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

We decided that the Plan does not have to waive the coinsurance for the outpatient surgery services received on
December 11, 2020.
You asked the Plan to waive the coinsurance for the outpatient surgery services. You say that you were advised
that you would have no liability for these services. The Plan denied your request. The Plan says the claim was
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 outpatient surgery.
You have been asked to pay 20% coinsurance for the outpatient surgery services. The outpatient surgery
services fall within the outpatient surgery 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
for the outpatient surgery services received on December 11, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic exercises provided on May 18, 2020.
You asked the Plan to pay for the therapeutic exercises. The Plan denied your request. The Plan says the
documentation submitted in appeal consists of duplicates of medical documents previously reviewed.
The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or
carrier sufficient information to determine whether payment is due and the amount of payment.
We looked at the file and Medicare rules. The file shows that you did not submit sufficient medical documents
to justify payment of the claim. Based on this information, we decided that Medicare rules for coverage of the
therapeutic exercises have not been met. Therefore, we decided that the Plan does not have to pay for
therapeutic exercises provided on May 18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on October 8, 2020.
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 testing is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on October 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgery provided January 11, 2021.
You asked the Plan to waive the copayment for the outpatient surgery. You say that you do not believe this copayment should be this high because you did not stay in the hospital overnight. The Plan denied your request. The Plan says the copayment processed correctly in this case.
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 $325 copayment for outpatient hospital facility visit. You have been asked to pay a $325 copayment for the outpatient surgery. This service falls within the outpatient hospital facility visit 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 outpatient surgery provided January 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for adding a tooth to an existing partial denture (D5650)
provided on March 9, 2021.
You asked the Plan to pay for adding a tooth to an existing partial denture. You say that the service was
necessary. The Plan denied your request. The Plan says the service at issue is not a covered benefit.
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 adding a
tooth to an existing partial denture (D5650) provided on March 9, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the replacement of knee joint on side of knee (27446).
You asked the Plan to pre-approve the replacement of knee joint on side of knee. You say that the requested procedure is medically reasonable for the enrolle's condition. The Plan denied your request. The Plan says the requested surgery 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 replacement of knee joint on side of knee. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is a 71-year-old female was being treated for pain and a varus deformity of the right knee. She notes gradual increase in sharp pain when she bears weight. The pain is increasing and becoming more common and not relieved with time. She finds she stumbles because of the combination of her Parkinson's and this pain. She is worried about falling. Exam reveals right knee does extend all the way, but when she stands, she has more varus deformity. There is small amount of swelling and the knee is tender on the medial side.
In this case, formal imaging studies as read by a radiologist were not provided. Furthermore, detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures. Additionally, there is limited published, large-scale, long-term peer-reviewed literature that shows the request to be an effective and/or safe treatment for the (plausible-significant) tri-compartmental pathology (versus standard procedures including total knee replacement.) In conclusion, there is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for replacement of right knee medial joint (27446) is 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 replacement of knee joint on side of knee have not been met. Therefore, we decided that the Plan does not have to pre-approve the replacement of knee joint on side of knee (27446).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hereditary cardiovascular screening provided on
November 2, 2020.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says Medicare
denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
We looked at the file and the rules. There were insufficient records to show that the results of the testing would
be used in the management of a specific medical problem. The testing was requested solely for screening
purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the
Plan does not have to pay for the hereditary cardiovascular screening provided on November 2, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the Axumin PET scan coded as 78816 and A9588 provided
February 5, 2021.
You asked the Plan to pay for the diagnostic service. You say that please consider full payment for the services
provided and supported. The services were necessary for treatment of the enrollee. The Plan denied your
request. The Plan says the clinical value and effectiveness of an Axumin Pet scan in the setting of newly
diagnosed prostate cancer have not been demonstrated in the peer-reviewed literature.
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are
medically necessary.
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 pay for the diagnostic service. Our reviewer says
that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the provided records reveal that the patient had not yet been treated for his prostate
cancer diagnosis at the time of the PET scan. Without having had a recurrence of disease, the PET scan is not
justified. MRI and first line treatment options should have been utilized at this stage. Therefore, this request for
PET scan does not meet criteria based on the provided documentation.
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 diagnostic service have not been met. Therefore, we decided that the Plan
does not have to pay for the Axumin PET scan coded as 78816 and A9588 provided February 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a shingles vaccination (90750, 90471) provided October 26, 2020.
You asked the Plan to pay for the shingles vaccination. You say that this service was medically necessary and should be covered. The Plan denied your request. The Plan says the shingles vaccine is not covered under the Part B medical benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccination. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the shingles vaccination. Therefore, we decided that the Plan does not have to pay for a shingles vaccination (90750, 90471) provided October 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on November 24, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider on November 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit with a podiatrist (99213) and
debridement of nails (11721) provided on February 25, 2021.
You asked the Plan to waive the copayment for an office visit and debridement of nails. You say that you had a
visit with your provider to trim your toenails as you are diabetic. You also say that you have never paid a
copayment for this service. 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 $40
copayment for each podiatry visit.
You have been asked to pay a $40 copayment for an office visit and debridement of nails. The EOC confirms
$40 is the required copayment for this service. An office visit and debridement of nails fall within the podiatry
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 an office visit with a
podiatrist (99213) and debridement of nails (11721) provided on February 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided by an out-of-network provider on May 1, 2020.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says prior authorization was required but not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for laboratory services provided by an out-of-network
provider on May 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive exam provided on January 15, 2020.
You asked the Plan to pay for the services provided. You say that the visit is covered by the plan. The Plan
denied your request. The Plan says payment cannot be made to a provider who is not eligible to participate in
Medicare.
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 a provider who
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the
preventive exam provided on January 15, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic radiology provided on January 30, 2021.
You asked the Plan to pay for the diagnostic radiology. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
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 January 29, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for diagnostic radiology provided on January 30, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the oxygen concentrator rendered on June 1, 2018.
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 for equipment to be covered, it must be appropriate
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.
Records show that these services were used in a SNF or hospital. Therefore, we decided that the Plan does not
have to pay for the oxygen concentrator rendered on June 1, 2018
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on February 2, 2021.
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 claim was billed incorrectly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT
codes describing the component test results.
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the
laboratory services rendered on February 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a TENS device (E0730) prescribed by a chiropractor
provided on November 16, 2020.
You asked the Plan to pay for a TENS device. You say that the requested item is a necessity for the enrollee's
care. The Plan denied your request. The Plan says the requested item is not a benefit as prescribed of Medicare
or the Plan.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
The records show that the item/service at issue is not manual manipulation of the spine. Therefore, we decided
that the Plan does not have to pay for a TENS device (E0730) prescribed by a chiropractor provided on
November 16, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the arthrocentesis procedure you had at an
outpatient hospital facility on January 6, 2021.
You asked the Plan to waive the copayment for the arthrocentesis procedure. You say that you were not in an
operating room, so this should not be considered surgery. 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 $100
copayment for surgery in an outpatient hospital facility.
You have been asked to pay a $100 copayment for the arthrocentesis procedure. Medicare rules state that
arthrocentesis is considered a surgical procedure. The arthrocentesis procedure falls within the surgery and
other services in an outpatient hospital facility 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 arthrocentesis procedure you had at an outpatient hospital facility on January 6, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory service (88304) rendered by the out of network (OON) provider on September 14, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal.
The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for
this service. Therefore, we decided that the Plan does not have to pay for the laboratory service (88304)
rendered by the out of network (OON) provider on September 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for diagnostic radiology services and a specialist office visit provided by a participating provider on January 29, 2021.
You asked the Plan to waive the copayment for diagnostic radiology services and a specialist office visit. You say that you should not be charged for the radiology services. The Plan denied your request. The Plan says the correct copayments have 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 $110 copayment for outpatient diagnostic tests/diagnostic radiology services and a $45 copayment for physician/practitioner services/specialist.
You have been asked to pay a $110 copayment for diagnostic radiology services and a $45 copayment for a specialist office visit. The total amount you are being asked to pay is $155 ($110 + $45 = $110). When additional services are provided during an office visit additional copayments are applied. Diagnostic radiology services fall within the outpatient diagnostic tests/diagnostic radiology services benefit category and a specialist office visit falls 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 diagnostic radiology services and a specialist office visit provided by a participating provider on January 29, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on December 5, 2020.
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 testing is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on December 5, 2020.