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

We decided that the Plan does not have to waive the copayment for office or other outpatient visit for the
evaluation and management of an established patient (99213) provided on March 1, 2019.
You asked the Plan to waive the copayment for office visit. You say that the service should be covered. The
Plan denied your request. The Plan says the cost share was 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 a $30
copayment for a specialist visit for Physician/Practitioner services, including doctor's office visits.
You have been asked to pay a $30 copayment for a specialist visit for office visit. This service 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 office or other outpatient visit for the evaluation and management of an established
patient (99213) provided on March 1, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forrespiratory virus testing (87631) provided on June 24, 2020.You asked the Plan to pay forrespiratory virus testing. You say that this is supported by the records.The Plan denied your request. The Plan says the criteria for coverage have not been met.The Plan must follow Medicare rules. Medicare rules say that codes for Respiratory Viral Panels such as 87631 are covered when billed in places of service 20, 21, or 23or when ordered by an infectious disease specialist who is diagnosing and treating the beneficiary.We looked at the file and Medicare rules. The record shows that this service was billed with a place of service of 81 and does not show that this service was ordered by an infectious disease specialist. Based on this information, wedecided that Medicare rules for coverage of respiratory virus testing have not been met.Therefore, we decided that the Plan does not have to pay forrespiratory virus testing (87631) provided on June 24, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forinfectious agent detection (87801) provided on March 30, 2021.You asked the Plan to pay forthe infectious agent detection. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the medical records submitted do not include a signed physician order or signed laboratory requisition for the billed test.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. Based on this information, we decided that Medicare rules for coverage of the infectious agent detection have not been met. Specifically, the record does not include a physician order or clinical information documenting the physician's intentfor the billed test to be performed.Of note, the record indicates that the Plan made multiple attempts to obtain this information from the provider.Therefore, we decided that the Plan does not have to pay forinfectious agent detection (87801) provided on March 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on
August 10, 2020.
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 enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan.
The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan
did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for
these items/services. Therefore, we decided that the Plan does not have to pay for out of network physician
services provided to the enrollee on August 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe injection services received on March 2, 2020.You asked the Plan to waive the coinsurance forthe injection services. You say that you disagree with the amount owed.The Plan denied your request. The Plan says the claim has been processed correctly per your plan benefits.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 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay 20% coinsurance for the injection services. The injection services fall within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount based on yourcontract 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 forthe injection services received on March 2, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea vacuum-assisted suction system (VASS) for a prosthesis.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not medically necessary.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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the submitted records show that you have below-knee amputations of both legs and use lower extremity prosthetics. The VASS is not the standard of care for your condition. The records do not support that the requested VASS is reasonable and medically necessary at this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pre-approvea vacuum-assisted suction system (VASS) for a prosthesis.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveProlia.You asked the Plan to pre-approveProlia. You say that the requested Prolia is medically necessary.The Plan denied your request. The Plan says the enrollee must try and fail an oral bisphosphonate drug and zoledronic acid first.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 Prolia. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found based on the documentation provided, the enrollee is noted to have osteoporosis. A request has been made for Prolia to treat the osteoporosis.The health plan requires that other forms of osteoporosis medications be used. There is no evidence that the enrollee is allergic to or intolerant of all of these other forms of medication. There is no evidence that the enrollee has tried and not responded to all of these other forms of medication. There is no documentation as to why all of these other forms of medication would not be expected to be safe and effective for the enrollee. Therefore, the requested Prolia is not shown to be currently medically necessary and reasonable.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules forcoverage of Prolia have not been met.Therefore, we decided that the Plan does not have to pre-approveProlia
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for drug testing provided on May 12, 2020.
You asked the Plan to pay for drug testing. You say that specimens were sent to your lab by the enrollee's
treating provider to perform time-sensitive medically necessary tests. The Plan denied your request. The Plan
says that the denial of payment for this testing is correct, because progress notes from the treating provider are
needed in order to determine the clinical utility of this testing.
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.
This drug testing was ordered by an in-network provider. The file does not show that the plan provided notice
that drug testing would not be covered. Under Medicare rules, this means drug testing is considered approved
by the plan. Therefore, we decided that the Plan has to pay for drug testing provided on May 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not have to pay forthe post and core in addition to a crown (D2954) and root canal (D3310) for tooth #6 provided on June 24, 2020.You asked the Plan to pay forthe dental services. You say that you feel the provider has been paid twice for the services you received. You also say that you do not owe $1,303.The Plan denied your request. The Plan says there is a maximum benefit of $2,500. The Plan says that the maximum benefit has been exhausted. The Plan also says that after the annual maximum is exhausted, any remaining charges are your responsibility.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 maximum benefit of $2,500 has been exceeded.Date of ServiceTotal ClaimPlan Paid1/6/2020$900.70$5181/21/2020$470$2731/27/2020$300$1651/29/2020$300$707/22/2020$3,245$1,2126/1/2020$453$2446/24/2020$1,320$18TOTAL:$2,500
The Evidence of Coverage clearly states that after the annual maximum is exhausted, any remaining charges are your responsibility. Therefore, we decided that the Plan does not have to pay forthe post and core in addition to a crown (D2954) and root canal (D3310) for tooth #6 provided on June 24, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a hearing aid (V5261) and hearing services (V5299)
provided on June 12, 2020.
You asked the Plan to pay for a hearing aid and hearing services. You say that the items are medically
necessary. The Plan denied your request. The Plan says hearing aids and assessments are only eligible through
the Plan's provider.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for up
to two Plan-branded hearing aids every year (one per ear per year).
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for
coverage of hearing services and hearing aid have not been met. Specifically, you did not receive these items
from the Plan's provider. Therefore, we decided that the Plan does not have to pay for a hearing aid (V5261)
and hearing services (V5299) provided on June 12, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe epidural injections (64483) provided on June 17, 2019.You asked the Plan topay forthe injections. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says CPT code 64483 has an MUE value of 1 but the provider billed 2 units.The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied.In this case, the MUE for CPT code 64483 is 1. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the injections have not been met.Therefore, we decided that the Plan does not have to pay forthe epidural injections (64483) provided on June 17, 2019
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transport provided on June 11, 2020.
You asked the Plan to pay for the ambulance transport. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the enrollee was enrolled in hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Original Medicare is responsible for payment for services until the first day of the month after the
hospice election has been revoked or terminated.
The enrollee ended Medicare Hospice benefits on June 10, 2020. The services in question were provided before
the end of that month. Therefore, we decided that the Plan does not have to pay for the ambulance transport
provided on June 11, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approvestereotactic body radiation therapy (SBRT) for the enrollee.You asked the Plan to pre-approvethe therapy. You say that this is medically necessary to treat pelvic lesions in the setting of stage III ovarian cancer.The Plan denied your request. The Plan says this is not medically necessary.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 therapy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found for the enrollee, the intent is palliative, and does not seem to meet the ASTRO model policy or generic indications for SBRT being able to encompass all sites of disease. The prescribed dose of 8 Gy x 3 is accordingly palliative in nature (as opposed to typical SBRT doses of 10-20 Gy x 3). The NCCN guidelines for ovarian cancer do not address SBRT for oligometastases or oligoprogression (as they do for other disesease sites). The case file does not include any references, publications or guidelines that support the use of SBRT as opposed to palliative 3D radiation.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 therapy have not been met.Therefore, we decided that the Plan does not have to pre-approvestereotactic body radiation therapy (SBRT) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement socket for the enrollee.
You asked the Plan to pre-approve the socket. You say that this is medically necessary. The Plan denied your
request. The Plan says there is no indication of the age of the current prosthesis.
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 socket. Our reviewer says that the
requested socket is not considered medically reasonable and necessary in this case. Our physician reviewer
found the provided medical records do not document changes in the residual limb, functional need changes, or
irreparable damage or wear and tear due to excessive beneficiary weight or prosthetic demands of a very active
amputee. There is also no documentation that the present socket has exceeded its reasonable useful lifetime.
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 socket have not been met. Therefore, we decided that the Plan does not have
to pre-approve a replacement socket for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Kalio patches purchased on June 25, 2020 by a retail provider.You asked the Plan to pay forthe Kalio patches. You say that the item should be covered per the Americans with Disabilities Act that requires full and equal access for people with disabilities.The Plan denied your request. The Plan says the codes did not meet the guidelines established by Medicare, the Kailo patches were purchased from a non-Medicare participating provider and there is not valid prescription provided prior to the purchase of the patches. Based on this information the denial of authorization has been upheld.Medicare rules say that payment can only be made to suppliers that are enrolled in the Medicare program.In this case, the Kailo patches were purchased from a provider that is not enrolled in Medicare.Therefore, we decided that the Plan does not have to pay forthe Kalio patches purchased on June 25, 2020 by a retail provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services rendered on April 20, 2020 and April 27, 2020.You asked the Plan to pay forthese 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. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. There are no medical records to support that the testing was medically necessary. Based on this information, we decided that Medicare rules forcoverage of these services have not been met. Therefore, we decided that the Plan does not have to pay forthe laboratory services rendered on April 20, 2020 and April 27, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered.

You asked the Plan to pay for the services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 95999 is not supported.

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 95999 is unlisted neurological or neuromuscular diagnostic procedure.

We find that CPT code 95999 is not supported in the medical record. Specifically, the file shows that Train of Four testing was performed and there is a more appropriate code for these services. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay for the testing services rendered.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the out of network cost share forthe oral exam (D0120), bitewing x-rays (D0272), and prophylaxis (D1110) provided on August 10, 2020.You asked the Plan to waive the out of network cost share forthe dental services. You say that your Medicare guide for dental benefits shows there is a $0 copayment for exams, cleanings, x-rays and fluoride. You say that you received a bill for $122. You say that the benefit page is misleading. You also say that this bill was a total surprise to your budget and would like the bill to be paid.The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says you may be billed by the out of network provider for any amount greater than the payment made by the plan to the provider. The Plan saysMedicare 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, you may be billed more by an out of network provider if the charge is greater than MAC.CPT CodeBilled AmountAllowed AmountPlan PaidYour ResponsibilityD0120$38$18$18$20D0272$55$15$15$40D1110$100$38$38$62TOTAL:$122Cost sharing is a contractual obligation underthe plan and cannot be waived.Therefore, we decided that the Plan does not have to waive the out of network cost share forthe oral exam (D0120), bitewing x-rays (D0272), and prophylaxis (D1110) provided on August 10, 2020
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe insertion of a gastric neurostimulator provided on July 9, 2020.You asked the Plan to waive the copayment forthe insertion of a gastric neurostimulator. You say that you did not know you would owe a copayment per each 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 $350 copayment for outpatient surgery,including services provided at hospital outpatient facilities. You have been asked to pay a $350 copayment for the insertion of a gastric neurostimulator. The insertion of a gastric neurostimulator falls within the outpatient surgery, including servicesprovided 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 forthe insertion of a gastric neurostimulator provided on July 9, 2020
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay foroffice services provided by opted out provider from January 16, 2019, to December 3, 2019.You asked the Plan to pay foroffice services. You say that the Plan must reimburse you for these claims.The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider has opted out of Medicare coverage and is not payable.The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program.Therefore, we decided that the Plan does not have to pay foroffice services provided by opted out provider from January 16, 2019, to December 3, 2019.