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

We decided that the Plan does not have to waive the copayment for cataract surgery provided on October 12, 2020.

You asked the Plan to waive the copayment for cataract surgery. You say that you were not told about this copayment. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.

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 $200 copayment for cataract surgery at an ambulatory surgical center. 

You have been asked to pay $200 copayment for cataract surgery. Cataract surgery 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 cataract surgery provided on October 12, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Genvisc intra-articular injection (J7320).

You asked the Plan to pre-approve Genvisc. You say that this drug is preferred because the enrollee has used it in the past. You also say that the requested drug is medically necessary. The Plan denied your request. The Plan says no clinical reason provided as to why one of the alternative preferred drugs cannot be used. The Plan says that the step therapy requirements were not met. The Plan also says that the requested drug is not medically necessary.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Genvisc. Our reviewer says that Genvisc is not medically necessary. Our physician reviewer found based on the provided documentation the enrollee has not tried and failed the required drugs, Synvisc or Synvisc One and Euflexxa. The reviewer found that the provided documentation does not indicate that the Plan's required drugs would likely be less effective or likely have adverse effects for the enrollee.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Genvisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Genvisc intra-articular injection (J7320).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis coded L1833 and the addition coded L2397 provided on September 4, 2020.

You asked the Plan to pay for the knee orthosis and the addition. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the items rendered are not a covered benefit.

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 codes L1833 and L2397 are not supported in the medical record. Specifically, the documentation does not support that the prescribing physician ever saw the enrollee. There were no claims submitted for the ordering physician. This means that an established relationship between the prescribing physician and the enrollee has not been supported. Based on this information, we decided that Medicare rules for coverage of the knee orthosis and the addition have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis coded L1833 and the addition coded L2397 provided on September 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and related services provided by an out of network (OON) provider.

You asked the Plan to pay for the office visit and related services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.

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 office visit and related services provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 80053, 82306, 82607, 82728, 82746, 83540, 83550, 83735, 84443, 85025, 85652, 86140, 86225, 86235, 86431, 86704, 86706, 87340, and G0472 provided on February 18, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.

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 codes 80053, 82306, 82607, 82728, 82746, 83540, 83550, 83735, 84443, 85025, 85652, 86140, 86225, 86235, 86431, 86704, 86706, 87340, and G0472 are not supported in the medical record. Specifically, the medical records submitted did not include documentation of a comprehensive metabolic panel, Vitamin D testing, Cyanocobalamin testing, Ferritin testing, Folic acid testing, Iron testing, Iron binding, Magnesium testing, Thyroid stimulating hormone testing, blood count, Sedimentation rate, C-reactive protein testing, Deoxyribonucleic acid antibody testing, Extractable nuclear antigen testing, Rheumatoid factor, Hepatitis B core antibody testing, Hepatitis B surface antibody testing, infectious agent antigen detection by immunoassay technique testing, and Hepatitis C antibody screening. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 80053, 82306, 82607, 82728, 82746, 83540, 83550, 83735, 84443, 85025, 85652, 86140, 86225, 86235, 86431, 86704, 86706, 87340, and G0472 provided on February 18, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to adjust the cost share liability for the total knee arthroplasty (27447) and the physical therapy (97161) provided from September 29, 2020, through September 30, 2020.

You asked the Plan to adjust the cost share liability. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the cost share liability has been applied correctly to the services provided.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance per visit for outpatient surgery. Additionally, you pay a $40 copayment for each Medicare-covered outpatient therapy visit. 

You have been asked to pay $2,639.75 (Plan allowed amount of $13,096.68 x 20% coinsurance= $2,619.34) for the outpatient surgery and a $20.41 copayment for the Medicare-covered outpatient therapy provided. This is the Plan allowed amount for the therapy provided, which is less than the applicable copayment. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to adjust the cost share liability for the total knee arthroplasty (27447) and the physical therapy (97161) provided from September 29, 2020, through September 30, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the inpatient hospital services provided from September 18, 2020, to September 22, 2020.

You asked the Plan to waive the cost share for the inpatient hospital services. You say that you had no control on how long you were in the hospital. The Plan denied your request. The Plan says you were charged the cost share 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 deductible for in-network services and 10% coinsurance for inpatient care. 

You have been asked to pay $242.72 towards your deductible and $1049.69 for your inpatient coinsurance. 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 inpatient hospital services provided from September 18, 2020, to September 22, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the CxBladder testing.

You asked the Plan to pay for the CxBladder testing. You say that you would like reconsideration because this testing was medically necessary. The Plan denied your request. The Plan says that the test is not covered for screening purposes.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 

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 CxBladder testing. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found incorporation of Cxbladder testing results into the clinical evaluation may reduce the number of unnecessary invasive diagnostic procedures in patients with asymptomatic microscopic hematuria, based on a real-world utility analysis. This member fits criteria and given smoking history he is at higher risk for bladder cancer. 

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 CxBladder testing have been met. Therefore, we decided that the Plan has to pay for the CxBladder testing.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the power mobility device (E0971, E0956, E1161, E1028).

You asked the Plan to pay for the power mobility device. You say that the items were medically necessary. The Plan denied your request. The Plan says there were network providers available.

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 at issue in this appeal. The Plan did not pre-approve the item at issue. We found no exception that would require the Plan to pay for these items. Therefore, we decided that the Plan does not have to pay for the power mobility device (E0971, E0956, E1161, E1028).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share liability for the dental cleaning (D1110) provided on October 1, 2020.

You asked the Plan to waive the cost share liability. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the cost share liability has been applied correctly to the service provided.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $0 copayment for a routine teeth cleaning when provided by an in-network dentist. If your dental services are performed by a dentist outside of the network, you will be responsible for paying the difference between the dentist's fees and the Plan dental fee schedule. 

You have been asked to pay $29 (the billed amount of $100 minus the Plan allowed amount of $71) for the dental cleaning provided by an out of network provider. 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 liability for the dental cleaning (D1110) provided on October 1, 2020.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that it is felt this is medically necessary. The Plan denied 
your request. The Plan says Medicare criteria for this device are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic digital breast tomosynthesis (G0279).

You asked the Plan to pay for the diagnostic digital breast tomosynthesis. You say that you would like reconsideration because the member had multiple exams on the same date of service. The Plan denied your request. The Plan says the submitted documentation supports 1 unit of G0279, which was previously approved/paid.

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 G0279 is diagnostic digital breast tomosynthesis, unilateral or bilateral (list separately in addition to 77065 or 77066). 

We find that CPT code G0279 is not supported in the record. Specifically, the record indicates that one unit of CPT code G0279 was previously processed and paid. The documentation submitted does not support an additional unit of CPT code G0279 being performed. Based on this information, we decided that Medicare rules for coverage of the diagnostic digital breast tomosynthesis have not been met. Therefore, we decided that the Plan does not have to pay for diagnostic digital breast tomosynthesis (G0279).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 18, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the OON services. You say that the visits are not pre-scheduled, so an authorization was not obtained. The Plan denied your request. The Plan says prior authorization was not obtained.

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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. 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 the medical services provided on September 18, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an out of network (OON) provider.

You asked the Plan to pay for the OON services. You say that neither the group nor the enrollee was informed that pre-authorization was required. The Plan denied your request. The Plan says prior authorization was not obtained as required.

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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the /services at issue in this appeal. 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 the medical services provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the vision care services.

You asked the Plan to waive the copay for the services provided. You say that your plan was inadvertently
changed. The Plan denied your request. The Plan says 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 $40
copay for Medicare-covered vision services.

You have been asked to pay a $40 copay for each visit. The services fall within the vision care benefit
category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we
decided that the Plan does not have to waive the copay for the vision care services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (88104, 88305, 88312, 88361) provided
on July 1, 2020.

You asked the Plan to pay for laboratory services. You say that this was medically necessary. The Plan denied
your request. The Plan says this was not billed with the required modifier.

The Plan must follow Medicare rules. Medicare rules say that only the hospital may bill for the TC of a
physician pathology service provided to an inpatient or outpatient.

We looked at the file and Medicare rules. The record shows that the enrollee was a hospital outpatient at the
time of service. These services were not billed with the necessary modifier to bill for only the professional
component. Based on this information, we decided that Medicare rules for coverage of laboratory services have
not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (88104, 88305,
88312, 88361) provided on July 1, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a Computed Tomography (CT) scan provided on October 15, 2020.

You asked the Plan to waive the copayment for CT scan. You say that this test was supposed to be performed with a previous test on October 13, 2020, and you were told that rescheduling would not cause another copayment. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.

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 $200 copayment per visit for in-network CT scan. This was a separate visit, therefore a separate copayment applies to this claim. 

You have been asked to pay $200 copayment for CT scan. 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 a Computed Tomography (CT) scan provided on October 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an out of network (OON) provider.

You asked the Plan to pay for the services provided. You say that the specimen was sent by an authorized provider. The Plan denied your request. The Plan says services rendered by non-participating providers require prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

Neither the referring provider, nor the rendering provider in this case is a network provider with the Plan. The Plan had network providers available to provide the services at issue in this appeal. The Plan did not pre-approve the services. We found no exception that would require the Plan to pay for these OON services. Therefore, we decided that the Plan does not have to pay for the medical services provided by an out of network (OON) provider.