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

We decided that the Plan does not have to waive the copayment for the endoscopy provided on December 12, 2020.
You asked the Plan to waive the copayment for the endoscopy. You say that you disapprove of the cost. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 copayment for each Medicare-covered ambulatory surgical center visit. You have been asked to pay a $295 copayment for the endoscopy. The endoscopy 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 the endoscopy provided on December 12, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health care services provided from January 3, 2020, to January 13, 2020.
You asked the Plan to pay for the home health care services. You say that the provider is not required to be enrolled in Medicare. The Plan denied your request. The Plan says the services were rendered by a provider who is not licensed with Medicare, and is not eligible to be paid for the service on the date it was provided.
The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered Medicare items or services, a provider or supplier must be enrolled in the Medicare program. We looked at the file and Medicare rules. The services were rendered by a provider who is not eligible to provide services under Original Medicare. Based on this information, we decided that Medicare rules for coverage of the home health care services have not been met. Therefore, we decided that the Plan does not have to pay for the home health care services provided from January 3, 2020, to January 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Cxbladder testing rendered on November 12, 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 the testing is not covered.

The Plan must follow Medicare rules. The rules say that the CxBladder testing is non-covered.

We looked at the file and Medicare rules. The test at issue is CxBladder. This test is not covered by Medicare.Therefore, we decided that the Plan does not have to pay for the Cxbladder testing rendered on November 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction rendered on February 2, 2021.

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 not for a routine eye exam.

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 covers an eye refraction only when performed as part of a routine eye exam.

We looked at the file and the Plan's rules. The file shows that you received an eye refraction that was not part of a routine eye exam. Based on this information, we decided that the Plan's rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay for the eye refraction rendered on February 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the shingles vaccine provided on September 30, 2020.

You asked the Plan to pay for the shingles vaccine. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the shingles vaccine is not covered under your Medicare Part B benefit.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. The Plan follows the same rules. 

Records do not show that you have been injured or directly exposed to any illness related to the shingles vaccine. Therefore, we decided that the Plan does not have to pay for the shingles vaccine provided on September 30, 2020.

Benefits for the shingles vaccine may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on January 22, 2021.
You asked the Plan to pay for a comprehensive oral evaluation. You say that you were told you would be covered for a teeth cleaning. The Plan denied your request. The Plan says the service is a covered benefit, but you have exceeded the frequency limit of one every 36 months.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation have not been met. Specifically, the record shows that you had exceeded the frequency limit prior to this service on February 5, 2020. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on January 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an outpatient surgery provided by a participating hospital on September 21, 2020, to September 22, 2020.

You asked the Plan to waive the coinsurance for an outpatient surgery. You say that you had the same surgery last year and you did not have to pay this much. The Plan denied your request. The Plan says the correct copayment has been applied.

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 25% coinsurance for outpatient surgery/outpatient hospital. 

You have been asked to pay a 25% coinsurance of the allowed amount for an outpatient surgery. The total allowed amount is $14,417.71. The total amount you are being asked to pay is $3,604.43 ($14,417.71 x 25% = $3,604.43). The correct coinsurance has been applied to the services that were provided. An outpatient surgery falls within the outpatient surgery/outpatient hospital 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 coinsurance for an outpatient surgery provided by a participating hospital on September 21, 2020, to September 22, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (83550, 82728, 82306) provided December 2, 2020.

You asked the Plan to pay for the lab services. You say that the services should be covered. The Plan denied your request. The Plan says these tests were for screening purposes and are not covered. A notice was provided advising the services would not be covered prior to them being provided.

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 tests at issue in this appeal were requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for lab services (83550, 82728, 82306) provided December 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound of arm and leg arteries provided on December 22, 2020.

You asked the Plan to waive the copayment for the ultrasound. You say that the nurse misdiagnosed your condition and the necessity for a procedure that you didn't need. You say that the Plan should absorb 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 a $130 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a free-standing facility.

You have been asked to pay a $130 copayment for the ultrasound. the 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 the ultrasound of arm and leg arteries provided on December 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (00811) provided November 30, 2020.
You asked the Plan to pay for the anesthesia services. You say that the services were medically necessary. The Plan denied your request. The Plan says an Explanation of Benefits (EOB) from the member's primary insurance carrier is needed before this claim can be considered.
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 requested an Explanation of Benefits from the primary carrier. As the secondary insurer, the Plan cannot be held responsible for the anesthesia services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for anesthesia services (00811) provided November 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for prostate specific antigen (PSA) (84153) venipuncture (36415) provided on September 16, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the laboratory services. You say that the records are attached to support the lab procedures as medically necessary. No authorization was needed as your doctor is in network. Please review the attached records and allow for processing of payment on these claims. 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 prostate specific antigen (PSA) (84153) venipuncture (36415) provided on September 16, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.

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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for pneumonia. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 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. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care.

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 laparoscopy (CPT code 43644).

You asked the Plan to pre-approve the surgery. You say that you feel that you meet the criteria for the surgery. You state you are on several (7) medications and have other health issues.The Plan denied your request. The Plan says you do not have a comorbid condition.

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 surgery. Our physician reviewer found you do not meet the criteria listed in the LCD. The surgical management for the treatment of morbid obesity is considered reasonable and necessary when ALL of the following conditions are met and recorded in the medical record: The patient meets the definition of morbid obesity which is defined as a body mass index (BMI) greater than 35 and comorbid conditions exist (e.g., hypertensive cardiovascular disease, pulmonary/respiratory disease, diabetes, sleep apnea or degenerative arthritis of weight-bearing joints). Documentation of the level of severity of the comorbid existing condition must be included in the patient's medical record; AND, the patient has been previously unsuccessful with medical treatment for obesity; AND, treatable metabolic causes for obesity (e.g., adrenal or thyroid disorders) have been ruled out or have been clinically treated if present. The enrollee is not on maximal doses of three antihypertensive medications.

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 surgery have not been met.Therefore, we decided that the Plan does not have to pre-approve laparoscopy (CPT code 43644).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the child prophylaxis (D1120) and topical application of fluoride excluding varnish (D1208) provided on December 14, 2020.
You asked the Plan to pay for the child prophylaxis and topical application of fluoride excluding varnish. You say that these services should be covered. The Plan denied your request. The Plan says these services are 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 child prophylaxis (D1120) and topical application of fluoride excluding varnish (D1208) provided on December 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre monitor for the enrollee.
You asked the Plan to pre-approve the monitor. You say that the diabetes has been much more controlled with the use of this monitor. The Plan denied your request. The Plan says this 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 the monitor. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Freestyle Libre monitor would not be considered therapeutic. The enrollee has not been using insulin at all and did not require frequent adjustments according to the notes. 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 monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre monitor for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for wound care provided from May 1, 2020, through May 22, 2020 and the ER visit on June 10, 2020.

You asked the Plan to waive the copayment for the wound care and ER visit. You say that you have no income and don't understand why you are paying a lot of money. The Plan denied your request. The Plan says the claim reprocessed to apply a $45 copayment for each wound care visit and the ER copayment applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 copayment for wound care provided at an in-network outpatient hospital and a $90 copayment for emergency services in an emergency room. 

You have been asked to pay a total of $270 for the wound care and ER visit.

The wound care falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The ER visit falls within the "Emergency 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 wound care provided from May 1, 2020, through May 22, 2020 and the ER visit on June 10, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drug services provided by a participating provider on January 27, 2021.
You asked the Plan to waive the coinsurance for Medicare Part B drug services. You say that this extra charge is a burden for you. The Plan denied your request. The Plan says the correct coinsurance has been applied.
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 Medicare Part B prescription drugs. You have been asked to pay a 20% coinsurance of the allowed amount for Medicare Part B drug services. The total allowed amount is $316. The total amount you are being asked to pay is $63.20 ($316 x 20% = $63.20). Medicare Part B drug services falls within the Medicare Part B prescription drugs 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 coinsurance for Medicare Part B drug services provided by a participating provider on January 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed (93306) provided February 2, 2021.
You asked the Plan to waive the copayment for the diagnostic services. You say that you went for your annual physical and they told you needed an echo because your EKG showed a glitch. The doctor wanted it done and it turned out completely normal. The Plan denied your request. The Plan says the claim was processed and the correct copayment was applied per the Evidence of Coverage.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $100 copay for diagnostic procedures and test in an outpatient hospital. You have been asked to pay $100 copay for the diagnostic services. The diagnostic services fall 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 echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed (93306) provided February 2, 2021.