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

We decided that the Plan does not have to waive the coinsurance for discharge observation care provided on September 25, 2019.
You asked the Plan to waive the coinsurance for discharge observation care. You say that you were in the hospital on this date and paid the hospital copayments. You say that you are not responsible for the doctor bills. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for each in-network surgical or observation room service you get at an outpatient hospital.
You have been asked to pay $12.30, which is 20% of the allowed amount for discharge observation care. The allowed amount is $61.48 (20% x $61.48 = $12.30). Discharge observation care falls within the "Outpatient hospital 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 for discharge observation care provided on September 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on December 1, 2019 by an out of network provider.You asked the Plan to pay forthe medical services. You say that you were unaware you needed prior authorization in order to go outside of the network.The Plan denied your request. The Plan says you did not request 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 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. 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 forthe medical services provided on December 1, 2019 by an out of network provide.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay foroutpatient hospital clinic visit provided on July 17, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe outpatient hospital clinic visit. You say that please reconsider these charges with the requested records submitted.The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to services being rendered.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 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 foroutpatient hospital clinic visit provided on July 17, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for podiatry services provided on October 8, 2019 by an out of network (OON) provider.
You asked the Plan to pay for podiatry services. You say that the member provided a Medicare card. You say that due to the member's misrepresentation of insurance no prior authorization was obtained. The Plan denied your request. The Plan says no prior authorization was 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 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 podiatry services provided on October 8, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlab work provided October 4, 2019 by an out of network (OON) provider.You asked the Plan to pay forlab work. You say that you were told that the provider was participating.The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that no prior authorization was obtained.Medicare rules say that plans canrequire 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 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 forlab work provided October 4, 2019 by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for Emergency Room Visits on August 6 and November 2, 2016. You asked the Plan to waive the copayments for the Emergency Room Visits. You say that the copayments should be waived. The Plan denied your request. The Plan says the correct copayment was 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 $75 copayment for Emergency Care. You have been asked to pay a $75 copayment for each Emergency Room Visit. The Emergency Room Visits falls within the Emergency 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 copayments for Emergency Room Visits on August 6 and November 2, 2016.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forevaluation by ocularist (S9150) provided to the enrollee from September 26, 2019 through October 24, 2019.You asked the Plan to pay forthe services. You say that the claim should be paid.The Plan denied your request. The Plan says the medical records do not support this service.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.Medicare guidance says procedure code S9150 has a status code of "I". You can find this guidance in the 2019 National Physician Fee Schedule Relative Value File July Release.Therefore, we decided that the Plan does not have to pay forevaluation by ocularist (S9150) provided to the enrollee from September 26, 2019 through October 24, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services (CPT 80047) provided on November 21, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the billed service 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 CPT code.In this case, the CPT Code Manual definition of code 80047 is "Basic metabolic panel (Calcium, ionized) This panel must include the following: Calcium, ionized (82330) Carbon dioxide (bicarbonate) (82374) Chloride (82435) Creatinine (82565) Glucose (82947) Potassium (84132) Sodium (84295) Urea Nitrogen (BUN) (84520)".We asked our coding 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 services. Our reviewer says that the use of CPT code 80047 is not supported by the records provided. Our coding reviewer found that the medical records submitted do not include lab results, therefore this service cannot be validated as being performed on November 21, 2019.We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay forthe services (CPT 80047) provided on November 21, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for digital breast tomosynthesis (77062) provided on December 10, 2019.
You asked the Plan to pay for the digital breast tomosynthesis. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 77062 has a status code of I which is not valid for Medicare purposes.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 77062 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code 77062 has a status code of I. This means that CPT code 77062 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the digital breast tomosynthesis have not been met. Therefore, we decided that the Plan does not have to pay for digital breast tomosynthesis (77062) provided on December 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit rendered to you on November 4, 2019.
You asked the Plan to waive the copayment for these services. You say that the services were a wellness visit and should have no copayment. The Plan denied your request. The Plan says the copayment 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 $25 copayment per in-network primary care office visit.
Review of the file shows that you had an office visit on November 4, 2019. It is noted that you received an annual wellness visit for which the Plan applied a $0 copayment; however, the medical records from this visit also show that you received services outside of the scope of an annual wellness visit that qualified as an office visit. You have been asked to pay a $25 copayment for these services. These services fall within the in-network primary care office 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 office visit rendered to you on November 4, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea transcatheter placement of an intravascular stents into a vertebral artery and an inpatient stay.You asked the Plan to pre-approvethe services. You say that this is the only treatment option available.The Plan denied your request. The Plan says this is not coverable to treat obstructive lesions of the vertebral arteries.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 enrollee does not have a covered condition, per the policy language, as vertebral artery angioplasty and stenting is an uncovered procedure.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 serviceshave not been met.Therefore, we decided that the Plan does not have to pre-approvea transcatheter placement of an intravascular stents into a vertebral artery and an inpatient stay.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for preventative cardiac screening provided on November 8, 2019 by an out of network (OON) provider.
You asked the Plan to pay for preventative cardiac screening. You say that you were in Florida and a mobile bus testing facility made preventative care cardio tests available to the residents. You say that you assumed you would be covered by your insurance. The Plan denied your request. The Plan says these services were out-of-area. The Plan says that no prior authorization was obtained. The Plan says that these services could have been provided in-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 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 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 preventative cardiac screening provided on November 8, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for diagnostic mammograms provided on December 18, 2019.
You asked the Plan to waive the copayments for diagnostic mammograms. You say that you are considered high risk and feel that the mammograms should be considered as screenings. 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 $30 copayment for each basic imaging service. The medical records show that you received diagnostic mammograms on December 18, 2019. Therefore, you are responsible to pay a $30 copayment per each service. The total amount you owe is: $60. You have been asked to pay the total copayment amount of $60 for diagnostic mammograms. Diagnostic mammograms 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 diagnostic mammograms provided on December 18, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the application of a skin substitute.You asked the Plan to pre-approve the application of a skin substitute. You say that the treatment is needed to preclude long-term damage by the wound growing deeper and larger. The Plan denied your request. The Plan says you do not meet all the requirements for this service.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 application of a skin substitute. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no assessment of this patient's lower extremity vascularity and if the member does have diminished vascular status including a reduced ABI, then the graft will be of no use as it will be unable to heal or incorporate.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 application of a skin substitute have not been met. Therefore, we decided that the Plan does not have to pre-approve the application of a skin substitute.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the osseous surgery (D7950) provided on October 31, 2019.
You asked the Plan to pay for the dental service. You say that you had oral surgery. You say that you paid $650 out of pocket. You also say that the surgery should be covered by either your dental rider or your Part B coverage. The Plan denied your request. The Plan says the osseous surgery is not listed as a covered service.
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 osseous surgery is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the osseous surgery (D7950) provided on October 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system (E2300).
You asked the Plan to pre-approve a power seat elevation system. You say that the requested item is necessary. The Plan denied your request. The Plan says the item is not primarily medical in nature. Therefore, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily medical in nature. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a power seat elevation system have not been met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system (E2300).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that long term acute care hospital services are medically necessary.The Plan denied your request. The Plan says that the enrollee does not meet criteria for coverage of LTACH services.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is currently undergoing treatment at an acute care hospital(ACH)for pneumonia. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long-term care needs.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 LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a breast biopsy provided at an outpatient hospital facility on October 24, 2019.
You asked the Plan to waive the copayment for a breast biopsy. You say that you disagree with the surgery copayment. 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 and ambulatory surgical centers. You have been asked to pay a $350 copayment for a breast biopsy. A breast biopsy 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 breast biopsy provided at an outpatient hospital facility on October 24, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.
You asked the Plan to pre-approve the Euflexxa. You say that the member does not eat chicken byproduct and
would like a drug without rooster comb. The Plan denied your request. The Plan says there is no documentation
that Hyalgan, Hymovis or Synvisc was tried within last 365 days.
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 the Euflexxa. Our reviewer says that the
member has not trialed viscosupplemental treatments such as Hyalgan, Hymovis or Synvisc. Our physician
reviewer found the documentation does not outline contraindications or why these medications were not
considered.
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 Euflexxa have not been met. Therefore, we decided that the Plan does not
have to pre-approve Euflexxa.