestyle Libre Kit and Sensor for the enrollee.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthere is a lack of criteria satisfaction, as injectable insulin is not being used.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found there is no evidence of the enrollee being on insulin. Based on the medical records provided, the monitor is not considered medically reasonable or 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 services have not been met.Therefore, we decided that the Plandoes not haveto pre-approvethe Freestyle Libre Kit and Sensor for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections (64493, 64494, and 64495).
You asked the Plan to pre-approve facet joint injections. You say that you need these procedures to relieve your pain. The Plan denied your request. The Plan says this does not meet criteria for coverage.
The Plan follows Medicare rules. Medicare rules say that facet joint injections are covered when pain is predominantly axial and not associated with radiculopathy or neurogenic claudication. 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 facet joint injections. Our reviewer says that the criteria for coverage have not been met for the injections at issue. Our physician reviewer found the submitted medical records show the presence of radiculopathy. Facet joint injections are therefore not indicated under Medicare rules. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections (64493, 64494, and 64495).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a nerve block provided by at an outpatient hospital facility on December 23, 2019.You asked the Plan to waive the copayment for a nerve block. You say that you were not aware that you copayment would be $500 and feel that the doctor should have told you.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 $500 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You received a nerve block at an outpatient hospital facility on December 23, 2019. A nerve block is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $500 copayment. You have been asked to pay a $500 copayment for a nerve block. A nerve block 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 fora nerve block provided by at an outpatient hospital facility on December 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe transition lenses and frames provided on November 1, 2019.You asked the Plan to pay forthe transition lenses and frames. You say that you would like the plan to reconsider their decision.The Plan denied your request. The Plan says the claim has been processed correctly per your plan benefits. Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers standard frames and lenses after cataract surgery.We looked at the file and the Plan's rules. Review of the file shows that the plan covers standard frames and lenses. While you did receive glasses after cataract surgery, you received transition lenses and non-standard frames. Therefore, you have been asked to pay the difference in price for these upgraded, non-standard lenses and frames. Based on this information, we decidedthat the Plan's rules for coverage of the transition lenses and frames have not been met. Therefore, we decided that the Plan does not have to pay forthe transition lenses and frames provided on November 1, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services provided on October 16, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says assistant surgeon
services are not necessary for this procedure.
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1,
assistant surgeon services are not covered. In this case, the provider billed assistant surgery services for CPT
code 27596. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This
means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid.
Based upon this information, we find that Medicare coverage criteria for the services have not been met.
Therefore, we decided that the Plan does not have to pay for the assistant surgeon services provided on October
16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forocclusion analysis -mounted case (D9950) provided on September 26, 2019.You asked the Plan to pay forthe dental services. You say that you do not understand why 1) Rebuilding a tooth to put a crown on it is not covered and 2) why making an impression of my tooth to make a crown is not covered. You state your doctor is a participating provider so it seems like you should not have to pay out of pocket for necessary work.The Plan denied your request. The Plan says the service is not a covered benefit under the 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.The Plan verified that dental code D9950 is a mold that is taken for adjustment of the teeth. This was billed correctly, and is not a covered service. There was no change to the charge for dental code D9950 as it was billed and denied correctly. You are responsible for the entire billed amount for non-covered services because the Plan does not apply an allowed amount to services that are not a covered benefit.Therefore, we decided that the Plan does not have to pay forocclusion analysis -mounted case (D9950) provided on September 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve therapeutic continuous glucose monitor supplies and accessories (CPT K0553).
You asked the Plan to pre-approve the therapeutic continuous glucose monitor supplies and accessories. You say that the records provided support the need for the requested device. The Plan denied your request. The Plan says a CGM system sensor is not medically necessary and appropriate at this time. The Plan says that the enrollee is not being treated with multiple daily injections of insulin, and the Medicare criteria for coverage of this item have not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor. Medicare rules also say that for equipment to be covered, it must primarily serve a medical purpose.
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 therapeutic continuous glucose monitor supplies and accessories. Our reviewer says that the requested CGM supplies and accessories are not medically reasonable and necessary. Our physician reviewer found the enrollee is noted to have type II diabetes. The enrollee does not use insulin and does not monitor his blood glucose. As such, there is no evidence that the enrollee uses the results of blood glucose monitoring to self-adjust self-administered insulin multiple times per day. 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 therapeutic continuous glucose monitor supplies and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve therapeutic continuous glucose monitor supplies and accessories (CPT K0553).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the SNF stay provided from July 10, 2019 to August 4, 2019.
You asked the Plan to waive the copayment for the SNF stay. You say that you asked several times how long your insurance would let you stay at the SNF. You say you disagree with the copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $0 copayment for each day for days 1 to 20 and a $160 copayment each day for days 21 to 42. You have been asked to pay a total of $800 copayment for the SNF stay. The SNF stay falls within the "Skilled Nursing Facility (SNF) Care" benefit category. See chart below.
Dates of Service
Service
Copayment per Day
SNF Days
Number of Days
Member Liability
July 10, 2019 to July 29, 2019
SNF stay
$0
1-20
20
$0
July 30, 2019 to July 31, 2019
SNF stay
$160
21-22
2
$320
August 1, 2019 to August 4, 2019
SNF stay
$160
23-25
3
$480
Total
$800
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 SNF stay provided from July 10, 2019 to August 4, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthetic agent injection (64447) provided on September 10, 2019.
You asked the Plan to pay for the injection. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service billed.
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, the CPT Code Manual definition of code 64447 is injection, anesthetic agent; femoral nerve, single. We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the injection. Our reviewer says that CPT code 64447 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records submitted do not include documentation of an Injection(s), anesthetic agent(s) and/or steroid; femoral nerve, therefore this service cannot be verified as being performed on September 10, 2019. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not have to pay for the anesthetic agent injection (64447) provided on September 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99190) provided on October 21, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says payment for this service is included in the Part A DRG payment to the facility.The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. Payment for all fees related to this service would have been included under the facility claim.Therefore, we decided that the Plan does not have to pay forthe services (CPT 99190) provided on October 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on November 7, 2019.
You asked the Plan to waive the copayment for the office visit. You say that you have never heard of this doctor. You say that you did not see him. 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 $50 for each Medicare-covered visit with an in-network specialist. You have been asked to pay a $50 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that the office visit was for shortness of breath. 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 office visit provided on November 7, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low dose CT scan of the lungs.
You asked the Plan to pre-approve the scan. You say that this cannot be approved, as you stopped smoking in 1995. The Plan denied your request. The Plan says this is medically necessary, as your father died of cancer and you occasionally experience shortness of breath.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. Low dose CT scans have more specific eligibility requirements. 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 scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found while you had smoked for twenty years, how much you smoked each day is not documented. Therefore, your pack year history cannot be calculated. Furthermore, by your own admission, you occasionally have shortness of breath, meaning that
you are not asymptomatic. As such, the coverage criteria for this request has not been met. 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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a low dose CT scan of the lungs.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered to the enrollee from December 3, 2019 to December 10, 2019.
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 are not covered.
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered to the enrollee from December 3, 2019 to December 10, 2019.
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.