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

We decided that the Plan does not have to waive the copayment for specialist services provided by a participating provider on April 12, 2021.
You asked the Plan to waive the copayment for specialist services. You say that you did not have an office visit. The Plan denied your request. The Plan says the correct copayment has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for physician/practitioner services/specialist. You have been asked to pay a $35 copayment for specialist services. A specialist copayment is applied to a specialist services that are provided; therefore, the correct copayment has been applied. Specialist services fall within the physician/practitioner services/specialist 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 specialist services provided by a participating provider on April 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab testing services provided on August 10, 2020.
You asked the Plan to pay for the testing services. You say that the enrollee has a benefit for lab services. The Plan denied your request. The Plan says the testing was not approved by the ordering physician.
The Plan must follow Medicare rules. Medicare rules say tests not ordered by the physician who is treating the beneficiary are not reasonable and necessary. We looked at the file and the rules. We find that the cardiovascular hereditary testing is not supported. The file shows that the physician listed on the requisition form did not order the testing at issue.
Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing services provided on August 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two periodontal scalings and root planings (D4341 x2) and two gingival irrigations (D4921 x2) provided on April 29, 2021.
You asked the Plan to pay for the scalings and planings and gingival irrigations. You say that the provider's office told you that these services would be covered. The Plan denied your request. The Plan says these services are not covered. The Plan also says that you did not contact the Plan prior to this date of service to verify benefits and provider eligibility.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the two periodontal scalings and root planings (D4341 x2) and two gingival irrigations (D4921 x2) provided on April 29, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an endoscopy provided by a participating provider on March 3, 2021.
You asked the Plan to waive the deductible for an endoscopy. You say that you think this should be considered preventative. The Plan denied your request. The Plan says the correct deductible has been applied.
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 $1,000 deductible for outpatient surgery/in-network. The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient surgery/in-network. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,000 deductible for outpatient surgery/in-network. This cost sharing is a contractual obligation that had not been met at the time an endoscopy was received on March 3, 2021. The total amount you are being asked to pay is $500.62. The endoscopy provided is not considered preventative; therefore, the correct deductible has been applied. Therefore, we decided that the Plan does not have to waive the deductible for an endoscopy provided by a participating provider on March 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab testing services provided on September 10, 2020.

You asked the Plan to pay for the testing services. You say that the testing should be covered. The Plan denied
your request. The Plan says the billed code cannot be verified.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate code.

We looked at the file and the rules. The billed claim shows a place of service as an independent laboratory. The
records do not indicate the specimen at issue was obtained at an independent laboratory. Based on this
information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore,
we decided that the Plan does not have to pay for the lab testing services provided on September 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99213) provided on January 5, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says prior authorization must be obtained for non-emergent services rendered by 
an out-of-network provider. 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. The records provided for review do not show that the services at issue were urgent or 
emergent. 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 an office visit (99213) provided on January 5, 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 a cystourethroscopy surgical procedure 
(52332) provided on April 8, 2021. 
 
You asked the Plan to waive the copayment for a surgical procedure. You say that you do not feel the 
copayment should be your responsibility as this was a request from your provider after the first surgery. The 
Plan denied your request. The Plan says the copayment you are being charged is correct. 
 
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 $550 
copayment for each outpatient surgery, including services provided at hospital outpatient facilities and 
ambulatory surgical centers. You have been asked to pay a $550 copayment for a surgical procedure. The records show you had a surgical 
procedure at an outpatient facility. The EOC confirms $550 is the required copayment for this service. A 
surgical procedure 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 a cystourethroscopy surgical procedure (52332) provided on April 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a home visit (99347) provided on December 9, 2020, by an out-of-network (OON) provider.

You asked the Plan to pay for a home visit. You say that that the services were medically necessary. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services rendered by an out-of-network provider.

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. The records provided for review do not show that the services at issue were urgent or emergent. 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 a home visit (99347) provided on December 9, 2020, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for ophthalmic services, ophthalmic diagnostic imaging, and an ultrasound provided on September 11, 2020.
You asked the Plan to waive the copayments for ophthalmic services, ophthalmic diagnostic imaging, and an ultrasound. You say that you disagree with the charges. 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 $40
copayment for specialist visits. Your contract with the Plan also clearly says that you must pay a $50 copayment for all other diagnostic procedures and tests and diagnostic radiology. You received ophthalmic services on September 11, 2020. Therefore, you are responsible to pay the $40 copayment. You received ophthalmic diagnostic imaging on September 11, 2020. Therefore, you are responsible to pay the allowed amount of $43.63, which is less than the $50 copayment. You received an ultrasound on September 11, 2020. Therefore, you are responsible to pay the allowed amount of $14.38, which is less than the $50 copayment. The total amount you owe is: $98.01. You have been asked to pay the total copayment amount of $98.01 for ophthalmic services, ophthalmic diagnostic imaging, and an ultrasound. Ophthalmic services fall within the physician/practitioner services, including doctor's office visits benefit category. Ophthalmic diagnostic imaging and an ultrasound 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 copayments for ophthalmic services, ophthalmic diagnostic imaging, and an ultrasound provided on September 11, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99284) provided on December 17, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the left, right or is bilateral. If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side. We looked at the file and Medicare rules. In this case, it is appropriate to report left and right diagnosis codes
when a bilateral diagnosis code is available. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (99284) provided on December 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the amalgams (D2160 x 2) provided on 
March 24, 2021. 
 
You asked the Plan to pay an additional amount for the dental service. You say that your dentist gave you a 
treatment plan. You say that you contacted the plan to see what services would be covered. You say that you 
were not told anything about services being covered differently if you went out of network. You also say that 
the information on the Summary of Benefits is very misleading. The Plan denied your request. The Plan says 
there is a 50% coinsurance for fillings. The Plan also says that the claim was processed correctly as the 
provider in this case is out of network. 
 
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 and fillings are listed as covered, dental services performed out of network may have a higher cost share. The Evidence of Coverage clearly states that 
if your dental services are performed by a dentist outside of the Dental Plan's network, you will be responsible 
for paying the difference between the dentist's fees and the Plan's what the Plan pays. Therefore, we decided 
that the Plan does not have to pay an additional amount for the amalgams (D2160 x 2) provided on March 24, 
2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health care provided to the enrollee from
May 3, 202,1 to May 17, 2021.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says The Medicare allowable for Psychotherapy services 90834 and 90837 is $ 0.00. There is
no allowable reimbursement rate. Therefore, no payment can be made
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate codes. In this case, the services billed have no revenue
payment amount for Medicare purposes. Medicare rules for coverage of this service have not been met.
Therefore, we decided that the Plan does not have to pay for outpatient mental health care provided to the
enrollee from May 3, 202,1 to May 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on July 1, 2020.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.

The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.

We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on July 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the observation services you received from
February 20, 2021, to February 22, 2021.
You asked the Plan to waive the copayment for the observation services. You say that it was your
understanding that if you were admitted through the emergency room there would not be a copayment. The
Plan denied your request. The Plan says you were charged this copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300
copayment for outpatient observation services.
You have been asked to pay a $300 copayment for the observation services. Records show that you were not
admitted to the hospital as an inpatient, but were rather kept in an outpatient observation status. The
emergency room copayment is only waived if you are admitted as an inpatient. There is no provision in your
Evidence of Coverage for a waiver of any copayments if you are moved to observation from the emergency
room. 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 observation services you received from
February 20, 2021, to February 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro orthotic device (L8702). 
 
You asked the Plan to pre-approve the orthotic device. You say that say the medical records provided support 
the necessity of the services in dispute. The Plan denied your request. The Plan says MyoPro iis considered 
experimental and investigational. There is insufficient evidence of its effectiveness in those with stroke and 
hemiparesis. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-
approve the MyoPro orthotic device (L8702).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second diagnostic facet joint procedure.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the doctor is requesting a second injection only days after the first 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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the standard of care is to wait two weeks to assess the duration and degree of pain relief achieved. Therefore, the request, at the time of request, did not meet the LCD criteria and is deemed not 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 Plan does not have to pre-approve a second diagnostic facet joint procedure.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a skilled nursing stay provided by a participating provider on April 1, 2021, to April 13, 2021.
You asked the Plan to waive the copayment for a skilled nursing stay. You say that you were not there for those 6 days. The Plan denied your request. The Plan says the correct copayment has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $0 copayment per day for days 1-20. There is a $55 copayment per day for days 21-100 for skilled nursing facility (SNF) care. You have been asked to pay a $0 copayment per day for days 1-20. There is a $55 copayment per day for days 21-26 a skilled nursing stay. The total amount you are being asked to pay is $330 ($55 x 6 days = $330). Since skilled nursing services were provided for days 21-26, the correct copayment has been applied. A skilled nursing facility stay falls within the skilled nursing facility (SNF) 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 a skilled nursing stay provided by a participating provider on April 1, 2021, to April 13, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Feraheme (Ferumoxytol).
You asked the Plan to pre-approve Feraheme. You say that the drug is medically necessary. The Plan denied your request. The Plan says the drug is not medically necessary.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Feraheme. Our reviewer says that the drug is not medically necessary. Our physician reviewer found a trial of drug Ferrlecit, INFeD or Venofer is required before the Plan will approve the requested drug. The documentation does not support that there has been a trial and inadequate response or intolerance to 2 preferred agents (Ferrlecit, INFeD or Venofer) or that the required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Feraheme have not been met. Specifically, the enrollee does not meet the step therapy requirements for the requested drug. Therefore, we decided that the Plan does not have to pre-approve Feraheme (Ferumoxytol).