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

We decided that the Plan has to waive the copayment for a diagnostic mammogram provided on August 6, 2019.You asked the Plan to waive the copayment for the diagnostic mammogram. You say that you would like reconsideration because you were not aware there would be a copayment for this service.The Plan denied your request. The Plan says that this copayment has been applied correctly per the EOC.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 does not say in clear and accurate terms how much you should expect to pay for diagnostic radiology services. We looked at your contract with the Plan. We did not see where the contract says enrollees must pay a $75 copayment for diagnostic radiology services. The Plan contract does not clearly say how much enrollees must pay for diagnostic radiology services. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information.Therefore, we decided that the Plan has to waive the copayment fora diagnostic mammogram provided on August 6, 2019.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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the outpatient specialist office visit or the
endoscopy provided on December 7, 2018 and December 10, 2018.
You asked the Plan to waive the cost share for the specialist office visit and the endoscopy. You say that you
are appealing these charges. You say you have had the procedure in the past and was never charged. 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. Your
contract with the Plan says that there is a $475 deductible that applies towards outpatient surgery at an
outpatient hospital facility, a $50 copayment for a specialist, and a $350 copayment per date of service, after
the deductible is met for an outpatient hospital facility.
You have been asked to pay a $50 copayment for the specialist office visit. The specialist office visit falls
within the "Physician/Practitioner services, including doctor's office visits" benefit category.
The endoscopy you asked the Plan to waive the cost share for falls within the "Outpatient surgery, including
services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The Plan
has followed Medicare rules by clearly disclosing in the contract that there is a $475 deductible per date of
service for an outpatient hospital facility.
The allowed amount for the endoscopy is $692.80. Therefore, $475 is the amount that is applied to your
deductible. The remaining allowed amount is $217.80 ($692.80 - $475 = $217.80). You have been asked to pay
a $124.05 copayment for the endoscopy, which is less than the standard copayment amount. The record shows
you were charged for the endoscopy and not for the colonoscopy.
The total charge you have been asked to pay is $649.05. ($50 + $475 + $124.05 = $649.05). This cost sharing
is a contractual obligation that had not been met at the time the endoscopy was received on December 7, 2018
to December 10, 2018. Therefore, we decided that the Plan does not have to waive the cost share for the
outpatient specialist office visit or the endoscopy provided on December 7, 2018 and December 10, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on November 27, 2019 by an out-of-network provider.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says you do not have out-of-network 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. The provider is not in-network and your EOC clearly states, services are only covered when received by a participating provider. Therefore, we decided that the Plan does not have to pay for the dental services provided on November 27, 2019 by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rocklatan eye drops.You asked the Plan to pre-approve the Rocklatan drops. You say that this medication is necessary to treat the enrollee's condition.The Plan denied your request. The Plan says self-administered eye drops are not covered by Medicare Part B.The Plan must follow Medicarerules. 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 Rocklatan eye drops.Benefits for the Rocklatan drops 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 ophthalmology exam (90214) and refraction services (92015) provided November 2, 2019.
You asked the Plan to pay for the vision services. You say that you was not told that this provider was not in network and do not feel that you should have to pay. Had you been informed you would not have went to this provider and incurred a large bill. The Plan denied your request. The Plan says enrollee's must receive their vision services from an in-network provider.
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 these services when routine vision services is covered when provided through a Health Plan Vision Care network provider. We looked at the file and the Plan's rules. [Insert determination explanation]. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for the ophthalmology exam (90214) and refraction services (92015) provided November 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 5, 2019.You asked the Plan to pay for the physician's 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 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 provided on November 5, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for incision and drainage (22010) provided on November 9, 2019.You asked the Plan to pay for incision and drainage. You say that this is shown in the report.The Plan denied your request. The Plan says it would be more appropriate to bill 22310 for the services performed.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 22010 is  incision and drainage, open, of deep abscess (subfascial), posterior spine; cervical, thoracic, or cervicothoracic.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for incision and drainage. Our reviewer says that the billing of this code is not supported. Our physician reviewer found the submitted medical records do not indicate that this service was performed.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of incision and drainage have not been met.Therefore, we decided that the Plan does not have to pay for incision and drainage (22010) provided on November 9, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider from January 6, 2020, to January 14, 2020.You asked the Plan to pay for the services. The Plan denied your request. The Plan says out-of-network services are not covered.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 you by an out-of-network provider from January 6, 2020, to January 14, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from September 29, 2018 to October 5, 2018.You asked the Plan to pay for the skilled nursing services. You say that the continued skilled nursing services were never requested. You also say that the nursing facility told your mother she needed to make an additional deposit, along with a second payment, in order to keep the enrollee at the nursing facility.The Plan denied your request. The Plan says this service requires a referral or prior authorization. The Plan also says their records indicate that a referral or prior authorization was not obtained.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage ofthe skilled nursing services have not been met.Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from September 29, 2018 to October 5, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ophthalmological services provided on
January 2, 2020.
You asked the Plan to waive the copayment for ophthalmological services. You say that this was a follow-up
visit and you should not be responsible for 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 a $10
copayment for physician/practitioner services, including doctor's office visits.
You received ophthalmological services provided on January 2, 2020. Follow-up visits are subject to costsharing
charges. Therefore, you are responsible to pay the $10 copayment.
You have been asked to pay a $10 copayment for ophthalmological services. Ophthalmological services fall
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 ophthalmological services provided on January 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the spinal injection provided on December
5, 2019.
You asked the Plan to waive the copayment for the spinal injection. You say that you cannot afford this
copayment. 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 $290
copayment per visit for Medicare-covered outpatient surgery in an ambulatory surgical center or hospital
outpatient facility.
You have been asked to pay a $290 copayment for the spinal injection. The spinal injection 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 spinal injection
provided on December 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 95861) provided on July 8, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service cannot be verified.
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 95861 is "Needle electromyography; 2 extremities with or without related paraspinal areas." We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the use of CPT code 95861 is not supported by the records provided. Our coding reviewer found that the medical records provided to not include documentation of a needle electromyography; 2 extremities with or without related paraspinal areas, being performed on July 8, 2019, 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 the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (CPT 95861) provided on July 8, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a chest x-ray (71045), set-up of portable x-ray equipment
(Q0092), and transportation of portable x-ray equipment and personnel to home or nursing home (R0070)
provided on October 24, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the chest x-ray, set-up of portable x-ray equipment, and transportation of
portable x-ray equipment and personnel provided by an OON provider. You say that the services were provided
and payment should be rendered. The Plan denied your request. The Plan says non-emergent services rendered
by non-participating providers require prior authorization, therefore coverage criteria has not been met.
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 a chest x-ray (71045), set-up of portable x-ray
equipment (Q0092), and transportation of portable x-ray equipment and personnel to home or nursing home
(R0070) provided on October 24, 2019 by an out of network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (denosumab) injections.
You asked the Plan to pre-approve the Prolia treatments. You say that this treatment is necessary to prevent
broken bones due to her osteoporosis. The Plan denied your request. The Plan says there is no evidence of a
failure of zoledronic acid or other bisphosphonates.
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 the Prolia treatments. Our reviewer says
that the requested use of Prolia is not considered medically reasonable and necessary based on step therapy
rules. Our physician reviewer found the enrollee has a diagnosis of Age-related osteoporosis without current
pathological fracture. The case file does not contain documentation of trial and failure of Zoledronic acid. The
documentation does not support that Zoledronic acid would likely be less effective, and/or would likely 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 the Prolia treatments have not been met. Therefore, we decided that the Plan
does not have to pre-approve Prolia (denosumab) injections.
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 you would like reconsideration because you recently had knee surgery and it is not safe for you to be discharged home.The Plan denied your request. The Plan says the IRF admission is not medically necessary.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 complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your rehab needs can be met at a lower intensity setting such as in a Skilled Nursing Facility.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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the speech therapy services (92523) provided on November 12, 2019 by an out of network (OON) provider.You asked the Plan to pay for OON speech therapy services. You say that you were told this would be covered.The Plan denied your request. The Plan says this service 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 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 speech therapy services (92523) provided on November 12, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a CT scan provided on December 18, 2019.
You asked the Plan to pay for the CT scan. The Plan denied your request. The Plan says non-emergent, nonurgent
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
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 a CT scan provided on December 18, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 3, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the services were provided after this provider's contract with the Plan ended. Authorization is required.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The 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 provided on September 3, 2019.