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

We decided that the Plan does not have to waive the copayment forimmunotherapy service provided on February 14, 2020.You asked the Plan to waive the copayment forspecialist visit. You say that the cost-share for this was not on the Evidence of Coverage or Annual Notice of Change for 2020.The Plan denied your request. The Plan says the copayment amount 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 $35 copayment for specialist visit. You have been asked to pay the allowed amount of $10.36, which is less than the $35 copayment for specialist visit. Specialist visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits benefit category. This means that you havebeen 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 forimmunotherapy service provided on February 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe comprehensive oral evaluation (D0150), prophylaxis (D1110), the complete series x-ray (D0210), and the panoramic x-ray (D0330) provided on August 21, 2020.You asked the Plan to pay forthe dental services. You say that you called before your appointment to confirm that the dental office was in network. You say that you did not know that the dentist you saw was out of network until after you received the services.The Plan denied your request.The Plan says the provider in this case is out of network. The Plan says that dental services that you receive out of network are not covered.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, dental services that you receive out of network are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe comprehensive oral evaluation (D0150), prophylaxis (D1110), the complete series x-ray (D0210), and the panoramic x-ray (D0330) provided on August 21, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvelumbar spinal fusion surgery for the enrollee.You asked the Planto pre-approvethe surgery. You say that this is medically necessary.The Plandenied your request. The Plansaysthe plan requires a statement that the individual is a non-smoker orwill refrain from use of tobacco products for at least six weeks prior to the planned surgery.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 surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the criteria for fusion has not been met. There is no documentation of smoking cessation. Smoking is a contraindication to fusion.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 surgery have not been met.Therefore, we decided that the Plandoes not haveto pre-approvelumbar spinal fusion surgery for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endovenous ablation therapy.
You asked the Plan to pre-approve the endovenous ablation therapy. You say that the medical records provided
support the need for the requested treatment. The Plan denied your request. The Plan says the enrollee does not
meet the requirements for approval.
The Plan follows Medicare rules. Medicare rules say that ERFA and laser ablation are covered for certain
medical indication and when specific criteria have been met.
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 endovenous ablation therapy. Our
reviewer says that the criteria for coverage have not been met. Our physician reviewer found the veins to be
treated are not the lesser or greater saphenous veins and their tributaries. There has been no effort to treat the
enrollee's foot tenderness and erythema with a non-interventional approach. There is no documentation of
ulceration.
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 endovenous ablation therapy have not been met. Therefore, we decided that
the Plan does not have to pre-approve endovenous ablation therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe injection procedure into sacroiliac joint.You asked the Plan to pre-approvethe injection procedure into sacroiliac joint. You say that this requested service is medically necessary for the enrollee's condition.The Plan denied your request. The Plan says the procedure is not medically reasonable and 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 correctin denying the request to pre-approve the injection procedure into sacroiliac joint. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is a lack of documentation of physical exam findings and imaging to support the diagnosis of Sacroilitis.  In addition, there is also lack of Physical therapy or other exercise program documentation to support the need for this service.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 injection procedure into sacroiliac joint have not been met.Therefore, we decided that the Plan does not have to pre-approvethe injectionprocedure into sacroiliac joint.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy (D3320).
You asked the Plan to pre-approve the endodontic therapy. You say that you need to save the enrollee's tooth
with a root canal procedure. The Plan denied your request. The Plan says this service is not covered.
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 pre-approve
endodontic therapy (D3320).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical assistant services provided to the enrollee on August 12, 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 According to the Medicare Surgery Manual, no other person can be paid. If the person who assists at surgery is a surgical technician, a first surgical assistant, scrub nurse or bears any title other than those listed, the service is not payable by Medicare and is not billable to the patient.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS. In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for surgical assistant services provided to the enrollee on August 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an annual physical examination provided on August 12, 2020.
You asked the Plan to pay for physical exam. You say that you believe this should not be a non-covered expense. The Plan denied your request. The Plan says the denial of payment for this service is correct, because you previously received an annual physical exam on January 29, 2020.
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once every 12 months. The Plan contract says that the Plan covers an annual physical exam, which is a more comprehensive exam than the AWV, once per calendar year. Based on review of the file, an annual physical exam was previously provided to you on January 29, 2020; therefore, this benefit was exhausted for the 2020 calendar year. Therefore, we decided that the Plan does not have to pay for an annual physical examination provided on August 12, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment for the computed tomography (CT) scan of the
thorax (71260) provided on August 14, 2020.
You asked the Plan to adjust the copayment. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to
the service provided.
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 per day for Medicare-covered diagnostic radiology services.
You have been asked to pay a $213.58 copayment for the diagnostic radiology service provided. This amount is
the Plan allowed amount which is less than the applicable copayment. This means that you have been asked to
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to adjust the
copayment for the computed tomography (CT) scan of the thorax (71260) provided on August 14, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay forthe COVID-19 testing provided on November 17, 2020.You asked the Plan to pay forthe COVID-19 testing. You say that you were exposed to someone who tested positive, so you needed this test since you help care for children.The Plan denied your request. The Plan says that this was done for preventative reasons which means it is not covered.Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules.You were provided with the COVID-19 testing by a contract provider. The file does not show that the Plan provided notice that the COVID-19 testing would not be covered. No medical records or other documentation was provided by the Plan. Although the Plan states this was preventive, you were exposed to a known COVID-positive individual which does not fall within the preventive definition of the policy. Under Medicare rules, this meansthe COVID-19 testing is considered approved by the Plan.Therefore, we decided that the Plan has to pay forthe COVID-19 testing provided on November 17, 2020.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide toopen the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for exercise equipment purchased on August 29,
2020.
You asked the Plan to reimburse you for the exercise equipment. You say that you would like to be reimbursed
for the exercise equipment. The Plan denied your request. The Plan says because of the date of service this
purchase is not eligible.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan will allow the
purchase of fitness equipment under the standard Wellness benefit for purchases made from October 1, 2020,
to December 31, 2020.
The Plan's rules for coverage of Wellness benefits have not been met because only purchases made during
October 1, 2020 to December 31, 2020, submitted by the deadline, are eligible for reimbursement. Therefore,
we decided that the Plan does not have to reimburse you for exercise equipment purchased on August 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CGM and supplies.
You asked the Plan to pre-approve the CGM and supplies. You say that you would like reconsideration based
on the records submitted. The Plan denied your request. The Plan says the notes do not show you require
insulin injections at least three times per day or use an insulin pump.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results.
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least
three daily injections. Based on this information, we decided that Medicare rules for coverage of the CGM and
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a CGM and
supplies.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance services provided onJune 7, 2020.You asked the Plan to waive the copayment forthe ambulance services. You say that you had to be transferred for a surgery.The Plan denied your request. The Plan says you were charged this cost sharing correctly.The rules say aplan 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 each ambulance trip. You had one ambulance trip. The Plan charged you $291.12 for these services. Your copayment is less because the allowed amount was less. You were not an inpatient at the originating facility, therefore the service is separately payable. 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 ambulance services provided on June 7, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the specialist office visit and the laser eye
surgery provided from September 16, 2020, to September 23, 2020.
You asked the Plan to waive the copayments for the specialist office visit and the laser eye surgery. You say
that you were told there would be no copayments for the procedure or follow-up visits. 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 a $45
copayment for specialty physician.
You have been asked to pay a $45 copayment for the specialist office visit and a $45 copayment for the laser
eye surgery. The specialist office visit and the laser eye surgery fall within the "Physician/Practitioner services,
including doctor's office visits" benefit category. Please note, there is no provision in the contract which
indicates a copayment would be waived if performed as a follow-up to a surgical procedure.
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 the specialist office visit and the laser eye surgery provided
from September 16, 2020, to September 23, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 5mg Eliquis tablets.
You asked the Plan to pre-approve 5mg Eliquis tablets. You say that the anticoagulant should continue long term due to the enrollee's elevated risk of embolic stroke associated with atrial fibrillation. The Plan denied your request. The Plan says this medication does not fall under Part B coverage.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The record indicates this drug is being requested due to atrial fibrillation. There is no indication that the drug is being requested for blood clotting factors for hemophilia. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve 5mg Eliquis tablets.
Benefits for 5mg Eliquis tablets may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
 
You asked the Plan to pre-approve
spine surgery. You say that an in-network doctor caused your problem and your friend recommended this treatment.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and you can be treated within the Plan network.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
the medical services to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab work provided by a participating
provider on September 10, 2020.
You asked the Plan to waive the copayment for lab work. You say that you do not agree with this copayment.
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 $15
copayment for outpatient diagnostic tests/lab services.
You have been asked to pay a $15 copayment for lab work. When additional services are provided during an
office visit/telehealth visit, additional copayments are applied; therefore, the correct copayment has been
applied. Lab work falls within the outpatient diagnostic tests/lab 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 lab work provided by a participating provider on September 10, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe ambulance ride provided on July 29, 2020.You asked the Plan to waive the coinsurance forthe ambulance ride. You say that you do not feel this should be your financial responsibility because the physician said to send by ambulance and you were admitted with the Plan coverage. 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 5% coinsurance per date of service regardless the number of trips. You have been asked to pay $27.77 which is 5% of the allowed amount for the ambulance ride. The allowed amount is $555.58. ($555.58 x 5% = $27.77). The ambulance ride falls within the "Ambulance 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 coinsurance forthe ambulance ride provided on July 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital care (99235) provided on May 10, 2019.
You asked the Plan to pay for hospital care. You say that this service was medically necessary. The Plan denied
your request. The Plan says this claim was not filed timely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010,
must be filed no later than one calendar year after the date of service.
The record shows that a claim for hospital care was not filed until July 23, 2020. This means that more than one
calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan
does not have to pay for hospital care (99235) provided on May 10, 2019.