Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM).
You asked the Plan to pre-approve the Dexcom G6 CGM. You say that the enrollee checks her blood sugars 3 times per day. 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 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 the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the Dexcom G6 CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided on February 22, 2021.
You asked the Plan to waive the copayment for physical therapy. You say that you met your maximum out-of-pocket and should not have to pay this copayment. The Plan denied your request. The Plan says the copayment 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 $20 copayment for each in-network, Medicare-covered therapy visit.
You have been asked to pay a $20 copayment for the physical therapy visit. Physical therapy falls within the
"Outpatient rehabilitation services" benefit category. The records show you met your maximum out-of-pocket
with the processing of this claim. 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 physical therapy provided
on February 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on February 1, 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 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 February 1, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for fluorescence in situ hybridization (FISH) testing (88120) provided on December 7, 2020.
You asked the Plan to pay for FISH testing. You say that the billed diagnosis is consistent with the service. The Plan denied your request. The Plan says this was a screening service.
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, FISH testing, 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 fluorescence in situ hybridization (FISH) testing (88120) provided on December 7, 2020
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room services provided on February 19, 2021.
You asked the Plan to waive the copayment for the emergency room services. You say that you were told to go to the emergency room, you didn't have a choice. 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 $50 copayment for Emergency Care. You have been asked to pay a $50 copayment for the emergency room services. The emergency room services fall 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 copayment for the emergency room services provided on February 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on August 28, 2020.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you should not be financially responsible for something that was not your decision. 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 $380 copayment for days 1-5 for inpatient hospital care. The medical records show that you received inpatient hospital care on August 28, 2020. Therefore, you are responsible to pay the $380 copayment.
You have been asked to pay a $380 copayment for inpatient hospital care. Inpatient hospital care falls within the inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital care provided on August 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the re-cement crown (D2920) received December 3, 2020.
You asked the Plan to pay for the re-cement crown. You say that you have a $300 dental allowance for 2020 that should apply to the claim. The Plan denied your request. The Plan says the dental allowance is only applicable to routine dental services.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the re-cement crown (D2920) received December 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more than the benefit allowance for deluxe frames provided on April 1, 2021.
You asked the Plan to pay more than the benefit allowance for deluxe frames. The Plan denied your request. The Plan says the Plan paid the correct eyewear allowable of $175.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. The file shows that the Plan paid the correct eyewear allowance of $175. Therefore, we decided that the Plan does not have to pay more than the benefit allowance for deluxe frames provided on April 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 25, 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 services are not covered.

The Plan must follow Medicare rules. The rules say that genetic testing procedures submitted under CPT code 81455 are denied as not medically necessary. 

We looked at the file and Medicare rules. The services are billed under code 81455. 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 laboratory services rendered on January 25, 2021.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pay for the Mirena intrauterine device (IUD) rendered on November 4, 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 that the services are not covered.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan states that the services are not covered; however, Medicare may cover the Mirena IUD to treat a medical condition when medically necessary. The file shows that the services were performed for a billed diagnosis of N95.0 (postmenopausal bleeding). The Plan has not provided any documentation to support that the Mirena IUD was provided for contraceptive reasons. Therefore, we decided that the Plan has to pay for the Mirena intrauterine device (IUD) rendered on November 4, 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 to open the case again, we will send you a letter.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the imaging services rendered on February 21, 2019 to September 23, 2019.

You asked the Plan to waive the coinsurance for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for each Medicare-covered radiological diagnostic service.

Review of the file shows that you received a breast ultrasound on February 21, 2019. You have been asked to pay a 20% coinsurance for these services, for a total of $36.63. These services fall within the Medicare-covered radiological diagnostic service benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.

The file shows that you received a diagnostic mammogram and digital breast tomosynthesis on March 22, 2019. You have been asked to pay a 20% coinsurance for these services, for a total of $45.15.

These services fall within the Medicare-covered radiological diagnostic service benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.

The file shows that you received a diagnostic mammogram and digital breast tomosynthesis on September 23, 2019. You have been asked to pay a 20% coinsurance for these services, for a total of $45.15. These services fall within the Medicare-covered radiological diagnostic service benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.

The total amount you have been asked to pay for these services is $126.93. 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 imaging services rendered on February 21, 2019 to September 23, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Euflexxa injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your
request. The Plan says the medical office notes do not show a trial and failure of physical therapy.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and 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 pre-approve the injection. Our reviewer says that the
requested injection is not medically reasonable or necessary. Our physician reviewer found intra-articular
injections with hyaluronic acid (Euflexxa) are recommended as a possible option for severe osteoarthritis for
patients who have not responded adequately to recommended conservative treatments (exercise, PT, and/or
Acetaminophen) to potentially delay total knee replacement. However, while osteoarthritis of the knee is a
recommended indication, there is insufficient evidence for other conditions, including patellofemoral arthritis,
chondromalacia patellae, osteochondritis dissecans, or patellofemoral syndrome (patellar knee pain). The
documentation does not support that the Euflexxa is medically reasonable or necessary for you.
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 have not been met. Therefore, we decided that the Plan does not
have to pre-approve a Euflexxa injection for the enrollee
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) and
the incisional biopsy of oral tissue-soft (D7286) received February 15, 2021.
You asked the Plan to pay for the dental services. You say that the Plan should pay for the requested services.
The Plan denied your request. The Plan says the requested services are not covered under your supplemental
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 the
limited oral evaluation - problem focused (D0140) and the incisional biopsy of oral tissue-soft (D7286)
received February 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the progressive lens per lens (V2781), the tint (V2744), the anti-reflective coating (V2750), the polycarbonate lens (V2784) received March 13, 2021.
You asked the Plan to pay for the progressive lens, tint, anti-reflective coating, and polycarbonate lens. You say that your vision changes every year and you need new lenses annually. The Plan denied your request. The Plan says the requested item exceeds the maximum benefit per period.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers one pair of standard lenses every two years. We looked at the file and the Plan's rules. The Plan last covered lenses on February 20, 2020. Your benefit was exhausted on March 13, 2021. Based on this information, we decided that the Plan's rules for coverage of the progressive lens, tint, anti-reflective coating, and polycarbonate lens have not been met. Therefore, we decided that the Plan does not have to pay for the progressive lens per lens (V2781), the tint (V2744), the anti-reflective coating (V2750), the polycarbonate lens (V2784) received March 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment provided on February 15,
2021 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that authorization is not required for purchase items
at or below $500 per line item. The Plan denied your request. The Plan says services rendered by nonparticipating
providers require 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 items at issue in this appeal. The Plan did not pre-approve the items at issue. We
found no exception that would require the Plan to pay for these items. Therefore, we decided that the Plan does
not have to pay for the durable medical equipment provided on February 15, 2021 by an out of network (OON)
provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the fracture treatment rendered on February 5, 2021.

You asked the Plan to waive the deductible for these services. You say that the services should be covered. The Plan denied your request. The Plan says the deductible was applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $500 yearly deductible for your covered medical services.

The item or service you asked the Plan to waive the deductible for falls within the outpatient surgery benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $500 yearly deductible for your covered medical services. This cost sharing is a contractual obligation that had not been met at the time these services were received on February 5, 2021. The Plan is not denying coverage for these services. The amount you are being asked to pay is your contractual deductible charges. Therefore, we decided that the Plan does not have to waive the deductible for the fracture treatment rendered on February 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.

You asked the Plan to pre-approve foot orthotics. You say that orthotics keeps your feet from getting worse and allow you to operate somewhat normally. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services provided by a participating provider on March 23, 2021.
You asked the Plan to waive the copayment for specialist services. You say that these visits were post-op. You say that you shouldn't have to pay for this. 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 $40 copayment for physician/practitioner services/specialist. You have been asked to pay a $40 copayment for specialist services. The correct copayment has been applied to the services that were provided. Post-operative appointments are subject to copayments; therefore, the
correct copayment has been applied. Specialist services fall within the physician/practitioner services/specialist benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for specialist services provided by a participating provider on March 23, 2021
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an x-ray of the knee (73562) provided on January 21, 2021.
You asked the Plan to waive the copayment for an x-ray of the knee. You say that you switched plans in January and visited your doctor before your effective date and was billed for your office visit and follow-up tests. You also day that you are unemployed and dealing with hardships due to Covid-19. 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 $35 copayment for outpatient diagnostic tests and therapeutic services and supplies including a standard routine x-ray.
You have been asked to pay a $35 copayment for an x-ray of the knee. The EOC confirms $35 is the required copayment for this service. An x-ray of the knee falls 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 copayment for an x-ray of the knee (73562) provided on January 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (88346, 88350) provided September 24, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says this service cannot be paid as billed.
The Plan must follow Medicare rules. Medicare rules say that the OncoCee assay has insufficient evidence to support reasonable and necessary criteria for Medicare reimbursement. We looked at the file and Medicare rules. The service is non-covered under Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (88346, 88350) provided September 24, 2020