Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride varnish and provide
additional reimbursement for the periodic oral evaluation, bitewing x-ray and prophylaxis provided on
February 17, 2020.
You asked the Plan to pay for the topical application of fluoride varnish and provide additional reimbursement
for the periodic oral evaluation, bitewing x-ray and prophylaxis. You say that you believe the provider was in network.
The Plan denied your request. The Plan says that the claim processed correctly.
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. The Plan rules state that an out of network dentist can bill you for additional costs if what they charge is more than the maximum benefit
amount for services covered by the plan.
We looked at the file and Plan rules. The file indicates you went toan out of network dentist and the plan paid
up to the maximum benefit amount for the periodic oral evaluation, bitewing x-ray and prophylaxis. You are
responsible for any charges over that amount. Though the Plan offers a dental benefit in excess of Medicare
coverage, the topical application of fluoride varnish is not among those covered under this benefit. Therefore,
we decided that the Plan does not have to pay for the topical application of fluoride varnish and provide
additional reimbursement for the periodic oral evaluation, bitewing x-ray and prophylaxis provided on
February 17, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).
You asked the Plan to pre-approve the Prolia. You say that you would like reconsideration because this drug is medically necessary for the treatment of your condition. The Plan denied your request. The Plan says you do not meet step-therapy exception criteria.
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 Prolia. Our reviewer says that you have not tried and failed a trial of zoledronic acid. Our physician reviewer found the documentation does not support that zoledronic acid would likely be less effective or have adverse effects 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 Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for arthroscopy provided on January 6, 2020.
You asked the Plan to waive the copayment for arthroscopy. You say that you should only owe a $150 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 $250 copayment for each visit to an outpatient hospital facility. The record shows that you received arthroscopy on January 6, 2020. An arthroscopy is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $250 copayment. You have been asked to pay a $250 copayment for arthroscopy. Arthroscopy 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 arthroscopy provided on January 6, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the X-ray (73590) provided on January 15, 2020.
You asked the Plan to pay for the x-ray. You say that the service was medically necessary. The Plan denied your request. The Plan says the services were available from network providers.
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 services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the X-ray (73590) provided on January 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on December 31, 2019.
You asked the Plan to waive the copayment for the specialist office visit. You say that this was a post-operative visit and was told it would not require a copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $20 copayment for a specialty physician. You have been asked to pay a $20 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. Please note, there is no provision in the contract which indicates a copayment would be waived if performed as a follow-up to a surgical 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 specialist office visit provided on December 31, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from July 1, 2019 to July 25, 2019.
You asked the Plan to pay for home health services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the claim form does not have the appropriate home health data to process and pay claim.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the submitted claim does not include a valid type of bill code.. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from July 1, 2019 to July 25, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on December 26, 2019.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network 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 requested provider in this case is not a network provider with the Plan. 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 laboratory services provided on December 26, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on January 14, 2020.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 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 laboratory services provided on January 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (A4595, A4557) provided on October 17, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not covered.
The Plan must follow Medicare rules. Medicare rules say that unconditionally packaged services are services for which separate payment is never made because the payment for the service is always packaged into the payment for other services. We looked at the file and Medicare rules. Codes A4595 and A4557 are assigned a status indicator of "N" under the Hospital OPPS. This means that payment for these services is packaged into payment for other services. No separate payment can be made. 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 the services (A4595, A4557) provided on October 17, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for a colonoscopy provided on February 6, 2020.
You asked the Plan to waive the deductible for a colonoscopy. You say that you had polyps removed to screen for cancer and disagree with the charges. 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. Your contract with the Plan says that there is a $750 deductible for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You received a colonoscopy on February 6, 2020 where polyps were removed. Therefore, the colonoscopy is considered diagnostic, not preventative, and you are responsible to pay your share of the cost-sharing charges. The record shows that you had paid $0 toward the $750 deductible prior to receiving the services. Therefore, you are responsible to pay the allowed amount of $570.34. The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. This cost sharing is a contractual obligation that had not been met at the time a colonoscopy was received on February 6, 2020. Therefore, we decided that the Plan does not have to waive the deductible for a colonoscopy provided on February 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (99292 x 2) provided to the enrollee on October 31, 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 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. We find that CPT code 99292 is not supported in the medical record. Specifically, the documentation submitted indicates that a total critical care time of 55 minutes was performed. Therefore, the billed service for an additional 60 minutes (1 unit = 30 minutes) is not supported. It is noted that multiple attempts were made to contact the provider for additional information. 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 critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (99292 x 2) provided to the enrollee on October 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the ostomy supplies provided on February
11, 2020.
You asked the Plan to waive the coinsurance for the ostomy supplies. You say that the Plan should waive the
coinsurance because the supplies were free last year. The Plan denied your request. The Plan says you were
charged this coinsurance 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 Prosthetic devices and related supplies.
You have been asked to pay 20% coinsurance for the ostomy supplies. The ostomy supplies fall within the
Prosthetic devices and related 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 coinsurance
for the ostomy supplies provided on February 11, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc (J7325).
You asked the Plan to pre-approve the Synvisc. You say that you would like reconsideration because this drug is medically necessary. The Plan denied your request. The Plan says the member does not meet step-therapy exception criteria.
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 Synvisc. Our reviewer says that the documentation submitted does not support that the enrollee has had prior trial and failure with Orthovisc or Monovisc Our physician reviewer found the prescriber does not state why the alternatives required by the Plan (1) would not be as effective for the enrollee as the requested drug; and/or (2) would have adverse effects for the enrollee. 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 Synvisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc (J7325).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture services provided on January 31, 2020 and February 1, 2020.
You asked the Plan to pay for the acupuncture services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 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 acupuncture services provided on January 31, 2020 and February 1, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on December 12, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the billed services cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering physician's intent that the tests be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on December 12, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility services provided from December 1, 2019 to December 31, 2019.
You asked the Plan to pay for the skilled nursing facility services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are missing required information.
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 the skilled nursing facility services are not supported in the medical record. Specifically, the CPT/REV code is invalid. A REV code along with a valid PDPM code is required to process skilled nursing claims. Based on this information, we decided that Medicare rules for coverage of the skilled nursing facility services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility services provided from December 1, 2019 to December 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on December 23,
2019.
You asked the Plan to waive the copayment for an office visit. You say that you disagree with the charges
because there should be a $0 copayment for primary care provider visits. The Plan denied your request. The
Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees
must pay a $5 copayment per primary care provider visit.
The enrollee has been asked to pay a $5 copayment for an office visit. An office visit falls within the
physician/practitioner services, including doctor's office visits benefit category. This means that the enrollee
has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not
have to waive the copayment for an office visit provided on December 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 13, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the physician's services. 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 physician's services provided on September 13, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the echocardiogram provided on January
17, 2020.
You asked the Plan to waive the deductible for the echocardiogram. You say that you disagree with this high
charge for the echocardiogram. The Plan denied your request. The Plan says you have been charged the correct
cost sharing amount.
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 $1,250 deductible that applies towards ultrasounds.
The ultrasound you asked the Plan to waive the deductible for falls within the "Outpatient diagnostic tests and
therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing
in the contract that there is a $1,250 deductible that applies towards ultrasounds. This cost sharing is a
contractual obligation that had not been met at the time the echocardiogram was received on January 17, 2020.
Therefore, we decided that the Plan does not have to waive the deductible for the echocardiogram provided on
January 17, 2020.