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

We decided that the Plan does not have to pay for a duplex scan provided on January 7, 2020 by an out of network (OON) provider.
You asked the Plan to pay for a duplex scan. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the member's primary care physician did not refer these services.
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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for a duplex scan provided on January 7, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Orthovisc dosage of 6mL per 6 days. 
 
You asked the Plan to pre-approve Orthovisc. You say that this is medically necessary. The Plan denied your request. The Plan says the dosage requested is not supported. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Orthovisc. Our reviewer says that the requested dosage of Orthovisc does not meet criteria for coverage. Our physician reviewer found the recommended use of this drug calls for a lower dose. The directions and dosing provided indicate Orthovisc for 6mL per 21 days is available without prior authorization. In this case, the submitted request is for 6mL per 6 days, which conflicts with the directions provided. The documentation does not support that the Orthovisc at the requested dose of 6ml per 6 days is medically necessary or safe and effective for the patient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Orthovisc have not been met. Therefore, we decided that the Plan does not have to pre-approve an Orthovisc dosage of 6mL per 6 days.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on October 13, 2019 by an
out of network provider.
You asked the Plan to pay for the non-emergent ambulance service. You say that the Plan should pay this
claim. The Plan denied your request. The Plan says you did not request 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 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 ambulance services provided on October 13, 2019 by an out of network
provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on March 4, 2020.
You asked the Plan to pay for the physician's 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
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 March 4, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for non-covered item or service provided on February 19, 2020. 
 
You asked the Plan to pay for non-covered item or service. You say the Plan should pay the claim. The Plan denied your request. The Plan says the contracted provider billed a known non-covered benefit as A9270, and other services that are included in the biopsy payment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The rules say that Medicare Part B generally does not pay for drugs that are usually self-administered by the patients who take them. 
 
In this case, the CPT Code Manual definition of code A9270 is non-covered item or service, or selfadministered drug. 
 
We find that CPT code A9270 is not covered by the Plan. Specifically, the provider billed for a known noncovered services or self-administered drug. The other bundled services were written off by the provider. Therefore, we decided that the Plan does not have to pay for the non-covered item or service (A9270) provided on February 19, 2020.  
 
Benefits for the non-covered item or service (A9270) may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights for this code if it is for a self-administered drug.
Appeal type: Lab
Decision: Unfavorable

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 September 9, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency for these services.
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 September 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar injections.
You asked the Plan to pre-approve the requested injections. You say that the targeted levels are L4-5, and L5-S1. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that medical branch blocks are only covered under certain medical indications. 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 requested injections. Our physician reviewer found that the enrollee chronic low back pain. She has major psychiatric issues and has a Spinal Cord Stimulator in place. Her MRI shows lumbar facet joint pathology. She is taking opiates as well as other pain medications. The opiates are being tapered. The request is for diagnostic medial branch blocks. The enrollee has documented lumbar radiculopathy by EMG. This is a clearly documented source of back pain. Therefore, the requested services do not meet the criteria 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 requested injections have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the hospital outpatient clinic visit (G046325) provided February 12, 2020. 
 
You asked the Plan to waive the copayment for the outpatient clinic visit. You say that you have already paid the copay for the specialist and you want a correction for this bill because you don't want to pay another copay. The Plan denied your request. The Plan says the health plan contract says that when you visit a provider, you may be charged an additional fee. This fee reflects a trend in hospitals buying doctors' practices and adding additional fees to patient bills. In those cases, the outpatient cost-share applies to the services. You can find this information on page 58 of the plan's 2020 Evidence of Coverage. 
 
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 $30 per visit for specialists visits.  
 
You have been asked to pay $30 for the outpatient clinic visit. The outpatient clinic visit falls within the doctor 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 hospital outpatient clinic visit (G0463-25) provided February 12, 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 March 5, 2020.
You asked the Plan to waive the copayment for the specialist office visit. You say that you were not informed that office visits would have a copayment. You say you have never been charged a copayment for office visits in the past. 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. 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 5, 2020.
Our decision is only about the 2020 services. If you have any questions about prior years billing, please contact the plan directly.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spinal fusion surgery (22612, 22633). 
 
You asked the Plan to pre-approve spinal fusion surgery. You say that you need this because you are away from home and in pain. The Plan denied your request. The Plan says the records do not show that you have tried conservative treatment. 
 
The Plan follows Medicare rules. Medicare rules say that lumbar fusion is covered if the patient has any of the above listed indications. 
 
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 spinal fusion surgery. Our reviewer says that the requested surgery is not medically necessary at this time. Our physician reviewer found the records do not show spinal instability, fracture, or tumor. Spinal fusion is not needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of spinal fusion surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve spinal fusion surgery (22612, 22633).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99203) and the x-ray exam of the lumbar spine (72100) provided on January 21, 2020.
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 these services are not a covered benefit under your contractual policy.
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 services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the office visit (99203) and the x-ray exam of the lumbar spine (72100) provided on January 21, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER visit provided on January 29, 2020. 
 
You asked the Plan to waive the copayment for the ER visit. You say that the hospital found no issues and released you the same day. You say that this was against your will so you are appealing the bill. The Plan denied your request. The Plan says the copayment applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copayment for Medicare covered emergency room visits. 
 
You have been asked to pay a $90 copayment for the ER visit. The ER visit falls within the "Emergency care" benefit category. The records show that you received services during the ER visit. 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 ER visit provided on January 29, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to reduce the cost for the initial hospital care visit provided on January 3, 2020.
You asked the Plan to reduce the cost for the initial hospital care visit. You say that the doctor was selected by
the hospital or the surgeon. You say that the fee should be considered an in-network expense. The Plan denied
your request. The Plan says that the deductible applied correctly.
The Plan must follow Medicare rules. 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 physician services are excluded from the
Plan deductible. The rules say that Medicare health plans must make reasonable and diligent efforts to gather
and forward to the IRE information regarding its decision to deny coverage or payment.
The Plan says you must pay $1,000 for physician services. Based on the Plan contract, however, you cannot be
asked to pay any deductible amount for physician services because physician services are excluded from the
Plan deductible.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The records do not show whether the servicing hospital facility is in-network or
out-of-network with the Plan. Without this information, we cannot determine whether this inpatient physician
service would be included in the per day copayment applied to in-network inpatient stays.
Therefore, the Plan has not shown that its decision to apply separate cost-sharing to this claim is correct or
justified according to Medicare rules and the Plan contract. Therefore, we decided that the Plan has to waive
the $138.68 toward the deductible for the initial hospital care visit provided on January 3, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for certification fees to receive medical records for services provided outside of the United States.
You asked the Plan to pay for certification fees to receive medical records for services provided outside of the United States. You say that this should be covered. The Plan denied your request. The Plan says certification fees are not covered.
The Plan must follow Medicare rules. Medicare rules say that services furnished outside the United States are excluded from coverage except for the situations outlined above. The Plan covers worldwide emergency and urgent care services outside the United States. We looked at the file and Medicare rules. Certification fees to receive medical records are not considered emergency or urgent medical care. Based on this information, we decided that Medicare rules for coverage of certification fees to receive medical records for services provided outside of the United States have not been met. Therefore, we decided that the Plan does not have to pay for certification fees to receive medical records for services provided outside of the United States.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the paramedic intercept services provided on March 23,
2020.
You asked the Plan to pay for the paramedic intercept services. You say that you did not know the service
would not be covered. The Plan denied your request. The Plan says this item is not a covered benefit.
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances.
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area.
The paramedic intercept services at issue in this appeal were not furnished in a rural area. Therefore, we
decided that the Plan does not have to pay for the paramedic intercept services provided on March 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on January
23, 2020.
You asked the Plan to pay for the knee orthosis (L1833) and suspension sleeve (L2397). You say that the
orthoses were medically necessary. The Plan denied your request. The Plan says the services are
misrepresented.
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. The medical records do not mention or support medical necessity for
the orthosis. Based on this information, we decided that Medicare rules for coverage of the knee orthosis
(L1833) and suspension sleeve (L2397) have not been met. Therefore, we decided that the Plan does not have
to pay for the knee orthosis and suspension sleeve provided on January 23, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Euflexxa injection.
You asked the Plan to pre-approve Euflexxa. The Plan denied your request. The Plan says there is no clinical documentation explaining why the requested service is medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We looked at the file, and Medicare rules. In this case, there were insufficient records provided to show the requested injection would be used to treat a specific condition at this time. The records show that the Plan requested additional medical records, but none were provided. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve a Euflexxa injection.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for initial hospital care (CPT Code 99222) provided to the enrollee on October 11, 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 no documentation was received and complete medical records for 99222 are needed for review.
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. There are no medical records provided to corroborate services provided to the enrollee. Therefore, we decided that the Plan does not have to pay for initial hospital care (CPT Code 99222) provided to the enrollee on October 11, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the duplex scan and the specialist office
visit provided on January 30, 2020.
You asked the Plan to waive the copayments for the duplex scan and the specialist office visit. You say that
you are appealing the out of pocket charges. 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 $155
copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a
physician's office or at a free-standing facility and a $25 copayment for services obtained from a specialist, or
under circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health
care professionals in a specialist's office.
You have been asked to pay a $155 copayment for the duplex scan and a $25 copayment for the specialist
office visit. The duplex scan falls within the "Outpatient diagnostic tests and therapeutic services and supplies"
benefit category. 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 copayments for the duplex scan and the specialist office visit provided on
January 30, 2020.