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

We decided that the Plan does not have to waive the copayment for the ultrasound rendered to you on December 17, 2019.
You asked the Plan to waive the copayment for these services. You say that the ultrasound was needed for diagnosis. The Plan denied your request. The Plan says the copayment 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 $250 copayment per day for Medicare-covered diagnostic radiology services, such as ultrasound.
Review of the file shows that you received an ultrasound on December 17, 2019. You have been asked to pay a $250 copayment for these services. These services fall within the Medicare-covered diagnostic radiology services, such as ultrasound, 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 ultrasound rendered to you on December 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested supplies as they are not being ordered appropriately.
You asked the Plan to pre-approve the requested supplies. You say that you need these supplies to allow you to leave the house due to issues with incontinency. The Plan denied your request. The Plan says the codes and supplies ordered by your physician are not covered by Medicare.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. Medicare does not cover orders or claims for code A4221 when ordered for use with external infusion pumps for use in the home. While it is understood these supplies may be appropriate for your use, they are not being ordered in such a way by your provider that they can be covered by Medicare. Therefore, it is our decision that the Plan is not required to provide coverage for the requested supplies at this time. Please talk to your provider about the appropriate way to order these types of supplies for Medicare coverage.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on December 4, 2019You asked the Plan to waive the copayment for the office visit. You say that no solution was provided. You say that you don't agree with the copayment.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 $45 for each covered visit or consultation in an outpatient location with a specialist. You have been asked to pay a $45 copayment for the office visit. The 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 forthe office visit provided on December 4, 2019
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan provided on January 17, 2020.
You asked the Plan to waive the copayment for the CT scan. You say that the device was inserted improperly
so you needed a CT scan. You say that you shouldn't be responsible. 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 $250 per
day for Medicare-covered diagnostic radiology services.
You have been asked to pay a $250 copayment for the CT scan. The CT scan 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 the CT scan provided on January 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation provided on November 19, 2019.
You asked the Plan to pay for the periodic oral evaluation. You say that you do not feel that this exam should
not have exceeded your benefit limitation for the benefit year. The Plan denied your request. The Plan says you
have exceeded your benefit limitation.
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, oral examinations are limited to two
procedures per calendar year. The record shows that you received exams on January 30, 2019 and February 27,
2019 and your oral examinations benefit had been exhausted. Therefore, we decided that the Plan does not have
to pay for the periodic oral evaluation provided on November 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay additional reimbursement for gym membership, as the payment was not made in 2020 as is required by the Plan contract.
You asked the Plan to pay additional reimbursement for the 2020 gym membership which you actually paid in advance in 2019. You say that at the time it was more economical to pay for a two-year membership. You stated that on January 30, 2019 you paid $429.99. You stated that in 2019 the Plan paid $240 toward this membership. You would now like the Plan to pay the remaining $189.99 which technically is the cost of the 2020 gym membership or the second year. The Plan denied your request. The Plan states that this benefit will only be reimbursed for the date of service or for the benefit year in which it was paid. The Plan states you do not have a receipt for payment of gym membership in 2020.
Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers up to $240 per year for membership in Health Club/Fitness Classes. The date of service for this benefit is the date you make payment. Since there was no payment made in 2020, the 2020 benefit does not apply based on the Plans reimbursement guidelines. The Plan contract does not appear to allow the splitting of payment or the use of last year's receipt for payment toward the 2020 benefit. Medicare does not make exceptions to supplemental gym benefits. Therefore, we decided that the Plan does not have to pay further reimbursement for gym membership.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on December 2, 2019 by an out of network (OON) provider.You asked the Plan to pay forclinic visit and lab tests. You say that you were not aware that authorization was required.The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and the enrollee self-directed for service.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 forthe medical services provided on December 2, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran office visit provided on August 5, 2019 by an out of network (OON) provider.You asked the Plan to pay foran office visit. You say that you would like this appeal reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained.Medicare rules say that plans can require enrollees to get carefrom 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 foran office visit provided on August 5, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora colonoscopy provided on January6, 2020.You asked the Plan to waive the copayment fora colonoscopy. You say that you feel that you should not be responsible for a copayment for this type of service.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 $150 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. The record shows that you had polyps removed during a colonoscopy on January 6, 2020. Therefore, you are responsible to pay the $150 copayment. You have been asked to pay a $150 copayment for a colonoscopy. A colonoscopy 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 fora colonoscopy provided on January 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient consultation services (CPT 99254) services provided to the enrollee on January 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 thisis an invalid procedure code for this service.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 99254 is "Inpatient consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 80 minutes are spent at the bedside and on the patient's hospital floor or unit."We find that CPT code 99254 is not supported in the medical record. Specifically, this code has a status indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pay forinpatient consultation services (CPT 99254) services provided to the enrollee on January 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe complete series of periapical x-rays (D0210), the filling (D2335) for tooth # 9, the filling (D2393) for tooth # 30, and the periodontal scaling and root planing (D3231) for 2 quadrants provided from October 10, 2019 to December 26, 2019.You asked the Plan to pay forthe dental services. You say that the dentist's office advised the services would be covered because you received a cleaning.The Plan denied your request. The Plan says the complete series of x-rays, fillings and periodontal scaling and root planing are not listedas covered services.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 inexcess of Medicare coverage, the dental services you received are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe complete series of periapical x-rays (D0210), the filling (D2335) for tooth # 9, the filling (D2393) for tooth # 30, and the periodontal scaling and root planing (D3231) for 2 quadrants provided from October 10, 2019 to December 26, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services provided January 10, 2020, January 13, 2020, and January 15, 2020.
You asked the Plan to pay for the physical therapy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 physical therapy services. Our reviewer says that skilled services were not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found you were being seen for impaired balance after right total knee arthroplasty. The requested therapy dates in question were generally not accepted as specific and effective therapy for your condition. You have had prior therapy visits and the documentation reveals you were near baseline prior to acute exacerbation of back pain. The records do not demonstrate that the unique skills of a professional therapist were required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. You have been instructed in and competent in performing a home exercise program.
The requested services were not part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist were not required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration. Therefore, you did not meet criteria for the physical therapy services received. Review of the file shows that the plan uses Local Coverage Determination (LCD) L33631 to support their denial. However, this LCD is not valid for your home state of PA. Therefore, we cannot use this LCD to substantiate our decision. 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 physical therapy services have not been met. Therefore, we decided that the Plan does not have to pay for the physical therapy services provided January 10, 2020, January 13, 2020, and January 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a medication dispensing system.
You asked the Plan to pre-approve a medication dispensing system. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested item is not a covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a medication dispensing system.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a computed tomography (CT) scan of the head or brain (70450) provided on November 13, 2019 by the appealing provider.
You asked the Plan to pay for the CT scan of the head or brain. You say that the services were provided and payment should be rendered. The Plan denied your request. The Plan says procedure code 70450 is considered a column II procedure code and is not eligible for reimbursement when billed with 70460 a column I procedure code. These procedure codes were reported together, therefore Medicare billing criteria has not been met.
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, we have confirmed that code 70450 has a bundled relationship with code 70460 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for a computed tomography (CT) scan of the head or brain (70450) provided on November 13, 2019 by the appealing provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copays for the ambulance transport provided on November 11, 2019 and inpatient services provided from November 6, 2019 to November 30, 2019.
You asked the Plan to waive the copays for the ambulance transport and inpatient services. You say that this will create a financial hardship. The Plan denied your request. The Plan says that the claims processed 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 $300 copay for each Medicare-covered ground transportation service and a $310 copay per day for days 1 through 6 of inpatient hospital care. You have been asked to pay less than a $300 copay for the ambulance transport and a $310 copay per day for days 1 to 6 of inpatient services. The ambulance transport falls within the Medicare-covered ground transportation service and the inpatient services fall within the days 1 through 6 of 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 copays for the ambulance transport provided on November 11, 2019 and inpatient services provided from November 6, 2019 to November 30, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda.
You asked the Plan to pre-approve Keytruda. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Keytruda. Our reviewer says that the documentation does not support that the requested drug, Keytruda is medically reasonable or necessary. Our physician reviewer found the requested use of Keytruda is not FDA-approved for the enrollee's diagnosis. The use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. There is no data to support efficacy of switching to another PD-L1 inhibitor. Therefore, the enrollee does not meet criteria for the requested drug. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveTadalafil tablets.You asked the Plan to pre-approveTadalafil tablets. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says Tadalafil is not covered under the enrollee's Medicare Part B benefit.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveTadalafil tablets.Benefits for Tadalafil tabletsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe injection services rendered on June 6, 2019.You asked the Plan to pay forthese services. You say thatyou disagree with the denial.The Plan denied your request. The Plan says procedure codes J3475 and J3480 are not separately payable.The Plan must follow Medicare rules. The rules say that services with status indicator N are paid under the OPPS, but their payment is packaged into payment for a separately paid service.We looked at the file and Medicare rules. Procedure codes J3475 and J3480 have a status indicator of N under the OPPS and payment is packaged into a separately paid service. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe injection services rendered on June 6, 2019