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

We decided that the Plan does not have to waive the deductible foran office visit provided on April 29, 2019.You asked the Plan to waive the deductible foroffice visit. You say that according to the Explanation of Benefits you should only have to pay the deductible, which you did, but now you are being billed an additional amount.The Plan denied your request. The Plan says the deductible 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. Your contract with the Plan says that there is $185 deductible for primary care office visit. At the time this claim was processed, $0 of the $185 deductible had been met. The allowed amount of the claim is $63.62, resulting in a deductible obligation of $63.62.The item or service you asked the Plan to waive the deductible for falls within the benefit category Physician/Practitioner Services, Including Doctor's Office Visits. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $185 deductible forPhysician/Practitioner Services, Including Doctor's Office Visits. This cost sharing is a contractual obligation that had not been met at the time office visit was received on April 29, 2019.Therefore, we decided that the Plan does not have to waive the deductible foran office visit provided on April 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

e decided that the Plan does not have to reimburse you for the Stiltz Trio Classic Thru Car Wheelchair Home Lift purchased on July 15, 2019.You asked the Plan to reimburse you for the elevator. You say that the elevator was extremely necessary as you cannot walk up or down stairs.The Plan denied your request. The Plan says elevators are not covered by Medicare or the Plan.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is considered a convenience item by Medicare.Therefore, we decided that the Plan does not have to reimburse you for the Stiltz Trio Classic Thru Car Wheelchair Home Lift purchased on July 15, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four testing (95999) provided on May 21, 2019.
You asked the Plan to pay for train of four testing. You say that these services were medically necessary. The Plan denied your request. The Plan says payment of this service is bundled into other services.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 95999 is not supported in the medical record. Specifically, the use of unlisted CPT code 95999 to report train of four testing is not supported. According to CPT coding rules, train of four testing is not a separately reportable procedure and is included in the other interoperative neuromonitoring procedures. Based on this information, we decided that Medicare rules for coverage of train of four testing have not been met. Therefore, we decided that the Plan does not have to pay for train of four testing (95999) provided on May 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran office visit provided on October 8, 2019 by an out of network (OON) provider.You asked the Plan to pay foran office visit. You say that you would like this claim reprocessed and and approved for payment.The Plan denied your request. The Plan says no authorization was obtained for these services.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the 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 foran office visit provided on October 8, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approveCT scan of the sinus for the enrollee.You asked the Plan to pre-approvethe scan. You say that this is medically necessary.The Plan denied your request. The Plan says that this is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan wascorrect in denying the request to pre-approve the scan. Our reviewer says that the requested scan is medically reasonable and necessary. Our physician reviewer found the enrollee apparently lives far away from his doctor and clinical evaluation is difficult to arrange. The enrollee has had a significant abnormality on his prior CT, has gone through at least a 3 week course of accepted conservative therapy and subjectively says his symptoms are worsening. A hands on re-evaluation by the internist is probably of little value. If a repeat CT scan is improved, ENT referral is likely not necessary. On the other hand, if there is no change on the scan or worsening of the paranasal sinus disease that will be valuable information and trigger a referral to ENT. The ENT would certainly request a repeat CT prior to seeing this particular enrollee. Thus, based upon the clinical presentation, subjective perception of worsening symptoms, prior abnormal CT of the sinuses and logistic issues CT of the paranasal sinuses would be to the enrollee's best advantage.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 scan have been met.Therefore, we decided that the Plan has to pre-approveCT scan of the sinus for the enrollee.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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to you by an out-of-network provider on August 29, 2019.You asked the Plan to pay forthe services. You say that the provider told you they accepted your insurance.The Plan denied your request. The Plan says the services were 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 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 forthe medical services provided to you by an out-of-network provider on August 29, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One injection for the enrollee.You asked the Plan to pre-approve the injection. You say that this is medically necessary.The Plan denied your request. The Plan says the step therapy requirements encourages a trial and failure of Orthovisc and Monovisc.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 injection. Our reviewer says that the requested injection is not medically reasonable or necessary. Our physician reviewer found there is no evidence of a trial and failure of the required drugs. The documentation does not support that Orthovisc and Monovisc 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 injection have not been met.Therefore, we decided that the Plan does not have to pre-approve Synvisc-One injection for the enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 21, 2019 to August 21, 2019 by an out of network (OON) provider.You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says authorization for an out-of-network provider must be obtained prior to services being rendered unless it is anurgent or emergent situation.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, outof area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The record does not indicate that authorization was obtained. 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 June 21, 2019 to August 21, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe CxBladder testing (0013M) provided on August 6, 2019.You asked the Plan to pay forthe CxBladder testing (0013M). 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. The rules saythat the CxBladder test is non-covered. We looked at the file and Medicare rules. The test at issue is the CxBladder test. This test is not covered by Medicare for any indication.Therefore, we decided that the Plan does not have to pay forthe CxBladder testing (0013M) provided on August 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on December 2, 2019.
You asked the Plan to waive the copayment for the office visit. You say that the provider is your internal medicine physician. 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 $35 copayment for services obtained from an in-network specialist. You have been asked to pay a $35 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that the provider is a cardiovascular specialist. 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 December 2, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlaboratory testing provided on September 15, 2016.You asked the Plan to pay forlab tests. You say that your previous vendor failed to submit claims.The Plan denied your request. The Plan says the denial of payment for these services is correct, because this claim was filed later than 12 months (1 calendar year) after the date of service.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 lab tests was not filed until October 2, 2019. 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 forlaboratory testing provided on September 15, 2016
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forsurgical assistant services provided for a partial colectomy (44145 and 44139) on July 18, 2019.You asked the Plan to pay forsurgical assistant services. You say that these services should be reprocessed.The Plan denied your request. The Plan says these services are not covered for the requested provided.The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS.In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. The provider in this case is a Registered Nurse First Assistant (RNFA).Therefore, we decided that the Plan does not have to pay forsurgical assistant services provided for a partial colectomy (44145 and 44139) on July 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on April 16, 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 forthe laboratory services provided on April 16, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran EGD provided on September 26, 2019.You asked the Plan to waive the copayment foran EGD. You say that you disagree with the charges because no biopsy was taken.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 $290 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You received an EGD on September 26, 2019. An EGD is considered an outpatient surgical procedure and is not included in a colorectal cancer screening. Therefore, you are responsible to pay the $260 copayment. You have been asked to pay a $290 copayment for an EGD. An EGD falls within the outpatient surgery, including servicesprovided 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 foran EGD provided on September 26, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approveSupartz for the enrollee.You asked the Plan to pre-approveSupartz. You say that the enrollee has failed cortisone shots, therapy, and NSAIDs.The Plan denied your request. The Plan says the enrollee has not had previous treatment, contraindication, or intolerance to Orthovisc and Monovisc.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 physician reviewer found that the enrollee has primary osteoarthritis of the right and left knees. The Plan requires a trial of Orthovisc and Monovisc before they will approve the requested drug. The documentation does not show that the enrollee has tried and failed the required drugs. The documentation does not support that Orthovisc and Monovisc would likely be less effective, or would likely have adverse effects for the enrolleeWe lookedat 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-approveSupartz for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound examination of the heart provided on September 17, 2019.
You asked the Plan to waive the copayment for an ultrasound examination of the heart. You say that you feel that the services should be included as part of the pre-operative visit. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $50 copayment for each basic imaging service. The enrollee received an ultrasound examination of the heart on September 17, 2019. An ultrasound examination of the heart is not included in pre-operative visits. Therefore, the enrollee is responsible to pay the $50 copayment. The enrollee has been asked to pay a $50 copayment for an ultrasound examination of the heart. An ultrasound examination of the heart falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an ultrasound examination of the heart provided on September 17, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on April 23, 2019.You asked the Plan to pay fordrug tests. You say that you have submitted a valid laboratory requisition form.The Plan denied your request. The Plan says the denial of payment for these services is correct, because the documentation submitted does not include a valid physician order, lab requisition, or medical records stating exactly which tests were to be performed.The Plan must follow Medicare rules. Medicare rules say that aphysician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a physician order or clear intent to order the specific lab services billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug tests have not been met.Therefore, we decided that the Plan does not have to pay fordrug testing provided on April 23, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe dialysis services rendered to the enrollee on July 1, 2019 to July 31, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claims were not billed correctly.The Plan must follow Medicare rules. The rules say that code all dialysis claims using HCPCS code 90999 along with the appropriate G modifier.We looked at the file and Medicare rules. The claims were not billed with the required modifiers.Therefore, we decided that the Plan does not have to pay forthe dialysis services rendered to the enrollee on July 1, 2019 to July 31, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forambulance services provided on July 13, 2019.You asked the Plan to pay forthe ambulance services. You say that the ambulance service was medically necessary.The Plan denied your request. The Plan says the enrollee could have been safely transported by another type of vehicle.Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. We looked at the fileand Medicare rules. The record shows the enrollee, complaining of stress,was ambulatory, stable, in no acute respiratory or cardiac distress and had no sign of injury, stroke or hemorrhage. Neither oxygen nor emergency treatment was needed for transport. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met.Therefore, we decided that the Plan does not have to pay forambulance services provided on July 13, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on March 6, 2019.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 the claim was not billed correctly.The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for an independent laboratory; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11.Therefore, we decided that the Plan does not have to pay for the drug testing rendered on March 6, 2019.