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

We decided that the Plan does not have to waive the cost share for the office visits and Part B drugs provided
from January 31, 2019 through February 11, 2019.
You asked the Plan to waive the cost share for the office visits and Part B drugs. You say that you were not
informed there would be a charge every time you go. You say that you could have had it at home for free. The
Plan denied your request. The Plan says the cost share 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 $50
copayment for in-network specialist services and 20% coinsurance for chemotherapy drugs and all other drugs
covered under Medicare Part B from an in-network provider.
You have been asked to pay a total of $233.28 for the office visits and Part B drugs.
The office visits fall within the "Physician/Practitioner services, including doctor's office visits" benefit
category. The Part B drugs fall 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 cost share for the office visits and Part B drugs provided from January 31, 2019
through February 11, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 18, 2019 by an out
of network (OON) provider.
You asked the Plan to pay for laboratory testing. You say that you are an independent laboratory and just
perform testing on the specimen received. The Plan denied your request. The Plan says the denial of payment
for these services is correct, because this provider is out-of-network with the Plan and the ordering provider is
also out-of-network with the Plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the medical services provided on October 18, 2019
by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance fora cardiovascular procedure provided on October 10, 2018.You asked the Plan to waive the coinsurance fora cardiovascularprocedure. You say that this should be considered an outpatient surgical procedure.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 allcost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for non-radiological diagnostic services. You have been asked to pay $4,342.25, which is less than the20% coinsurance for a cardiovascular procedure. A cardiovascular procedure 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 coinsurance fora cardiovascular procedure provided on October 10, 2018
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Methylprednisolone injection (J1030), arthrocentesis, aspiration and/or injection (20610), a bupivicaine hydrochloride injection (S0020), and an outpatient office visit (99213).
You asked the Plan to pre-approve the Methylprednisolone injection, arthrocentesis, aspiration and/or injection, bupivicaine hydrochloride injection, and outpatient office visit. You say that you have a cyst in your left knee which is very painful. You also say you feel that any kind of physical therapy would be impossible, due to the pain that you are in, and you would prefer to pursue the treatment that your orthopedic doctor had originally recommended. The Plan denied your request. The Plan says there are no x-rays of the knee and there are no notes showing that all conservative measures (noninvasive treatment) have been tried and not been effective.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Methylprednisolone injection, arthrocentesis, aspiration and/or injection, bupivicaine hydrochloride injection, and outpatient office visit. Our reviewer says that these services are not medically reasonable and necessary. Our physician reviewer found that there is no radiographic evidence to support the diagnosis of osteoarthritis of the left knee. There is also no imaging or physical exam evidence documented to support a diagnosis of Baker's cyst. The documentation does not support that the requested Methylprednisolone would be considered medically reasonable and necessary or safe and effective for your medical 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 the Methylprednisolone injection, arthrocentesis, aspiration and/or injection, bupivicaine hydrochloride injection, and outpatient office visit have not been met. Therefore, we decided that the Plan does not have to pre-approve a Methylprednisolone injection (J1030), arthrocentesis, aspiration and/or injection (20610), a bupivicaine hydrochloride injection (S0020), and an outpatient office visit (99213).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a chest x-ray (71046) provided on November 3, 2019.You asked the Planto pay for the chest x-ray. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says it is inappropriate to report a procedure both as a global service and as the technical or professional component.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 71046 is not supported in the record. Specifically, the record indicates that this service was billed and paid globally on the same date of service. The claim does not include a modifier to indicate that this was a repeat procedure performed by a separate provider. Based on this information, we decided that Medicare rules for coverage of the chest x-ray have not been met. Therefore, we decided that the Plan does not have to pay for a chest x-ray (71046) provided on November 3, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on December 19, 2019.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening services are not covered.
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 lab services at issue in this appeal were requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on December 19, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for an outpatient surgery provided on September 3, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an outpatient surgery. You say that you would like this appeal reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that there is no network deficiency for these services and alternate network providers were found.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for an outpatient surgery provided on September 3, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physician's services providedon August 19, 2019 and October 24, 2019.You asked the Plan to waive the copayment for the physician's services. The Plan denied your request. The Plan says the correct copayment was applied to the claims.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 $50 copayment for a consultation, diagnosis, and treatment by a specialist. You have been asked to pay $50 copaymentfor the physician's services. The physician's services fall within the Physician/Practitioner services, including doctor's office visitsbenefit category. This means that you have been asked to pay the correct amount based on your contractwith 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 physician's services provided by on August 19, 2019 and October 24, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cyclobenzarine HCL.
You asked the Plan to pre-approve Cyclobenzarine HCL. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Cyclobenzarine HCL.
Benefits for Cyclobenzarine HCL 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 the eye refraction rendered to you on January 23, 2020.
You asked the Plan to pay for these services. You say that the services should be covered as a routine eye exam with no copayment. The Plan denied your request. The Plan says the services are not covered.
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 one routine eye exam per year.
We looked at the file and the Plan's rules. The file shows that you received an eye refraction on January 23, 2020. The services were not a routine eye exam because they were provided for a diagnosis of cataracts. Medicare does not cover eye refractions for this diagnosis. 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 to you on January 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed (E0296).You asked the Plan to pre-approve the total electric hospital bed. You say that the bed is medically necessary.The Plan denied your request. The Plan says this type of hospital bed is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item.Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed (E0296).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvepalliative (emergency) treatment (D9110) and endodontic therapy (root canal) (D3330).You asked the Plan to pre-approvethe dental services. You say that you are in pain and you really need this tooth taken care of. The tooth is attached to the bridge and the dentist does not want to extract the tooth.The Plan denied your request. The Plan says the requested service is not listed as covered benefits.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 pre-approvepalliative (emergency) treatment (D9110) and endodontic therapy (root canal) (D3330).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on September 3, 2019by an out of network (OON) provider.You asked the Plan to pay forlaboratory tests. You say that you are appealing based on medical necessity.The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe medical services provided on September 3, 2019 by an out of network (OON) provider
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home health services rendered from July 6, 2019 to October 30, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied yourrequest. The Plan says the claim was not billed correctly.The Plan must follow Medicare rules. The rules say that the Type of Bill (TOB) code 032x is required for home health services under a plan of treatment. We looked at the file and Medicare rules. The claims were not billed with the required TOB code. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe home health services rendered from July 6, 2019 to October 30, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on May 29, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency for these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the 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 to the enrollee by an out-of-network provider on May 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to provide additional reimbursement forthe surgical services provided between October 16, 2019 and October 19, 2019 in Costa Rica.You asked the Plan to provide additional reimbursement forthe surgical services. You say that you feel that the full amount paid should be reimbursed because you did not have the option to return to the US and had no choice but to pay this amount out of pocket.The Plan denied your request. The Plan says your plan does cover emergency services outside of the US; however, it is noted that reimbursement will be limited to the Medicare allowable rates and you may be charged more than this amount.The Plan must follow Medicare rules. Medicare rules say that most services provided outside of the United States are not covered. Your plan offers an additional benefit but indicates that payment is limited to the amount allowable by Medicare.In this case, these services do not meet the exceptions for Medicare coverage. Your plan has fulfilled its obligation and paid for these services up to the Medicare allowable for the procedure. No further reimbursement above this amount is required based on your contract.Therefore, we decided that the Plan does not have to provide additional reimbursement forthe surgical services provided between October 16, 2019 and October 19, 2019 in Costa Rica.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for digital breast tomosynthesis (77062) provided on December 13, 2019.
You asked the Plan to pay for the digital breast tomosynthesis. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 77062 has a status code if I which is not valid for Medicare purposes.
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 77062 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code 77062 has a status code of I. This means that CPT code 77062 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the digital breast tomosynthesis have not been met. Therefore, we decided that the Plan does not have to pay for digital breast tomosynthesis (77062) provided on December 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 3, 2019 by an out of network provider.You asked the Plan to pay for the medical services; C1767, C1778, and 95972. You say that the Plan should pay this claim.The Plan denied your request. The Plan says prior authorization was not requested.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for the medical services provided on September 3, 2019 by an out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve inpatient rehabilitation facility care. You say that an acute inpatient rehabilitation facility admission is medically necessary.The Plan denied your request. The Plan says you do not meet criteria for coverage of an acute inpatient rehabilitation facility admission.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 inpatient rehabilitation facility care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that your medical conditions appear stable. There are no complex wound care needs and no unaddressed medical issues. You do not require medical oversight of your condition at an acute hospital level of care. You require physical therapy for mobility and occupational therapy for remaining activities of daily living and adaptive equipment. You are ambulating household distances and performing essential activities of daily living without hands-on assistance and do not require an intensive rehabilitation therapy program.You would not be expected to be able to fully participate in or benefit from the required intensity of an acute rehabilitation therapy program. Additionally, an intensive rehabilitation therapy program would not significantly impact your condition differently compared with therapy provided at a less intense level. Your care can be appropriately provided at a skilled nursing facility level.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient rehabilitation facility care have not been met.Therefore, we decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical supply services provided to the enrollee on September 24, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says separately billed services/tests have been bundled as they are considered components of the same procedure.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, the CPT Code Manual definition of HCPCS code A4550 is "surgical trays." We find that CPT code A4550 is not supported in the medical record. Specifically, this code is not allowed to be billed separately. It is included in the payment for the surgical procedure Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for surgical supply services provided to the enrollee on September 24, 2019.