Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for myocardial perfusion imaging provided on February 20, 2020.You asked the Plan to waive the copayment formyocardial perfusion imaging. You say that the services were pre-operative and you should not owe a copayment.The Plan denied your request. The Plan says the claims were processed correctly an 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 $60 copayment for X-rays and ultrasounds. You received myocardial perfusion imaging on February 20, 2020. Myocardial perfusion imaging is not included in pre-operative visits and is subject to cost-sharing charges. Therefore, you are responsible to pay the $60 copayment. You have been asked to pay a $60 copayment for myocardial perfusion imaging. Myocardial perfusion imaging 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 myocardial perfusion imaging provided on February 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on February 20, 2020.
You asked the Plan to waive the copayment for a specialist visit. You say that this was a follow-up visit and you 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment a specialist office visit. You had a specialist visit on February 20, 2020. Follow-up visits are subject to cost-sharing charges. Therefore, you are responsible to pay the $40 copayment. You have been asked to pay a $40 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a specialist visit provided on February 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-covered chiropractic services provided on December 24, 2019.
You asked the Plan to pay for the non-covered chiropractic services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
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 non-covered chiropractic services provided on December 24, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the breast biopsy provided on January 14,
2020.
You asked the Plan to waive the copayment for the breast biopsy. You say that you were never told that you
would be charged $250 by the hospital. 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 $250
copayment for Medicare-covered surgery at an outpatient hospital facility.
You have been asked to pay a $250 copayment for the breast biopsy. The breast biopsy falls within the
"Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical
centers" benefit category. This means that you have been asked to pay the correct amount based on your
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the
Plan. Therefore, we decided that the Plan does not have to waive the copayment for the breast biopsy provided
on January 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodic oral exam (D0120) and prophylaxis (D1110) provided May 29, 2019 by an out-of-network provider. 
 
You asked the Plan to pay for the dental services. You say that you was assured by the provider's office that everything was up to date, that no fees were past due or unpaid and that the Plan's insurance coverage had been applied and approved. The Plan denied your request. The Plan says enrollee's must receive their dental services from an in-network provider. 
 
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 health plan contract says preventive dental services from a participating provider in your dental plan network are covered under the dental plan. 
 
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 periodic oral exam (D0120) and prophylaxis (D1110) provided May 29, 2019 by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitoring system. 
 
You asked the Plan to pre-approve a continuous glucose monitor. You say that the enrollee needs a continuous glucose monitor. The Plan denied your request. The Plan says the enrollee does not meet criteria for a CGM. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.  
 
We looked at the file and Medicare rules. You are not insulin treated so you do not meet the Medicare coverage criteria for a CGM. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitoring system.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services provided on February 28, 2020. 
 
You asked the Plan to pay for the outpatient hospital 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 outpatient hospital services provided on February 28, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve a carotid entarterectomy in the inpatient hospital setting.You asked the Plan to pre-approvethe carotid entarterectomy in the inpatient hospital setting. You say that the records provided support the need for inpatient care.The Plan denied your request. The Plan says that the enrollee does not have any current symptoms of severe stenosis of the carotid artery. The Plan says that the enrollee does not have any acute or active comorbidities that would indicate the need for an extended stay in the hospital.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review thecase file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the carotid entarterectomy in the inpatient hospital setting. Our reviewer says that it is medically reasonable and necessary for the enrollee to receive carotid endarterectomy at the inpatient level of care. Our physician reviewer found although asymptomatic, the enrollee has a 90% unilateral stenosis, progression of disease to severe stenosis despite medical therapy and a reasonable life expectancy to make the benefit of lowering her long-term stroke risk worthwhile. However, although not a prohibitive risk, she has multiple other medical issues including coronary artery disease, atrial fibrillation and an implanted pacemaker. This puts her at higher risk for a perioperative complication (particularly cardiac) after carotid vascular surgery.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of thecarotid entarterectomy in the inpatient hospital setting have been met.Therefore, we decided that the Plan has to pre-approvea carotid entarterectomy in the inpatient hospital setting.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: Lab
Decision: Favorable

We decided that the Plan has to pre-approve DPYD gene analysis testing for the enrollee. You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says that this test cannot be approved, as it is not thought to be medically necessary. The Plan must follow Medicare rules. Medicare rules say that services are covered when they are medically necessary and meet the applicable coverage requirements. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found DPYD gene analysis can result in genotype-based dose reductions that improve the patient safety of fluoropyrimidine treatment. DPYD genotype-guided individualized dosing of fluoropyrimidine can be considered a standard of care. 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 been met. Therefore, we decided that the Plan has to pre-approve DPYD gene analysis testing for the enrollee. 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 waive the copayment for the specialist office visit provided on March 6, 2020.
You asked the Plan to waive the copayment for the specialist office visit. You say that you do not feel responsible for this copayment as it is a new change beginning on January 1, 2020. 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 per visit to a specialist. 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. The medical record shows services were received on March 6, 2020.
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 March 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (CPT 0005U) provided to the enrollee on March
5, 2020.
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 is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the
services at issue in this case were not medically reasonable or necessary. Our physician reviewer found no lab
results have been submitted for review. No provider records have been submitted for review.
Therefore, there is no evidence to support that the requested service was performed or that it was medically
necessary and reasonable to diagnose, treat or otherwise manage the enrollee's condition(s).
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 lab services (CPT 0005U) provided to the enrollee on March 5, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a Skilled Nursing Facility (SNF).
You asked the Plan to pre-approve SNF admission. You say that you need exercise to get stronger. The Plan
denied your request. The Plan says the denial of authorization for SNF service is correct.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is 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 SNF admission. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found you do not have daily skilled nursing
needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not
have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled
professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a
Skilled Nursing Facility (SNF) setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF admission have not been met. Therefore, we decided that the Plan does not
have to pre-approve admission to a Skilled Nursing Facility (SNF).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a tuberculosis test (86580) provided on April 15, 2019.
You asked the Plan to pay for a tuberculosis test. You say that this was medically necessary. The Plan denied your request. The Plan says this was performed for screening purposes.
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 tuberculosis test, 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 a tuberculosis test (86580) provided on April 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit provided on February
9, 2020.
You asked the Plan to waive the copayment for the urgent care visit. You say that you should not be
responsible for this copayment because the provider only spent three minutes with you. 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 $65
copayment per visit for out-of-network urgently needed services.
You have been asked to pay a $65 copayment for the urgent care visit. The urgent care visit falls within the
"Urgently needed services" benefit category. The record shows you were seen at the urgent care office.
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 urgent care visit provided on February 9, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan
denied your request. The Plan says that the you do not meet criteria for SNF care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is 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 SNF services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet
Medicare criteria for SNF services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the for tooth 14 (D2950).
You asked the Plan to pre-approve the dental service. You say that the crown can't be down without the core
buildup and the core buildup and crown are necessary to repair the tooth. The Plan denied your request. The
Plan says this service is not covered under the plan benefits.
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 health plan contract on
page 166 specifically lists core buildup, including pins (D2950) is not covered under any condition.
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 pre-approve the
for tooth 14 (D2950).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-ofnetwork
provider on October 17, 2019.
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 has network providers
available who can provide 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 medical services provided to the enrollee by an out-of-network provider
on October 17, 2019.
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
February 12, 2020.
You asked the Plan to waive the copayment for the specialist office visit. You say that you would like this
claim reviewed. 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 $40
copayment for specialist visits.
You have been asked to pay a $40 copayment for the specialist office visit. The specialist office visit falls
within the "Physician/Practitioner services, including doctor's office visits" 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 specialist office visit provided on February 12, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an epidural injection provided on March 3,
2020.
You asked the Plan to waive the copayment for an epidural injection. You say that the charges are too much.
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 $300
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory
surgical centers.
You have been asked to pay a $300 copayment for an epidural injection. An epidural injection 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 an epidural injection provided on
March 3, 2020.