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

We decided that the Plan does not have to waive the deductible for laboratory tests provided on January 28, 2021.
You asked the Plan to waive the deductible for laboratory tests. You say that you do not understand why the Plan did not submit the charges to Medicare. 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. Your contract with the Plan says that there is a $100 deductible for outpatient diagnostic tests and therapeutic services and supplies. You received laboratory services on January 28, 2021. The record shows that you had only paid $6.75 toward the $100 deductible prior to receiving the services. Therefore, you are responsible to pay the remaining deductible balance of $93.25. The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly
disclosing in the contract that there is a $100 deductible for outpatient diagnostic tests and therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time laboratory tests was received on January 28, 2021. Therefore, we decided that the Plan does not have to waive the deductible for laboratory tests provided on January 28, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health care provided to the enrollee on February 26, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the claim was submitted with an inappropriate place of service (POS) code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case POS code 31 is not an appropriate code for the services and location billed.
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for outpatient mental health care provided to the enrollee on February 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Myeloid panel 68.
You asked the Plan to pre-approve Myeloid panel 68. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the requested services are not a covered benefit.
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 Myeloid panel 68 test at issue in this appeal is being 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 preapprove
Myeloid panel 68.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214, 93000) provided on April 27, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for an OON office visit. You say that this was medically necessary. The Plan denied your request. The Plan says this was not authorized.

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 an office visit (99214, 93000) provided on April 27, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genetic testing to be provided by an out-of-network
(OON) provider.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are available from network providers.
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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
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.
We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve genetic testing to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME and related supplies provided on March 12, 2021, and April 12, 2021.
You asked the Plan to waive the coinsurance for DME and related supplies. You say that you have not received the devices yet and disagree with the charges. 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 10% coinsurance for DME and related supplies. You received DME and related supplies on March 12, 2021, and April 12, 2021. Therefore, you are responsible
to pay your share of the cost-sharing charges. Please see the chart below.
Date of Service Service Codes Allowed Amount Amount You Owe
3/12/2021 E0431 $25 $2.50
3/12/2021 E1390 $135 $13.50
4/12/2021 E0431 $25 $2.50
4/12/2021 E1390 $135 $13.50
The total amount you owe is: $32.
You have been asked to pay the total coinsurance amount of $32 for DME and related supplies. DME and
related supplies fall within the DME and related 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 coinsurance for DME and related supplies provided on March 12, 2021, and April 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a neurectomy of the greater and lesser occipital nerves.
You asked the Plan to pre-approve a neurectomy of the greater and lesser occipital nerves. You say that this request is medically necessary. The Plan denied your request. The Plan says there is insufficient evidence of efficacy for the requested procedure.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a neurectomy of the greater and lesser occipital nerves. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a 58-year-old woman with a diagnosis of occipital neuralgia. In this case, the role of neurectomy of the greater and lesser occipital nerves in the enrollee's clinical setting has not been established. The requested procedure would be considered experimental/investigational for the enrollee's condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a neurectomy of the greater and lesser occipital nerves have not been met. Therefore, we decided that the Plan does not have to pre-approve a neurectomy of the greater and lesser occipital nerves.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory tests provided on March 24, 2021.

You asked the Plan to waive the copayment for laboratory tests. You say that the laboratory tests were part of your annual wellness visit and you should not owe a copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 copayment for laboratory tests. 

You received laboratory tests during an annual wellness visit on March 24, 2021. Laboratory tests are not included in annual wellness exams. Therefore, you are responsible to pay the $10 copayment. 

You have been asked to pay a $10 copayment for laboratory tests. Laboratory tests 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 laboratory tests provided on March 24, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (88305) provided on March 8, 2021 by an out-of-
network (OON) provider.

You asked the Plan to pay for the lab services. You say that the services 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 services at issue in this appeal. The Plan did not pre-approve the service
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 lab services (88305) provided on March 8, 2021 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 extraction, erupted tooth requiring removal of bone
and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) received
December 17, 2020 from the out-of-network provider.
You asked the Plan to pay for the extraction. You say that the Plan should cover the requested service. The
Plan denied your request. The Plan says there are no benefits available for dental services that are rendered
from an out-of-network provider.
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 when received from an out-of-network provider. Therefore, we decided
that the Plan does not have to pay for the extraction, erupted tooth requiring removal of bone and/or sectioning
of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) received December 17, 2020 from
the out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for trifocal lenses (V2302), progressive lenses (V2781) index 
1.54 to 1.65 plastic lenses (V2782), spherocylinder lenses (V2303), anti-reflective coating (V2750) and 
ultraviolet lenses (V2755) provided on November 5, 2020. 
 
You asked the Plan to pay for eyewear lenses. You say that you were told by your eye surgeon, that you should 
go back to your regular eye doctor and get glasses after cataract surgery. You also say that this was not 
discussed with the provider and you were not aware that the services would not be covered. The Plan denied 
your request. The Plan says the services are not covered benefits. 
 
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 does not cover these services. 
 
We looked at the file and the Plan's rules. The lenses that you purchased are not covered benefits of Medicare 
or the Plan. The EOC confirms that a basic pair of frames or lenses are covered and upgrades are not a covered 
benefit. Based on this information, we decided that the Plan's rules for coverage of eyewear lenses have not 
been met. Therefore, we decided that the Plan does not have to pay for trifocal lenses (V2302), progressive 
lenses (V2781) index 1.54 to 1.65 plastic lenses (V2782), spherocylinder lenses (V2303), anti-reflective 
coating (V2750) and ultraviolet lenses (V2755) provided on November 5, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a transthoracic echocardiograph (93306).
You asked the Plan to pre-approve the transthoracic echocardiograph. You say that the procedure is medically necessary. The Plan denied your request. The Plan says that coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that transthoracic echocardiography is covered when 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 pre-approve the transthoracic echocardiograph. Our reviewer says that the requested procedure is medically necessary. Our physician reviewer found given the ongoing and persistent symptoms, the borderline findings on the echocardiograph from 3 months prior, and the active consideration for transcatheter aortic valve replacement (TAVR), a repeat transthoracic echocardiogram to reassess the gradients and the other needed parameters prior to TAVR is reasonable and medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the transthoracic echocardiograph have been met. Therefore, we decided that the Plan has to pre-approve a transthoracic echocardiograph (93306).
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the periodic oral evaluation and prophylaxis provided on February 17, 2021 by an OON provider.

You asked the Plan to pay more for the periodic oral evaluation and prophylaxis. You say that these services are supposed to be covered at 100%. The Plan denied your request. The Plan says the treating provider does not have a contract with the Plan as a participating provider and is allowed to bill the difference of the allowed amount and their billed amount to you.

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, you are responsible for the difference between the billed amount and allowed amount for dental services received OON. Therefore, we decided that the Plan does not have to pay more for the periodic oral evaluation and prophylaxis provided on February 17, 2021 by an OON provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for ultrasounds provided on October 1, 2020.

You asked the Plan to waive the copayments for ultrasound. You say that you disagree with the additional copayment and feel the charges are too high. 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 $125 copayment for each ultrasound. 

You received two ultrasounds on October 1, 2020. Therefore, you are responsible to pay a $125 copayment per each ultrasound. However, you are only being asked to pay the total allowed amount of $200, which is less than the total copayment amount. 

You have been asked to pay the total amount of $200 for ultrasounds. Ultrasounds 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 copayments for ultrasounds provided on October 1, 2020.
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 for the enrollee.
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 the enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care
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 e and blunt head trauma after a fall. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's 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 for the enrollee.reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the biopsy provided on March 10, 2021.

You asked the Plan to waive the copayment for the biopsy. You say that you cannot afford the copayment. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing 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 $295 copayment for all other outpatient services not provided in an ambulatory surgical center.

You have been asked to pay a $295 copayment for the biopsy. The biopsy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the biopsy provided on March 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on March 9, 2021.
You asked the Plan to waive the copayment for a specialist visit. You say that this was a follow-up visit to a surgical procedure and you should not owe a copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for specialist visits. You had a specialist visit on March 9, 2021. Follow-up visits are subject to cost-sharing charges. Therefore, you are responsible to pay the $40 copayment.
You have been asked to pay a $40 copayment for a specialist visit. A specialist 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 for a specialist visit provided on March 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a Fitbit provided on November 29, 2020.
You asked the Plan to reimburse you for the Fitbit. The Plan denied your request. The Plan says a Fitbit is not
covered for the 2020 Wellness Allowance Reimbursement Benefit.
The Plan contract provides a Wellness Allowance Reimbursement benefit.
We looked at the file and the Plan's rules. The file shows that this item is not a covered benefit. Therefore, we
decided that the Plan does not have to reimburse you for a Fitbit provided on November 29, 2020.