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

We decided that the Plan does not have to waive the copayment for the CT angiography during the ER visit provided from August 21, 2020 and August 22, 2020.
You asked the Plan to waive the copayment for the CT angiography during the ER visit. You say that the treatment you went for was not the treatment you received. You say that you are requesting reconsideration of the claim. 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 if advanced imaging services are received as part of an emergency department evaluation then you will only pay the advanced imaging copayment, not the emergency room copayment. Your contract with the Plan clearly says that you must pay a $225 copayment for each Medicare-covered advanced imaging service (not including x-rays). You have been asked to pay a $225 copayment for the CT angiography during the ER visit. The CT angiography falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show a CT angiography was performed during the ER visit, which applies the advanced imaging copayment. 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 CT angiography during the ER visit provided from August 21, 2020 and August 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from November 9, 2020, to November 12, 2020.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were told that the stay would be completely covered. 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 $370 copayment for days 1-5 for inpatient hospital care. You have been asked to pay a $370, which is less than the total copayment amount for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital care 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 inpatient hospital stay from November 9, 2020, to November 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar orthosis provided on September 5, 2020.
You asked the Plan to pay for the orthosis. You say that the progress note clearly documents a detailed history. The Plan denied your request. The Plan says the enrollee did not receive a video or telephonic visit by the ordering physician.
The Plan must follow Medicare rules. Medicare rules say that lumbar orthoses are only covered under certain medical indications. We looked at the file and Medicare rules. In this case, the records do not contain sufficient documentation of the patient's medical condition to substantiate the necessity. The records do not include objective findings or a previous physical exam that notes healing from an injury or surgical procedure, or spine instability.
Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar orthosis provided on September 5, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the hearing services provided on January 27, 2021.
You asked the Plan to waive the copay for the services provided. You say that you were not there for a hearing test. The Plan denied your request. The Plan says the cost share is listed in your EOC and services were provided.
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 in a specialty physician's office for a Medicare-covered or routine hearing exam. You have been asked to pay a $35 copay for the services provided. The services fall within the hearing 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 hearing services provided on January 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that you need bladder and bowel training. The Plan denied your request. The Plan says there is not a solid discharge plan.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 IRF care. Our physician reviewer found that you were admitted to the acute hospital for surgical decompression and fusion of cervical spine after a fall resulting in cervical fractures at C5-C6. Your medical problems are stable. There are no complex nursing needs. You do not require treatment by multiple therapies in an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve removal of a breast implant with mastopexy.
You asked the Plan to pre-approve the breast implant removal. The Plan denied your request. The Plan says this is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that the removal of breast implants is covered for the indications established in the applicable LCD. 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 breast implant removal. Our reviewer says that the requested breast implant removal is not medically reasonable and necessary. Our physician reviewer found that the enrollee presented with concern of asymmetry and painful implants. The medical records do not indicate that there has been implant contracture or rupture. The medical records indicate that the request for removal is cosmetic in nature. The elements of the coverage rule 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 breast implant removal have not been met. Therefore, we decided that the Plan does not have to pre-approve removal of a breast implant with mastopexy.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0482 provided on August 5, 2020.

You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.

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 G0482 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting, place of service 11. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0482 provided on August 5, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Evenity for the enrollee.

You asked the Plan to pre-approve Evenity. You say that this is medically necessary for the enrollee. The Plan
denied your request. The Plan says that the enrollee has not tried any of the preferred agents.

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 Evenity. Our reviewer says that Evenity
is not medically reasonable and necessary for the enrollee. The Plan requires a trial of Prolia or Reclast before
they will approve the requested drug. In this case, the patient has not tried and failed the required drugs. There
is no documentation provided indicating that the Plan's required drugs would likely be less effective and/or
likely have adverse effects for the enrollee. Our physician reviewer found that the enrollee's condition does not
meet step therapy criteria for Evenity.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to
pre-approve Evenity for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an immediate upper denture (D5130), an immediate lower denture (D5140), and surgical placement of implant bodies (D6010) provided on February 25, 2020.

You asked the Plan to pay for the dentures and surgical implants. You say that your provider told you these services would be covered. The Plan denied your request. The Plan says that out-of-network dental care is not covered. The Plan contacted the supplemental dental plan and confirmed that you were not informed that this provider was in-network, and the call logs show that you were directed to use a different provider that was in-network.

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 covers routine dental services when they are provided in-network. 

Though the Plan offers a dental benefit in excess of Medicare coverage, out-of-network care is not covered under this benefit. Therefore, we decided that the Plan does not have to pay for an immediate upper denture (D5130), an immediate lower denture (D5140), and surgical placement of implant bodies (D6010) provided on February 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99214) provided on February 14, 2020 to February 19, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the office visit. You say that at the time of service you were informed that the enrollee was covered under Medicare. Authorization was impossible to obtain due to the enrolle misleading you with incorrect insurance information. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the 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 the outpatient office visit (99214) provided on February 14, 2020 to February 19, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for refraction provided on September 28, 2020.
You asked the Plan to pay for determination of refractive state (92015). You say that this service was to determine whether you needed cataract surgery. The Plan denied your request. The Plan says refraction is not a covered service.
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 does not cover refraction. We looked at the file and the Plan's rules. Refraction is not covered by Medicare or the Plan. Based on this information, we decided that the Plan's rules for coverage of determination of refractive state (92015) have not been met. Therefore, we decided that the Plan does not have to pay for refraction provided on September 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee brace (L1833) and a suspension sleeve (L2397)
provided on October 9, 2020.
You asked the Plan to pay for a knee brace and a suspension sleeve. You say that the requested items are a
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not
been met.
The Plan must follow Medicare rules. Medicare rules say that a supplier of a covered item of DME may not
contact an individual by telephone regarding the furnishing of a covered item to the individual except in
situations outlined under "Medicare rules."
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of a knee brace and a suspension sleeve have not been met. Specifically, the Plan has attested that this
enrollee was contacted via an unsolicited phone call regarding provision of the items at issue. As such, no
payment may be made for these items. Therefore, we decided that the Plan does not have to pay for a knee
brace (L1833) and a suspension sleeve (L2397) provided on October 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the polycarbonate lenses received on
January 14, 2021, from an OON provider.
You asked the Plan to pay an additional amount for the polycarbonate lenses. You say that your cost share
amount for the covered items should be $0. The Plan denied your request. The Plan says you may pay a greater
amount when you visit an out-of-network provider.
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 $0
copayment for one pair of Medicare-covered eyeglasses after cataract surgery.
You have been asked to pay the difference between what the out-of-network provider charged and the
Medicare allowable amount for the polycarbonate lenses. The Plan provided reimbursement up to 100% of the
Medicare allowable amount for the covered service. The Plan contract states that if you utilize an out-ofnetwork
provider, your share of the costs for your covered services may be higher. 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 pay an additional amount for the polycarbonate lenses received on January 14, 2021, from an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on September 17, 2020.
You asked the Plan to pay for the laboratory 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 not supported by the documentation.
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 laboratory services are not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates that the laboratory specimens were obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting, place of service 11. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on September 17, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the ambulance transportation services provided on October 2, 2020.
You asked the Plan to waive the copay for the services provided. You say that you should not be charged because you were admitted to the hospital. The Plan denied your request. The Plan says the copay 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 $150 copay for ambulance services.
We looked at the file and the rules. The Plan documents show that if you are admitted to the hospital within 24 hours, you do not have to pay your share of the cost for emergency care or urgent care services. The transportation services you received do not fall under the urgently needed services or emergency care benefit categories. You have been asked to pay a $150 copay for the services provided. The services fall within the ambulance 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 ambulance transportation services provided on October 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the inpatient hospital services provided from July 15, 2020, to July 18, 2020.
You asked the Plan to waive the copay for the inpatient services. You say that you were supposed to be transferred but was refused. The Plan denied your request. The Plan says your plan requires an inpatient copay.
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 $235 copay per day for days 1-7 for inpatient hospital care. You have been asked to pay a $235 copay per day for the inpatient services, totaling $705. The copay was applied based on your in-network benefits. The services fall within the inpatient hospital care 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 inpatient hospital services provided from July 15, 2020, to July 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for MyOwn Skin (Q4226) and fluid flow (Q4206).

You asked the Plan to pay for the MyOwn Skin and fluid flow. You say that you would like reconsideration because the purpose of treatment is to heal the member's legs and get her off chronic and dangerous narcotics. The Plan denied your request. The Plan says The progress of healing during an organized comprehensive conservative therapy could not be determined.

The Plan follows Medicare rules. Medicare rules say that documentation (in the pre-service record) specifically addressing circumstances as to why the wound has failed to respond to standard wound care treatment of greater than 4 weeks and must reference specific interventions that have failed.

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 MyOwn Skin and fluid flow. Our reviewer says that the member does not meet LCD criteria for coverage of the requested service. Our physician reviewer found the member has received standard wound therapy and has documented only one wound measurement. The progress of healing during an organized comprehensive conservative therapy could therefore not be determined.

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 MyOwn Skin and fluid flow have not been met. Therefore, we decided that the Plan does not have to pay for MyOwn Skin (Q4226) and fluid flow (Q4206).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on December 9, 2020 by a non-participating provider.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-participating provider 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 the physician services provided on December 9, 2020 by a non-participating provider.