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

We decided that the Plan does not have to waive the copayment for an ultrasound provided on November 10,
2020.
You asked the Plan to waive the copayment for an ultrasound. You say that you feel that the ultrasound should
be included as a mammogram screening. 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 $45
copayment for x-rays.
You have been asked to pay a $45 copayment for an ultrasound. An ultrasound falls within the outpatient
diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the
copayment for an ultrasound provided on November 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular genetic panel testing provided on May 29, 2020.
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this testing is not a Medicare benefit for the diagnoses listed and 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 record does not show that this panel testing was ordered to evaluate or treat a specific condition. The testing at issue in this appeal, genetic testing, was requested for screening purposes. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for molecular genetic panel testing provided on May 29, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex device.
You asked the Plan to pre-approve a Vertiflex device. You say that the requested Vertiflex device is medically
necessary. The Plan denied your request. The Plan says the requested Vertiflex device is not medically
necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve a Vertiflex device. Our reviewer says
that the requested Vertiflex device is not medically necessary. Our physician reviewer found the enrollee is
with chronic low back pain. The enrollee is diagnosed with post-laminectomy syndrome, degenerative disc
disease, spondylosis of lumbar region without myelopathy or radiculopathy, lumbar spinal stenosis with
neurogenic claudication, and chronic pain disorder. The Vertiflex device is experimental. More research is
needed to show safety and efficacy. The device is not medically necessary at this time.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a Vertiflex device have not been met. Therefore, we decided that the Plan does
not have to pre-approve a Vertiflex device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a breast biopsy provided on September 30, 2020.
You asked the Plan to waive the copayment for a breast biopsy. You say that you disagree with the charges because you had a mammogram in the same room and did not have to pay a 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 $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 a breast biopsy. A 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 a breast biopsy provided on September 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services provided from July 13, 2020, to October 26, 2020.
You asked the Plan to waive the copayment for specialist services. You say that you feel that the charges are fraudulent and you cannot afford them. 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 $45 copayment for each specialist visit. You have been asked to pay the total allowed amount of $469.92, which is less than the total copayment amount for specialist services. Specialist services fall 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 specialist services provided from July 13, 2020, to October 26, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee.
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee can be safely managed at a lower level of care.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric hospital services. Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary for the enrollee. It is not expected this enrollee would improve in a reasonable period of time as he is not showing any dangerousness to self or others, no auditory or visual hallucinations and no aggressive behaviors. This patient was not compliant with treatment refusal group and refusing alternatives offered. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for inpatient psychiatric hospital 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 inpatient psychiatric hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgery services you received on October 16, 2020.
You asked the Plan to waive the copayment. The Plan denied your request. The Plan says you are responsible for the copayment.
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 $325 copayment for outpatient surgery services at an outpatient hospital facility. Review of the file shows that you were provided an injection on October 16, 2020. You have been asked to pay a $325 copayment for the services. The injection falls within the outpatient surgery 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 outpatient surgery services you received on October 16, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI provided on November 4, 2020.
You asked the Plan to waive the copayment for an MRI. You say that you disagree with the charges because you were told that you would not owe a 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 $155 copayment for each radiological diagnostic service. You have been asked to pay a $155 copayment for an MRI. An MRI falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an MRI provided on November 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis cleaning (D1110) provided on November 18, 2020.
You asked the Plan to pay for the prophylaxis cleaning. You say that your dentist scheduled this appointment, and you should not be held responsible for payment. You did not know that your Plan only covered one cleaning every six months. The Plan denied your request. The Plan says the Plan's contract clearly states that this service is covered once every six months. Your last prophylaxis cleaning was provided on July 20, 2020, which is less than six months before this cleaning.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Specifically, the Plan's contract states that only one dental cleaning will be covered every six months. The Plan provided documentation that showed that your last cleaning was only four months prior. Therefore, we decided that the Plan does not have to pay for the prophylaxis cleaning (D1110) provided on November 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyewear you received on October 21, 2020.
You asked the Plan to pay for the eyewear. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The services you asked the Plan to pay for are considered routine vision services or eyewear. You are not enrolled in the Plan's supplemental vision benefit. Neither Medicare, nor the Plan, covers routine eyewear. Therefore, we decided that the Plan does not have to pay for the eyewear you received on October 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient hospital facility visit provided on December 8, 2020.
You asked the Plan to waive the copayment for an outpatient hospital facility visit. You say that you disagree with the charges because you have never been charged more than $45 in the past. 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 $350 copayment for outpatient surgery, including services provided at hospital outpatient facilities. You have been asked to pay the allowed amount of $133.70, which is less than the $350 copayment for an outpatient hospital facility visit. An outpatient hospital facility visit 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 outpatient hospital facility visit provided on December 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lift chair purchased from a non-Medicare provider and sales tax.
You asked the Plan to pay for lift chair and sales tax. You say that you were advised that this chair could be covered at 80%, and you would not have purchased the chair if you had known it would not be covered. The Plan denied your request. The Plan says the denial of payment for this item is correct, because this provider is not enrolled in the Medicare program and is not eligible for payment.
The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered Medicare items, a provider or supplier must be enrolled in the Medicare program. Medicare rules also say that Medicare does not make separate payment for sales tax. We looked at the file and Medicare rules. This provider is a retail company which does not participate in the Medicare program and is not payable. Furthermore, the sales tax you requested reimbursement for is not payable by Medicare. Based on this information, we decided that Medicare rules for coverage of lift chair and sales tax have not been met. Therefore, we decided that the Plan does not have to pay for a lift chair purchased from a non-Medicare provider and sales tax.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prosthetic leg with advanced foot and knee features (L5321, L5650, L5920, L5856, L8460, L5624, L5651, L5950, L5828, L8480, L5631, L5673, L5981, L5848, L5649, L5968, L5845, L8430).
You asked the Plan to pre-approve a prosthetic leg with advanced foot and knee features. You say that these items will increase the enrollee's functionality. The Plan denied your request. The Plan says these items would exceed the enrollee's needs.
The Plan follows Medicare rules. Medicare rules say that lower limb prosthetics and accessories are covered when medically necessary per the LCD guidelines. 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 a prosthetic leg with advanced foot and knee features. Our reviewer says that the criteria for coverage of the requested items have not been met. Our physician reviewer found the submitted prosthetic evaluation clearly states that the member uses walker and cane and indicates that he always uses of assistive device. The prosthetist's notes state that member uses up to 6-ply socks but does not clearly explain the medical necessity for a new socket. There is no documentation supporting need for new socket and insufficient documentation to support need for a K3 level knee and foot. The review has determined that the member does not meet the criteria for K3 components. The requested items at issue in this case are not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a prosthetic leg with advanced foot and knee features have not been met. Therefore, we decided that the Plan does not have to pre-approve a prosthetic leg with advanced foot and knee features (L5321, L5650, L5920, L5856, L8460, L5624, L5651, L5950, L5828, L8480, L5631, L5673, L5981, L5848, L5649, L5968, L5845, L8430).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for physician services provided by an out-of-network
provider on November 17, 2020.
You asked the Plan to waive the deductible for physician services. You say that you verified that this provider
was in-network. The Plan denied your request. The Plan says the correct deductible amount has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that there is a $1,500 deductible for physician/practitioner services/out-of-network.
The item or service you asked the Plan to waive the deductible for falls within the benefit category
physician/practitioner services/out-of-network. The Plan has followed Medicare rules by clearly disclosing in
the contract that there is a $1,500 deductible for physician/practitioner services/out-of-network. This cost
sharing is a contractual obligation that had not been met at the time physician services was received on
November 17, 2020. The total amount you are being asked to pay is $133.09. Therefore, we decided that the
Plan does not have to waive the deductible for physician services provided by an out-of-network provider on
November 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for magnetic resonance imaging (MRI) brain, including brain stem (70553) provided November 13, 2020. You asked the Plan to pay for the MRI. You say that you receive infusions every 6 weeks, and this MRI was done to see if there had been any growth. You have never had a problem with this being covered prior to having the Plan. The Plan denied your request. The Plan says there is another plan that is the primary insurance, and the claim needs to first be processed through that carrier. The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has another carrier as primary. As the secondary insurer, the Plan cannot be held responsible for the MRI until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for magnetic resonance imaging (MRI) brain, including brain stem (70553) provided November 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services (CPT 99129) provided on June 26, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99291 is "Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes". We find that CPT code 99291 is not supported in the medical record. Specifically, the records provided do not show that 30-74 minutes of critical care services were provided on the date of service in question. 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 critical care services (CPT 99129) provided on June 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex device.
You asked the Plan to pre-approve a Vertiflex device. You say that the requested Vertiflex device is medically necessary. The Plan denied your request. The Plan says the requested Vertiflex device is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a Vertiflex device. Our reviewer says that the requested Vertiflex device is not medically necessary. Our physician reviewer found the enrollee is with degenerative disc disease. The Vertiflex device is experimental at this time. More research is needed to show the safety and efficacy of the device. Open laminectomy is the gold standard for treatment of spinal stenosis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the Abutment Supported Porcelain/Ceramic Crowns (D6058) provided June 29, 2020.
You asked the Plan to pay for the crowns. You say that you would like the service covered by the Plan. The Plan denied your request. The Plan says the service is not covered under the Plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, 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 the Abutment Supported Porcelain/Ceramic Crowns (D6058) provided June 29, 2020.