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

We decided that the Plan does not have to waive the copayment for a duplex scan (93971) provided January 21, 2020.
You asked the Plan to waive the copayment for the duplex scan. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct cost-sharing 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 $110 copayment for Outpatient Diagnostic Radiology. You have been asked to pay a $110 copayment for the duplex scan. The duplex scan falls within the Outpatient Diagnostic Radiology 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 duplex scan (93971) provided January 21, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz (J7321).
You asked the Plan to pre-approve Supartz. You say that this is medically necessary. The Plan denied your request. The Plan says step therapy requirements have not been met.
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 Supartz. Our reviewer says that the criteria for coverage of Supartz have not been met. Our physician reviewer found the Plan requires a trial of Monovisc and Orthovisc before they will approve the requested drug. he documentation does not support that the enrollee has tried Monovisc and Orthovisc or that these drugs would likely be less effective or have adverse effects for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Supartz have not been met. Therefore, we decided that the Plan does not have to pre-approve Supartz (J7321).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) and a knee orthosis with
suspension sleeve (L1851, L2397) provided to the enrollee on February 6, 2020.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your
request. The Plan says the documentation does not indicate services are necessary for treatment of the
enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis
(L0650) and a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on February 6,
2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided by on January 30, 2020.
You asked the Plan to waive the copayment for the ambulance transport. You say that you did not have a choice of how you were transported. You say that you initially drove yourself to the hospital so you do not owe 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 $250 copayment for ground travel. You have been asked to pay a $250 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance services" benefit category. There is no provision in the contract which indicates a copayment would be waived if you are transferred by ambulance between hospitals. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance transport provided by on January 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic preventative exam provided on January 9, 2020.
You asked the Plan to pay for the periodic preventative exam. You say that you should not have to cover an exam that has been covered in prior years. The Plan denied your request. The Plan says upon review of your claim history, it shows that you had this same service previously on October 22, 2018 and the services denied a non-covered benefit.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the periodic preventative exam have not been met. Review of the file show that you received a periodic preventative exam provided on January 9, 2020. Your EOC states, services not covered by Medicare: preventative services, except for those services specifically covered by Original Medicare. Therefore, we decided that the Plan does not have to pay for the periodic preventative exam provided on January 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services that you provided on January 21, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must
receive care from in-network providers with the exception of emergency or urgent care or if the care cannot be
provided with an in-network provider, which requires prior authorization from 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 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 physician's services that you provided on January 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on October 4,
2019.
You asked the Plan to waive the copayment for the office visit. You say that this was a pre-operative exam for
a preventive colonoscopy. You say that the copayment charge should be removed. 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 $40
copayment for services obtained from an in-network specialist, or under certain circumstances, treatment by a
nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's
office. Covered services include consultation, diagnosis, and treatment by a specialist.
You have been asked to pay a $40 copayment for the office visit. The office visit falls within the
"Physician/Practitioner Services, Including Doctor's Office Visits" benefit category. There is no provision in
the contract which indicates a copayment would be waived if performed as a pre-operative service. 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 office visit provided on October 4, 2019.
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 the enrollee requires 3 hours of therapy a day and
multiple visits from multidisciplinary team. The Plan denied your request. The Plan says the guidelines for
coverage have not been met. The Plan says that the care needed can be provided in an alternate setting.
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 IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the enrollee was medically stable with no evidence of need for supervision by a
physical medicine and rehabilitation physician or needs acute rehab nursing care. Functionally, given his
fatigue and current level, he does not require IRF level of therapies. The enrollee may benefit from further
physical therapy and occupational therapy, but does not require an intensive therapy program. An IRF
admission is not medically necessary based on the enrollee's current functional status, fatigue and medical
stability.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crowns on teeth #24 and #25 for the enrollee.
You asked the Plan to pre-approve the crowns. You say that this is medically necessary. The Plan denied your request. The Plan says there is coverage for two crowns per calendar year, as long as the medical necessity criteria for the services are met.
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. The Plan covers the crowns when the services are medically necessary and reasonable. 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 crowns. Our reviewer says that the requested crowns are not medically reasonable or necessary. Our physician reviewer found crowns are a covered service if the tooth has significant coronal breakdown due to caries or fracture. The documentation provided does not show that teeth #'s 24 and 25 have significant coronal breakdown due to caries or fracture to warrant this service. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crowns have not been met. Therefore, we decided that the Plan does not have to pre-approve crowns on teeth #24 and #25 for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repeat bariatric surgery (43659, 43848). You asked the Plan to pre-approve repeat bariatric surgery. You say that this should be covered. The Plan denied your request. The Plan says this is not considered reasonable and necessary under Medicare rules. The Plan must follow Medicare rules. Medicare rules say that repeat bariatric surgery is generally not reasonable and necessary. Medicare does not provide prior authorization for these services. We looked at the file and Medicare rules. The requested service is generally not reasonable and necessary. Based on this information, we decided that Medicare rules for coverage of repeat bariatric surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve repeat bariatric surgery (43659, 43848).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for vision services provided on March 11, 2020.
You asked the Plan to pay for the vision services. You say that the provider told you the vision services would be covered. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from 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 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 vision services provided on March 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed and mattress.
You asked the Plan to pre-approve a semi-electric hospital bed and mattress. You say that because of the CPAP the enrollee cannot lay flat and needs a semi-electric hospital bed and mattress. The Plan denied your request. The Plan says the documentation does not indicate that the enrollee requires frequent and immediate need for a change in body position or evidence of pressure ulcers.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient: 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. Requires attachments which can only be attached to a hospital bed; AND 3. Requires frequent changes in body position and/or has an immediate need for a change in body position. We looked at the file and Medicare rules. The medical records do not show the frequent or immediate need for a change in body position. Based on this information, we decided that Medicare rules for coverage of a semi-electric hospital bed and mattress have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed and mattress.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided January 3, 2020 to January 7, 2020.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you were not expecting such a large bill and this is a financial hardship. The Plan denied your request. The Plan says you have been charged 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 $200 copayment per day for days 1-5 and $0 after day 5, each time you are admitted to an acute care hospital. You have been asked to pay a $200 copayment for each day of the inpatient hospital stay. ($200 x 4 = $800). The inpatient hospital stay falls within the "Inpatient hospital stay" 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 inpatient hospital stay provided from January 3, 2020 to January 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision services provided on February 4, 2020.
You asked the Plan to pay for the services provided. You say that you were told the services were covered. The
Plan denied your request. The Plan says you were not seen 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 file shows that you received a medical eye exam. A $35 copay was applied for the exam. The exam falls
within the vision care benefit category. You have been asked to pay the correct amount based on the contract
with the Plan. This cost sharing is a contractual obligation you agreed to pay upon enrolling in the Plan.
You also received eye refraction services. We looked at the file and the Plan's rules. Eye refractions are
covered during routine eye exams. Because you did not receive a routine eye exam, the provided refraction
services are not covered. Based on this information, we decided that the Plan's rules for coverage have not been
met. Therefore, we decided that the Plan does not have to pay for the vision services provided on February 4,
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nerve conduction studies (95907), needle electromyography (95885) and an unlisted procedure (95999) provided on May 29, 2019.
You asked the Plan to pay for the neuromonitoring services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the services billed.
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 95907 is nerve conduction studies; 1-2 studies. The CPT Code Manual definition of code 95885 is needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited (List separately in addition to code for primary procedure). The CPT Code Manual definition of code 95999 is unlisted neurological or neuromuscular diagnostic procedure. We asked our coder 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 neuromonitoring services. Our reviewer says that CPT codes 95907 and 95885 do not meet criteria for billing or reimbursement consideration. The documentation submitted does not indicate that nerve conduction studies, 1-2 studies or needle electromyograhy services were rendered. Our reviewer found CPT code 95999 does not meet criteria for billing or reimbursement consideration. The record indicates that the provider is billing this code to describe train of four testing which is inclusive to the primary neuromonitoring services. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the neuromonitoring services have not been met. Therefore, we decided that the
Plan does not have to pay for nerve conduction studies (95907), needle electromyography (95885) and an unlisted procedure (95999) provided on May 29, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on February 7, 2020.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network 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. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the laboratory services. 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 laboratory services provided on February 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for cone beam CT capture and interpretation with limited field of view - less than one whole jaw (D0364) provided on January 17, 2020 by an out-of-network provider.
You asked the Plan to pay for the dental services. You say that you do not agree with the processing of this claim. You say that the claims should be paid at the in-network rate since there is no in-network dental within 90 miles. The Plan denied your request. The Plan says the service is not a covered benefit under the plan.
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. This service is not listed in your EOC as a covered benefit; therefore, it is not covered. Therefore, we decided that the Plan does not have to pay for cone beam CT capture and interpretation with limited field of view - less than one whole jaw (D0364) provided on January 17, 2020 by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on November 6, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed,
however, the physician must clearly document, in the medical record, his or her intent that the test be
performed.
We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the
medical record. We find that the issue of intent is not clear. There are no medical records in the case file in
regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided
that the Plan does not have to pay for the laboratory services provided on November 6, 2019.