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

We decided that the Plan does not have to waive the copayments for the specialist services rendered on February 26, 2020 and September 3, 2020.

You asked the Plan to waive the copayments for these services. You say that the providers did not help with your condition. The Plan denied your request. The Plan says the copayments were 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 $45 copayment per visit for specialist services.

Review of the file shows that you received specialist services from an orthopedist on February 26, 2020; March 9, 2020; and August 12, 2020. You have been asked to pay a $45 copayment per visit for these services, for a total of $135. These services fall within the specialist 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.

The file shows that you received podiatry services on September 3, 2020. You have been asked to pay a $25 copayment for these services. These services fall within the specialist 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.

The total amount you have been asked to pay for these services is $160. This cost sharing is a contractual obligation that 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 services rendered on February 26, 2020 and September 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation, first intraoral periapical x-ray, two additional intraoral periapical x-rays, bitewing x-rays, and prophylaxis provided on November 20, 2020.

You asked the Plan to pay for the comprehensive oral evaluation, intraoral periapical x-rays, bitewing x-rays, and prophylaxis. You say that you believe these services should be covered. The Plan denied your request. The Plan says your annual maximum benefit had been exhausted.

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 Plan offers a $1,000 annual dental benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are responsible for the full charges of any additional dental services. The record shows that you met the annual maximum benefit on November 15, 2020 and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation, first intraoral periapical x-ray, two additional intraoral periapical x-rays, bitewing x-rays, and prophylaxis provided on November 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on November 10, 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 November 10, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the abdominal ultrasound provided on October 23, 2020.

You asked the Plan to waive the copayment for the abdominal ultrasound. You say that the ultrasound was not a radiological test. 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 $110 copayment for Outpatient Diagnostic Tests including ultrasounds. 

You have been asked to pay a $110 copayment for the abdominal ultrasound. The abdominal ultrasound falls within the Outpatient Diagnostic Tests including ultrasounds benefit category. Medicare considers this procedure a diagnostic radiology 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 copayment for the abdominal ultrasound provided on October 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic continuous glucose monitor provided December 22, 2020.

You asked the Plan to pay for the therapeutic continuous glucose monitor. You say that this device provided was medically necessary. The Plan denied your request. The Plan says the documentation submitted did not indicate the provided discussed the need for the billed supply code.

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 3 daily injections. Based on this information, we decided that Medicare rules for coverage of the therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic continuous glucose monitor provided December 22, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for Stereotactic radiosurgery provided on September 30, 2020.

You asked the Plan to pay for Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional cranial lesion, simple (List separately in addition to code for primary procedure) (61797) and Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 complex cranial lesion (61798). You say that the Plan should pay this claim. The Plan denied your request. The Plan says that the submitted records indicates a stereotactic radiosurgery: 1 simple cranial lesion was performed and therefore the code 61797is denied also.

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 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 Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional cranial lesion, simple (List separately in addition to code for primary procedure) (61797) and Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 complex cranial lesion (61798). Our reviewers says that the service was medically necessary. Our physician reviewer found this patient with metastatic melanoma underwent stereotactic radiosurgery on 2 lesions, right frontal and right occipital on September 30,2020 by radiation oncology. CPT code 61798 was billed correctly. The service was reasonable and medically 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 Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional cranial lesion, simple (List separately in addition to code for primary procedure) (61797) and Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 complex cranial lesion (61798) have been met. Therefore, we decided that the Plan has to pay for Stereotactic radiosurgery provided on September 30, 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for eye surgery (66185) provided on July 20, 2020.

You asked the Plan to waive the copayment for eye surgery. You say that you were told your copayment would be only $40. The Plan denied your request. The Plan says this processed 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 $250 copayment for outpatient surgery. 

You have been asked to pay a $250 copayment for eye surgery. 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 eye surgery (66185) provided on July 20, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting from November 11, 2020, to November 12, 2020.

You asked the Plan to pay for the self-administered drugs. You say that you were in the hospital for a pacemaker update. You say that you are being charged for the medication you received while you were there. You say that these are medications that you take on a regular basis. You also say that these medications should be covered. The Plan denied your request. The Plan says the drugs you received are considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drugs you received are not covered under Medicare Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. 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 pay for the self-administered drugs provided in an outpatient setting from November 11, 2020, to November 12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant360 molecular pathology genomic profiling provided to the enrollee on November 13, 2019.

You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the Medicare rules have not been met.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. The enrollee had Guardant360 molecular pathology genomic profiling on November 13, 2019, for colon cancer. The denial remains upheld as there is a more appropriate code to describe the services provided. Procedures shall be reported with the most comprehensive CPT code that describes the services performed. Providers must not unbundle the services described by a HCPCS/CPT code. Therefore, we decided that the Plan does not have to pay for Guardant360 molecular pathology genomic profiling provided to the enrollee on November 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture visits you received from November 16, 2020, to December 7, 2020.

You asked the Plan to pay for the acupuncture services. The Plan denied your request. The Plan says you have exceeded the benefit limit.

The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. 

We looked at the file and the Plan's rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the Plan covers up to 25 routine acupuncture visits per year. The records show that you reached the benefit limit prior to receiving the services in question. The requested services exceed the benefit limit, and therefore are not covered. Therefore, we decided that the Plan does not have to pay for the acupuncture visits you received from November 16, 2020, to December 7, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to reduce the copayment for an office visit provided on December 18, 2020.

You asked the Plan to reduce the copayment for office visit. You say that you previously went to this provider and were only charged $20, and you would like to be charged this lower copayment amount. The Plan denied your request. The Plan says that 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. Your contract with the Plan says that enrollees must pay $20 copayment for in-network primary care visit. The rendering provider for this visit was a nurse practitioner of family medicine, which is not a specialist practitioner type, and the record does not show that you received specialist services at this visit. 

The Plan says you must pay $35 copayment for office visit. Based on the Plan contract, however, you cannot be asked to pay more than $20 copayment for office visit. Therefore, we decided that the Plan has to reduce the copayment for an office visit provided on December 18, 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: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for the EEG or unlisted procedure provided on July 29, 2020.

You asked the Plan to pay for Electroencephalogram (EEG) during non-intracranial surgery (95955) or Unlisted neurological or neuromuscular diagnostic procedure (95999). You say that the Plan should pay this claim.The Plan denied your request. The Plan says the services are not supported in the medical records submitted.

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 codes 95955 and 95999 is not supported in the medical record. Specifically,the technical report did not included documentation of an unlisted diagnostic procedure or an EEG during non-intracranial surgery.Based on this information, we decided that Medicare rules for coverage of Electroencephalogram (EEG) during non-intracranial surgery (95955) or Unlisted neurological or neuromuscular diagnostic procedure (95999) have not been met.Therefore, we decided that the Plan does not have to pay for the EEG or unlisted procedure provided on July 29, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the heart you received on August 4, 2020.

You asked the Plan to pay for the CT scan. The Plan denied your request. The Plan says this is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that CT 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 CT scan. Our reviewer says that the requested CT scan is not medically reasonable and necessary. Our physician reviewer found that the enrollee had a prior CT scan which showed coronary calcification. The only medical records provided are the results of the recent repeat CT calcium scan which showed a calcium score of 402. No other medical records are provided to make a determination as to medical necessity and indications for the repeat CT calcium scan. There are no appropriate clinical indications noted in the records provided to document medical necessity for the CT scan.

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 CT scan have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the heart you received on August 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Foundation One CDX test provided on August 19, 2020.

You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has been diagnosed with intrahepatic bile duct carcinoma. The documentation indicates that the Foundation One CDX receives a rating "D2" meaning that additional studies are needed to support the analytical validity and clinical utility of the Foundation One CDX test. The Foundation V5.0 October 2015 One CDX test is considered investigational. The Foundation One CDX testing in this case 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for the Foundation One CDX test provided on August 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the CPAP supplies and oxygen concentrator provided from January 29, 2020, through October 20, 2020.

You asked the Plan to waive the coinsurance for the CPAP supplies and oxygen concentrator. You say that the provider is in-network and the cost should be less. 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 Medicare-covered item from an in-network provider.

You have been asked to pay a total of $36.24 for the CPAP supplies and oxygen concentrator. 

Date of Service	Equipment	Allowed Amount	Coinsurance	Member Liability
January 29, 2020	Headgear	$27.91	20%	$5.58
January 29, 2020	Filter	$4.83	20%	$0.97
May 18, 2020	Tubing	$26.23	20%	$5.25
May 18, 2020	Filter	$2.07	20%	$0.41
September 23, 2020	Headgear	$19.54	20%	$3.91
September 23, 2020	Filter	$4.83	20%	$0.97
October 20, 2020	Oxygen Concentrator	$95.74	20%	$19.15
TOTAL:				$36.24

The CPAP supplies and oxygen concentrator fall within the "Durable medical equipment (DME) and related supplies" benefit category. The records show you were charged the in-network rate. 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 CPAP supplies and oxygen concentrator provided from January 29, 2020, through October 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the urinary tract infection panel rendered on March 11, 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 services are not covered.

The Plan must follow Medicare rules. Medicare rules say that urine culture with urinalysis is the standard of care for UTI evaluation. 

We looked at the file and Medicare rules. The services at issue exceeded the standard of care for the enrollee's condition. 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 urinary tract infection panel rendered on March 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the shingles vaccine you received on November 16, 2020.

You asked the Plan to pay for the vaccine. The Plan denied your request. The Plan says this vaccine is not covered under your Part B plan.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The Plan follows the same rules. 

The records do not show that you have been injured or directly exposed to any illness related to the vaccine. Therefore, we decided that the Plan does not have to pay for the shingles vaccine you received on November 16, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider on September 5, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.

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 to the enrollee by an out-of-network provider on September 5, 2020.