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

We decided that the Plan does not have to waive the copayment for an EKG provided by a participating provider on October 22, 2020.
You asked the Plan to waive the copayment for an EKG. You say that this was part of your yearly check-up. You say that this should be covered 100%. The Plan denied your request. The Plan says the correct copayment has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment for outpatient diagnostic tests/non-radiology tests. You have been asked to pay $17.04 which is less than your copayment amount of $20 for an EKG. The correct copayment has been applied to the services that were provided. An EKG falls within the outpatient diagnostic tests/non-radiology tests 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 an EKG provided a participating provider on October 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the fixed bridge for tooth #'s 9 to 14.

You asked the Plan to pre-approve the fixed bridge. The Plan denied your request. The Plan says the service is not medically necessary.

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 fixed bridge 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 fixed bridge. Our reviewer says that a fixed bridge would be considered to replace a single maxillary anterior tooth if no posterior teeth are missing and a removable partial denture is contraindicated due to medical or neurological reasons. Our physician reviewer found that tooth #'s 12 and 13 are posterior teeth and there was no indication that a removable partial denture could not be used. Our reviewer says that a fixed bridge to replace missing tooth #'s 10, 12 and 13 does not meet the criteria for coverage.

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 fixed bridge have not been met. Therefore, we decided that the Plan does not have to pre-approve the fixed bridge for tooth #'s 9 to 14.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve the injection procedure for sacroiliac (SI) joint.

You asked the Plan to pre-approve the injection procedure for sacroiliac joint. You say that this request is medically necessary. The Plan denied your request. The Plan says that the criteria for coverage have not been met.

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 pre-approve the injection procedure for sacroiliac joint. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is a 56-year-old man who has chronic low back pain and sacroiliitis. The sacroiliitis is demonstrated on physical exam. The patient is doing a home exercise program is taking medications. He underwent an SI joint injection and achieved 90% pain relief for one month. The request is to do a therapeutic SI joint block. A therapeutic block is indicated after achieving 90% pain relief for one month. Subsequent blocks may not be repeated in less than 2 months. The requested procedure is medically reasonable and 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 injection procedure for sacroiliac joint have been met. Therefore, we decided that the Plan has to pre-approve the injection procedure for sacroiliac (SI) joint.

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on June 9, 2020 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services provided by an OON provider. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 
provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network 
care.

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 laboratory services provided on June 9, 2020 
by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan (70486) provided March 4, 2021.

You asked the Plan to waive the copayment for the CT scan. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $160 copayment for diagnostic radiology.

You have been asked to pay a $160 copayment for the CT scan. The CT scan falls within the 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 computed tomography (CT) scan (70486) provided March 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the group 3 power wheelchair and accessories.

You asked the Plan to pre-approve the group 3 power wheelchair and accessories. You say that these items are medically necessary for your condition. The Plan denied your request. The Plan says the criteria for coverage have not been met.

The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether Medicare coverage criteria have been met. 

We looked at the file and Medicare rules. In this case, we requested medical records to determine if the Medicare coverage criteria have been met. The Plan indicated that the reached out to your provider but did not receive any information. Based on this information, we decided that Medicare rules for coverage of the group 3 power wheelchair and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve the group 3 power wheelchair and accessories.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (99291) provided on February 16, 2021.
You asked the Plan to pay for critical care services. You say that you want the Plan to pay for these services. The Plan denied your request. The Plan says the code billed for this date of service is not supported.
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 asked our coder 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 critical care services. Our reviewer says that services provided on February 16, 2021 do not meet criteria for billing or reimbursement consideration. Our coder reviewer found the medical records submitted do not include sufficient documentation to validate that an evaluation and management of the critically ill or critically injured patient, first 30-74 minutes was performed on February 16, 2021, therefore, this service cannot be verified.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of critical care services have not been met. Specifically, the medical records submitted do not include sufficient documentation to validate that an evaluation and management of the critically ill or critically injured patient was performed. Therefore, we decided that the Plan does not have to pay for critical care services (99291) provided on February 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bioimpedance spectroscopy.

You asked the Plan to pre-approve bioimpedance spectroscopy. You say that this is a Medicare-covered services and is medically necessary for the enrollee. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because scientific assessment of this technique has not been completed and its efficacy has not been established.

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 bioimpedance spectroscopy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is insufficient literature to establish this test as safe and effective for the enrollee's specific clinical 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 bioimpedance spectroscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve bioimpedance spectroscopy.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ultrasonic guidance for needle placement provided on March 19, 2021.

You asked the Plan to waive the copayment for ultrasonic guidance for needle placement. You say that you were told by a Plan representative that you would 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 $50 copayment for diagnostic radiology services. You received ultrasonic guidance for needle placement on March 19, 2021. Ultrasonic guidance for needle placement is considered a diagnostic test, not preventative. Therefore, you are responsible to pay the $50 copayment.

You have been asked to pay a $50 copayment for ultrasonic guidance for needle placement. Ultrasonic guidance for needle placement 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 ultrasonic guidance for needle placement provided on March 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drug (A9270) provided in an outpatient setting on January 16, 2021.

You asked the Plan to pay for the self-administered drug. You say that you went to get an injection in your right hip. You say that when you got there your pain was at a 10 in your left hip too. You say that the doctor advised that only the right hip injection was approved. You also say that the doctor advised that the left hip injection may get denied by your insurance. The Plan denied your request. The Plan says the drug you received is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drug you received is not covered under Medicare Part B.

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 pay for the self-administered drug (A9270) provided in an outpatient setting on January 16, 2021.

Benefits for the self-administered drug 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network provider.

You asked the Plan to pre-approve an out-of-network office visit. You say that you are requesting out of network medical coverage to deal with the on-going nature of the joint problem. The Plan denied your request. The Plan says your needs can be met within your health plan network.

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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the bitewing x-rays (D0274) provided on April 5, 2021.

You asked the Plan to reimburse you for the dental service. You say that the x-rays were necessary. You also say that 2 instances of decay were found. The Plan denied your request. The Plan says there is an annual allowance of $1,000 for preventive and comprehensive dental services. The Plan also says that the annual allowance has been exhausted.

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 and bitewing x-rays are listed as covered, the annual allowance has been exhausted. The record shows that the Plan paid $110.40 for dental services performed on January 14, 2021, $754 for dental services performed on March 11, 2021, and $135.60 for dental services performed on the date of service in this case. $110.40+$754+$135.60=$1,000. Therefore, we decided that the Plan does not have to reimburse you for the bitewing x-rays (D0274) provided on April 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (0037U) provided November 13, 2019. 
 
You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory 
tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary.  
 
We looked at the file and Medicare rules. The plan has performed outreach to the ordering physician on the 
records and has confirmed that the physician listed did not order the services at issue. Based on this 
information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, 
we decided that the Plan does not have to pay for genetic testing (0037U) provided November 13, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One.
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 step therapy requirement is not 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has bilateral primary osteoarthritis of the knee. She has not tried and failed the Plan's required drugs, Orthovisc and Monovisc. The records do not support that the required drugs would be contraindicated or less effective; therefore, Synvisc-One is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit and physician services provide on February 25, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for an office visit and physician services. You say that you have used this provider for two years. You say that this doctor said they accepted your plan. The Plan denied your request. The Plan says prior authorization was not obtained for these services. The Plan says that this provider is not participating with this specific 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 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 and physician services provide on February 25, 2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zioptan.

You asked the Plan to pre-approve Zioptan. You say that the drug is medically necessary. The Plan denied your request. The Plan says this is a self-administered drug.

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 Zioptan.

Benefits for Zioptan 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: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copay for the office visit provided on March 4, 2021.

You asked the Plan to waive the copay for the services provided. The Plan denied your request. The Plan says that the claim processed correctly.

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 enrollees must pay a $0 copay for services in a primary care office. 

The file shows that you received an office visit on March 4, 2021. You also received lab services on the date of service at issue. The Plan says you must pay a $25 copay for the services provided. Based on the Plan contract, however, you cannot be asked to pay more than a $0 copay for services in a primary care office. Therefore, we decided that the Plan has to waive the copay for the office visit provided on March 4, 2021.

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 for the surgical extraction (D7210) provided on November 9, 2020.

You asked the Plan to pay for the surgical extraction. You say that you do not have the money to pay for this service. The Plan denied your request. The Plan says this service is not covered under your 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, you are responsible for 100% of the
cost for extractions. Therefore, we decided that the Plan does not have to pay for the surgical extraction
(D7210) provided on November 9, 2020.