Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on January 11, 2021.
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 psychotherapy services provided on January 11, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on November 18, 2020 and November 22, 2020.
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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem. The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this
testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on November 18, 2020 and November 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the IRF admission is medically necessary.The Plan denied your request. The Plan says your needs can be met at a different level of care.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable andnecessary 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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your needs can be met at an alternate level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicarerules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services (90837) provided on July 14, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the psychotherapy services. You say that the medical records provided will show proof of medical necessity. 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 psychotherapy services (90837) provided on July 14, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) provided on November 24, 2020.

You asked the Plan to pay for the x-rays. You say that these services were necessary because your first provider refused to forward your recent x-rays to the provider in question.The Plan denied your request. The Plan says out of network services are not covered.The Plan has stated that they are addressing your other concerns as a separate matter.

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, items or services received out-of-network are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) provided on November 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the molecular genetic screening testing provided on September 18, 2020.

You asked the Plan to pay for the molecular genetic screening testing. You say that you would like reconsideration because this testing was medically necessary. The Plan denied your request. The Plan says molecular genetic screening testing is not a Medicare benefit for the diagnoses as listed on the claim and are done for screening purposes.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

The test at issue in this appeal, the molecular genetic screening testing, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Additionally, the documentation submitted does not include any medical records to determine why this testing was ordered or if it meets Medicare coverage criteria. Therefore, we decided that the Plan does not have to pay for the molecular genetic screening testing provided on September 18, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an electrocardiogram (93000) provided February 2, 2021.
You asked the Plan to pay for the electrocardiogram. You say that the services were medically necessary. The Plan denied your request. The Plan says this service was included in another CPT code paid. This CPT code is not eligible for separate 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. We find that CPT code 93000 is not supported in the medical record. Specifically, this service is included in CPT code 93284 which was paid for the same date of service. CPT code 93000 is not separately payable. There is no physician report to show this was a separate service. Based on this information, we decided that Medicare rules for coverage of the electrocardiogram have not been met. Therefore, we decided that the Plan does not have to pay for an electrocardiogram (93000) provided February 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation provided on March 4, 2021.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you sustained damage to your tooth during a surgical procedure, and needed to see the dentist to have it repaired. The Plan denied your request. The Plan says this procedure is not covered.
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 problem focused limited oral evaluation provided on March 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a hereditary cardiovascular screening (81401, 81404, 81405, 81406, 81185, 81479) provided on September 26, 2020.
You asked the Plan to pay for a hereditary cardiovascular screening. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular (CV) risk assessment panels, except the basic lipid panel, for symptomatic (with signs and symptoms) patients with suspected or documented CV disease because panel testing is not specific to a given patient's lipid abnormality or disease. We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not covered. Based on this information, we decided that Medicare rules for coverage of a hereditary cardiovascular screening have not been met. Therefore, we decided that the Plan does not have to pay for a hereditary cardiovascular screening (81401, 81404, 81405, 81406, 81185, 81479) provided on September 26, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the esophagogastroduodenoscopy procedure you had at an ambulatory surgical center on September 18, 2020.
You asked the Plan to waive the copayment for the esophagogastroduodenoscopy procedure. You say that you do not believe you should have to pay this copayment because this office hadn't charged you in the past. The Plan denied your request. The Plan says you were charged this copayment 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 $200 copayment for each visit to an ambulatory surgical center. You have been asked to pay a $200 copayment for the esophagogastroduodenoscopy procedure. The esophagogastroduodenoscopy procedure falls within the ambulatory surgical center 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 esophagogastroduodenoscopy procedure you had at an
ambulatory surgical center on September 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the continuous positive airway pressure (CPAP) supplies provided on January 29, 2021.
You asked the Plan to waive the cost share for the services provided. You say that you never had a problem with your previous insurance company. The Plan denied your request. The Plan says you are responsible for the coinsurance.
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% coinsurance for durable medical equipment and related supplies.
You have been asked to pay a 20% coinsurance for the services provided. The services fall within the durable medical equipment 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 cost share for the continuous positive airway pressure (CPAP) supplies provided on January 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the LifeVest wearable defibrillator you received on January 25, 2021.
You asked the Plan to waive the coinsurance for the LifeVest. You say that you did not accept this equipment, so you should not have to pay this amount. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for durable medical equipment. You have been asked to pay 20% coinsurance for the LifeVest. The LifeVest falls within the durable medical equipment benefit category. Records show that you signed a form on January 25, 2021 acknowledging receipt of this item. 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 coinsurance for the LifeVest wearable defibrillator you received on January 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay more for the sacroiliac injection you received from an out-of-network provider on March 17, 2021.
You asked the Plan to pay more for the sacroiliac injection. You say that you paid up front for these services and were not aware of the reimbursement process. You would like more paid towards this claim. The Plan denied your request. The Plan says this claim was paid at the full Medicare-allowed rate.
The rules say that Plans must pay non-contracted providers up to the Medicare-allowed amount for services rendered. In this case, the procedure code for the services you received is 27096. The Medicare-allowed amount for this code in an out-of-network facility is $80.70. This is the amount that your Plan reimbursed you, so the Plan has paid for these services appropriately. This provider has charged an amount above the Medicare-allowed amount. You have the right to go back to the provider and request a refund, advising them that you have a Medicare Advantage Plan. However, the Plan itself is not responsible for any further payment. Therefore, we decided that the Plan does not have to pay more for the sacroiliac injection you received from an out-of-network provider on March 17, 2021.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to waive the cost sharing charged for the bone density scan (DEXA scan) you had at an outpatient hospital facility on December 29, 2020.

You asked the Plan to waive the cost sharing charged for the DEXA scan. You say that you believed that bone density tests were covered in full.The Plan denied your request. The Plan says that you were charged this cost sharing correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan explicitly states that there is no cost sharing due for bone mass measurements and screening mammograms.  According to the medical records, on this date of service you received a DEXA scan (which is a type of bone mass measurement), and a screening mammogram.  Neither of these services has an applicable cost sharing amount.  It is not appropriate for the Plan to assess cost sharing for these services.  The Plan incorrectly assessed a deductible, stating that there is a $250 deductible for services in an outpatient hospital facility.  This is only true for outpatient hospital services that are not specifically excluded from cost sharing in your Evidence of Coverage.  Both the DEXA scan and the mammogram you had are excluded from this deductible. Therefore, we decided that the Plan has to waive the cost sharing charged for the bone density scan (DEXA scan) you had at an outpatient hospital facility on December 29, 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional 12 home health visits for physical therapy.
You asked the Plan to pre-approve additional home health physical therapy visits. You say that you do not feel ready to stop therapy yet because you get stronger every time you receive physical therapy. The Plan denied your request. The Plan says you have recovered to your previous level of ability and no further skilled needs are identified.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 additional home health physical therapy visits. Our reviewer says that the requested services are not medically necessary. Our physician reviewer found that the documentation doesn't support that you require skilled rehabilitation services to provide treatment that is medically necessary. You do not require skilled rehab services to effectively provide treatment, care, and/or services in order to improve your condition, perform a maintenance program to maintain your condition, and/or prevent deterioration. You have been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. You required physical therapy for strengthening and to improve function. You have improved and are at your baseline level of function. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional home health physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional 12 home health visits for physical therapy.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation (A0425, A0427) received February 2, 2021.
You asked the Plan to waive the copayment for the ambulance transportation. You say that the Plan's care team told you that you would not owe anything for the ambulance transportation. The Plan denied your request. The Plan says the correct cost share applied to the claim.
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 Ambulance Services. You have been asked to pay a $150 copayment for the ambulance transportation. The ambulance transportation falls 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 copayment for the ambulance transportation (A0425, A0427) received February 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan provided on May 8, 2020.
You asked the Plan to waive the copayment for the CT scan. You say that you were not informed this was not covered by your insurance and do not understand why it was denied. You say that you paid your $100 copayment, and the denial should be reversed. The Plan denied your request. The Plan says the copayment applied correctly. The Plan also says that the provider will reimburse you $37.53, and you will no longer be balance billed.
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 $100 copayment for advanced imaging services at an in-network provider.
You have been asked to pay $62.47, which is less than the standard $100 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 May 8, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a repeat Synvisc-One viscosupplementation injection.

You asked the Plan to pre-approve the Synvisc-One injection. You say that you feel that this should be allowed to be provided by a physician assistant because it has been able to help you in the past. You feel like the doctor did the injection incorrectly but that it would still be helpful for you. The Plan denied your request. The Plan says there is not sufficient evidence to show other treatments have failed or that prior injections were helpful based on any standardized assessment tool.

The Plan follows Medicare rules. Medicare rules say that repeat viscosupplementation injections, such as Synvisc-One, may be covered when the LCD criteria list in the Medicare rules section are met.

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 Synvisc-One injection. Our reviewer says that the requested injection is not shown to meet LCD criteria for medical necessity. Our physician reviewer found the enrollee has a diagnosis of Unilateral primary osteoarthritis of the left knee. The case file does not contain documentation since the 12/8/20 office visit to show that the enrollee's symptoms have recurred, and that there was a significant improvement in pain and functional capacity achieved with the prior series of injections using a standardized assessment tool, or there is significant reduction in the doses of NSAID medications taken or reduction in the number of intra-articular steroid injections to the knees during the six-month period following the injection(s). 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Synvisc-One injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a repeat Synvisc-One viscosupplementation injection.