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

We decided that the Plan does not have to waive the copay for the diagnostic testing services provided on April 1, 2021.
You asked the Plan to waive the copay for the services provided. The Plan denied your request. The Plan says the cost share 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 $35 copay for specialist services. The file shows that you received evaluation of cardiac rhythm monitor services. You have been asked to pay $27.03 for the services provided. Because the amount is less than the $35 copay, you were charged the lesser amount. The services fall within the physician 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 copay for the diagnostic testing services provided on April 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for additional health club membership fees (A9270) for the 2020 benefit allowance.
You asked the Plan to reimburse you for additional health club membership fees. You say that you only received $195.89 for membership and monthly fees. You also say that you submitted proof of payment for additional services. The Plan denied your request. The Plan says after review of the additional information received, your allowance request was for tennis fees. The Plan also says this is not a covered benefit.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers gym benefits in a qualified health club or fitness facility that provides cardiovascular and strength training exercise equipment on site. The Plan does not cover membership fees for sport activities such as tennis. The services at issue in this appeal are for health club benefits. The additional information received confirms that the allowance request was for tennis fees. The Plan does not cover sports activities such as tennis. Based on this information, we decided that you are not eligible for additional reimbursement. Therefore, we decided that the Plan does not have to reimburse you for additional health club membership fees (A9270) for the 2020 benefit allowance.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the transitional care management services (99496) rendered by the out-of-network (OON) provider on February 23, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network, 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 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 transitional care management services (99496) rendered by the out-of-network (OON) provider on February 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

You asked the Plan to waive the copayment for an ultrasound. You say that you feel that the Plan should pay for the ultrasound because it is to check for an abdominal aneurysm. 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 $110 copayment for X-rays provided by any provider other than a primary care physician. The medical records show that you received a diagnostic ultrasound for an abdominal aneurysm on April 1, 2021. This is not considered an abdominal aneurysm screening. Therefore, you are responsible to pay the allowed amount of $100.42, which is less than the $110 copayment. You have been asked to pay $100.42 for an ultrasound. An ultrasound 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 ultrasound provided on April 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the massage therapy services provided on April 23, 2021.

You asked the Plan to pay for the massage therapy services. You say that you feel these services should be covered. The Plan denied your request. The Plan says the services received are not a covered benefit.

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 service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the massage therapy services provided on April 23, 2021.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for the upper denture. We decided that the Plan does not have to pay for the denture repair.
You asked the Plan to pay for the dental services. You say that the denture should be covered. You say that you paid out of pocket for the denture that you received in 2019. The Plan denied your request. The Plan says dentures are covered once every 4 years. The Plan says that the frequency limit has been exceeded. The Plan also says that denture repair 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.
We decided that the Plan has to pay for the complete upper denture.
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the upper denture have been met. Specifically, the record shows that the enrollee was not enrolled in this plan on the date of service that the previous upper denture was provided. As a result, the frequency limit has not been reached. Therefore, we decided that the Plan has to pay for the complete upper denture.
We also decided that the Plan does not have to pay for the denture repair. Though the Plan offers a dental benefit in excess of Medicare, the denture repair is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the denture repair.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Stereotactic Body Radiation Therapy (SBRT).

You asked the Plan to pre-approve SBRT. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not show that the tumor burden is being completely targeted with SBRT.

The Plan follows Medicare rules. Medicare rules say that SBRT is not considered medically necessary if the tumor burden cannot be completely targeted with acceptable risk to critical normal structures. 

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 SBRT. Our reviewer says that the requested use of SBRT is not supported. Our physician reviewer found the treatment of only one lesion in a patient with more disease involvement does not meet the requirement for the tumor burden to be completely targeted with acceptable risk to critical normal structures. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SBRT have not been met. Therefore, we decided that the Plan does not have to pre-approve Stereotactic Body Radiation Therapy (SBRT).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for laboratory services provided by a participating provider on February 18, 2021.

You asked the Plan to waive the deductible for lab work. You say that this should be covered completely. The Plan denied your request. The Plan says the correct deductible has been applied.

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 a $500 deductible for outpatient diagnostic tests/lab. 

The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient diagnostic tests/lab. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible for outpatient diagnostic tests/lab. This cost sharing is a contractual obligation that had not been met at the time lab work was received on February 18, 2021. The total amount you are being asked to pay is $405.72. Therefore, we decided that the Plan does not have to waive the deductible for laboratory services provided by a participating provider on February 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a progressive lens (V2781) provided on March 1, 2021.

You asked the Plan to pay for a progressive lens. You say that in the past, you received services with an out-of-network provider and was reimbursed for those purchases. The Plan denied your request. The Plan says you must see an in-network vision provider to receive routine vision benefits. The Plan also says that there have been changes to the level of benefits for the past three years.

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 these services when they are received from a provider who participates in the Plan's specified vision network.

We looked at the file and the Plan's rules. The provider in this case is not part of the Plan's vision network. Based on this information, we decided that the Plan's rules for coverage of a progressive lens have not been met. Therefore, we decided that the Plan does not have to pay for a progressive lens (V2781) provided on March 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the infliximab injection provided on February 18, 2021.

You asked the Plan to waive the coinsurance for the infliximab injection. You say that you were never told of the impact switching plans would have on your Part B injections. You say that you are switching back to your old plan and the coinsurance should be waived. 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 Medicare Part B chemotherapy prescription drugs and 20% coinsurance for Medicare Part B non-chemotherapy prescription drugs.

You have been asked to pay $430.60, which is 20% of the allowed amount for the infliximab injection. The allowed amount is $2,153 (20% x $2,153 = $430.60). The infliximab injection falls within the "Medicare Part B prescription drugs" 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 infliximab injection provided on February 18, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided from March 23, 2021, through April 2, 2021.
You asked the Plan to waive the copayment for physical therapy. You say that they did not do anything to help your pain and you were refused heat treatment. You say that you should not have to pay the copayments for appointments that did not help. The Plan denied your request. The Plan says the copayments 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 $40 copayment for each Medicare-covered physical therapy visit and speech and language therapy visit.
You have been asked to pay a total of $150.76 for physical therapy.
Date of Service
Service
Standard Copayment
Member Liability
March 23, 2021
Physical Therapy
$40
$40
March 25, 2021
Physical Therapy
$40
$40
March 29, 2021
Physical Therapy
$40
$40
April 2, 2021
Physical Therapy
$40
$30.76
TOTAL:
$150.76
Physical therapy falls within the "Outpatient rehabilitation 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 physical therapy provided from March 23, 2021, through April 2, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services (A0429) provided to the enrollee on March 29, 2021.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this was billed with the QL modifier.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, the CPT Code Manual definition of Healthcare Common Procedure Coding System (HCPCS) code A0429 is "Ambulance service, basic life support, emergency transport (bls-emergency)." 

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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found that in this case, the record indicates that the provider placed the modifier in the origin code position. The modifier is not properly billed. The elements of the coverage criteria are not satisfied.

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 services have not been met. Therefore, we decided that the Plan does not have to pay for ambulance services (A0429) provided to the enrollee on March 29, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a repeat sacroiliac (SI) joint injection.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says that the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that an SI joint injection is covered when specific criteria are met. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has sacroilitis and has had previous SI joint injections with 100 percent pain relief for months. This would be considered a therapeutic injection, not a diagnostic injection, as the diagnosis has already been made and the diagnostic block provided sustained 100 percent pain relief. The injection is medically reasonable and 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 these services have been met. Therefore, we decided that the Plan has to pre-approve a repeat sacroiliac (SI) joint injection.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Maxillofacial Computed Tomography (CT) scan (70486).

You asked the Plan to pre-approve the CT scan. You say that the CT scan is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

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 pre-approve the CT scan. Our reviewer says that the CT scan is not medically necessary. Our physician reviewer found in this case a 4-week trial of antibiotics had not yet been tried and the enrollee was improving with doxycycline. There is no advantage to a CT scan at the time of this request. 

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 pre-approve a Maxillofacial Computed Tomography (CT) scan (70486).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2740) provided on February 22, 2021.
You asked the Plan to pay for the dental service. You say that you were misled by a plan representative. You say that you were advised you were covered for $3,000 in dental for 2021. You also say that you were never informed there was a limit on certain dental items. The Plan denied your request. The Plan says 2 crowns are covered per calendar year. The Plan also says that the frequency limit has been exceeded.
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 and crowns are listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for 2 crowns that you received on January 29, 2021. Therefore, we decided that the Plan does not have to pay for the crown (D2740) provided on February 22, 2021.
Your complaint about being misled by a plan representative is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the knee scooter delivery charge for the delivery on October 5, 2020.
You asked the Plan to reimburse you for the knee scooter delivery charge. You say that you were unable to drive to pick up the scooter ad the provider instructed you how to safely use it. The Plan denied your request. The Plan says delivery charges are not separately reimbursable. The Plan must follow Medicare rules. Medicare rules say that delivery and service are an integral part of oxygen and DME suppliers' costs of doing business and is accounted for in the calculation of the fee schedules. We looked at the file and Medicare rules. The delivery charge is not separately reimbursable. Therefore, we decided that the Plan does not have to reimburse you for the knee scooter delivery charge for the delivery on October 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac joint radiofrequency ablation.

You asked the Plan to pre-approve sacroiliac joint radiofrequency ablation. You say that this is a Medicarecovered
service. The Plan denied your request. The Plan says this is experimental.

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 sacroiliac joint radiofrequency ablation.

Our reviewer says that the requested services are not considered medically reasonable and necessary in this
case. Our physician reviewer found this procedure is considered experimental because of the wide variation in
efficacy reported in the literature. While you cite two articles showing support, there are a multitude of other
that don't show such efficacy.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of sacroiliac joint radiofrequency ablation have not been met. Therefore, we
decided that the Plan does not have to pre-approve sacroiliac joint radiofrequency ablation.