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

We decided that the Plan does not have to waive the coinsurance for an injection of nivolumab (a Medicare Part B prescription drug) and drug administration service.

You asked the Plan to waive the coinsurance for Part B drug. You say that it is imperative that the Plan review this charge. The Plan denied your request. The Plan says the coinsurance amount you are being charged is correct.

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 20% coinsurance for in-network Part B drugs. The allowed amounts of the drug and drug administration charges total $13,572.04, resulting in a coinsurance obligation of $2,714.41.

You have been asked to pay 20% coinsurance for Part B drug. Part B drug falls 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 coinsurance for an injection of nivolumab (a Medicare Part B prescription drug) and drug administration service.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory testing.

You asked the Plan to waive the copayment for lab test. You say that you cannot understand why this test would not be covered. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $10 copayment per day, per provider for in-network lab test.

You have been asked to pay the allowed amount of $6.63, which is less than $10 copayment for lab test. Lab test 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 laboratory testing.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rhinoplasty and small amount of nasal tip for the enrollee.

You asked the Plan to pre-approve Rhinoplasty and small amount of nasal tip for the enrollee. You say that this surgery is medically necessary. The Plan denied your request. The Plan says Rhinoplasty and small amount of nasal tip is not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are coverable. The medical records provided show this is being done for aesthetic reasons. This type of surgery is not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve Rhinoplasty and small amount of nasal tip for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation.

You asked the Plan to pay for provider visit. You say that your physician provided medically necessary services to the enrollee in good faith. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this claim was not submitted within the timely filing limit.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.

The record shows that a claim for provider visit was not filed until October 7, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for a psychiatric diagnostic evaluation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit.

You asked the Plan to pay for the office visit. You say that the evaluation was medically necessary. The Plan
denied your request. The Plan says the office visit was an evaluation of a replacement oral appliance without
first having a face-to-face evaluation with the treating physician to assess continued need.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the evaluation for an oral appliance have not been met. Therefore, we decided that the Plan does
not have to pay for the office visit.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for laser eye surgeries.

You asked the Plan to waive the copayments for outpatient surgeries. You say that you were told that all
copayments would be waived due to COVID-19. The Plan denied your request. The Plan says the copayment
amounts you are being charged are correct.

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 $175
copayment for outpatient surgery at an ambulatory surgical center. There were two visits for outpatient surgery,
resulting in a total copayment amount of $350.

You have been asked to pay $175 copayment for each outpatient surgery visit. Outpatient surgeries fall within
the Outpatient Surgery and Other Medical 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 copayments for laser eye surgeries.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services rendered on August 26, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 01992 is not separately payable.
The Plan must follow Medicare rules. The rules say that payment for post-operative services are included in the global surgical package. We looked at the file and Medicare rules. Billed procedure code 01992 (anesthesia for nerve block procedure) was performed the same day as the billed surgical procedure 64483 (transforaminal epidural steroid injection). Payment for code 01992 is included in payment for the global surgical package. Therefore, we decided that the Plan does not have to pay for the anesthesia services rendered on August 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the PNS trial.
You asked the Plan to pre-approve the PNS trial. You say that you would like reconsideration because this particular system targets the peripheral nerve fibers which are causing the member's pain. The Plan denied your request. The Plan says evidence for percutaneous electrical nerve stimulation of dorsal medical nerve is lacking.
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 the PNS trial. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this service is considered experimental/investigational. 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 PNS trial have not been met. Therefore, we decided that the Plan does not have to pre-approve the PNS trial.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care (99309) provided by an out of network (OON) provider.

You asked the Plan to pay for OON nursing facility care. You say that this was medically necessary. The Plan denied your request. The Plan says this was not authorized.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the nursing facility care (99309) provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an out of network (OON) provider.

You asked the Plan to pay for office services. 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 and authorization was not obtained.

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 medical services provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided by an out of network (OON) provider.

You asked the Plan to pay for the drug testing. You say that the services meet the medical necessity terms for the plan's policy. The Plan denied your request. The Plan says the services received were non-urgent and performed by a non-participating provider.

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 drug testing provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve facet joint injections.
You asked the Plan to pre-approve the facet joint injections. You say that you would like reconsideration because the member is living with severe pain. The Plan denied your request. The Plan says that the records do not show that the member had diagnostic injections or the percentage of relief from a diagnostic injection.
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 facet joint injections. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the records show that the member has had sustained relief from these blocks. 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 facet joint injections have been met. Therefore, we decided that the Plan has to pre-approve facet joint injections.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the prefabricated post and core in addition to crown (D2954) and endodontic therapy (D3320) provided on October 15, 2020 by an OON provider.
You asked the Plan to pay more for the prefabricated post and core and endodontic therapy. You say that you feel that the Plan should pay more for these services. The Plan denied your request. The Plan says the total $1,368.50 amount applied correctly as member liability. The Plan also says that cost sharing is a contractual obligation under the Plan and cannot be waived.
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 a 50% coinsurance for both the prefabricated post and core in addition to crown (D2954) and endodontic therapy (D3320). The Plan also says that you may be billed more by an out-of-network provider if the charge is greater than the MAC. Therefore, we decided that the Plan does not have to pay more for the prefabricated post and core in addition to crown (D2954) and endodontic therapy (D3320) provided on October 15, 2020 by an OON provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 7, 2020 by an out of network (OON) provider.

You asked the Plan to pay for physical therapy. 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 and authorization was not obtained.

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 medical services provided on July 7, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray provided on October 29, 2020 by a non-participating provider.
You asked the Plan to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray. You say that these services were provided at your usual dentist's office, but your regular dentist was not available that day. The Plan denied your request. The Plan says these services were rendered by a non-participating provider. The Plan also says that services done by an out-of-network provider are not covered.
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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray provided on October 29, 2020 by a non-participating provider.
Please Note: The Plan contacted the provider's office about this appeal. Due to miscommunication that was given, the provider has agreed to waive the charges for these services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a physician visit.

You asked the Plan to pay for physician visit. You say that services were provided prior to obtaining authorization to avoid a delay in care. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and the service was not urgent or emergent in nature.

The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan.

The services at issue in this appeal were not provided in an emergency or urgent care situation. These services were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not have to pay for a physician visit.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit and manual manipulation service provided by an out-of-network provider.

You asked the Plan to pay for office visit and manual manipulation. You say that your Plan covers 12 chiropractic visits for each calendar year. The Plan denied your request. The Plan says the denial of payment for the office visit charge is correct, because this service is not covered when performed by a chiropractor. The Plan also says that the deductible amount you are being charged for the manual manipulation service is correct.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. Your contract with the Plan says that there is $1,000 deductible for covered out-of-network chiropractic services. At the time this claim was processed, $0 of the $1,000 out-of-network deductible had been met. The allowed amount of the manual manipulation is $39.25, resulting in a deductible obligation of $39.25. You are also responsible for the $45 office visit charge because this service is not covered by Medicare or the Plan when performed by a chiropractor.

The Plan has followed Medicare rules by clearly disclosing in the contract that there is $1,000 deductible for covered out-of-network chiropractic services. This cost sharing is a contractual obligation that had not been met at the time office visit and manual manipulation. Therefore, we decided that the Plan does not have to pay for an office visit and manual manipulation service provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion Indirect Decompression System and implantation of Superion interspinous spacer for the enrollee.
You asked the Plan to pre-approve this surgery and device. You say that this surgery and device are medically necessary. The Plan denied your request. The Plan says the Vertiflex Superion Indirect Decompression System and Superion interspinous spacer are not covered by Medicare.
The Plan must follow Medicare rules. Medicare does not cover experimental services. This surgery and device intended to be implanted are currently considered experimental by Medicare and are not covered. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion Indirect Decompression System for implantation of Superion interspinous spacer for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay from September 26, 2020, to October 01, 2020.

You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you should not have to pay a copayment because your provider did not provide you with adequate care. The Plan denied your request. The Plan says the copayment was 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 $75 copayment per day, days 1 to 4 for an inpatient hospital stay. 

You have been asked to pay a total of $150 copayment for the inpatient hospital stay. This service falls within the Inpatient hospital care 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 from September 26, 2020, to October 01, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer.

You asked the Plan to pre-approve the Vertiflex Superion Spacer. You say that you would like reconsideration
because this device is medically necessary. The Plan denied your request. The Plan says this service is
experimental.

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 the Vertiflex Superion Spacer. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found this spacer is experimental and more research is needed to show the safety
and efficacy of the device.

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 Vertiflex Superion Spacer have not been met. Therefore, we decided that the
Plan does not have to pre-approve the Vertiflex Superion Spacer.