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

We decided that the Plan does not have to waive the copayment fora diagnostic colonoscopy provided by on September 23, 2019.You asked the Plan to waive the copayment fora diagnostic colonoscopy. You say that you did not receive services in an outpatient hospital facility and disagree with the outpatient hospital 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 $250 copayment for outpatient surgery, includingservices provided at hospital outpatient facilities and ambulatory surgical centers. The record shows that you received a diagnostic colonoscopy at an outpatient hospital facility on September 23, 2019. Therefore, you are responsible to pay the $250 copayment. You have been asked to pay a $250 copayment for a diagnostic colonoscopy. A diagnostic colonoscopy 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 fora diagnostic colonoscopy provided on September 23, 2019.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Keytruda for the enrollee.You asked the Plan to pre-approve Keytruda. You say that this drug is medically necessary.The Plan denied your request. The Plan says that Medicare coverage criteria are not met.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Keytruda. Our reviewer says that Medicare coverage criteria for Keytruda are met. Our physician reviewer found the medical records state the enrollee has a diagnosis of stage IVA metastatic squamous cell cancer of the head and neck. Chemotherapy with Keytruda, 5 FU and carboplatinis prescribed. This use is FDA approved for the enrollee's diagnosis.Medicare coverage criteria are met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have been met.Therefore, we decided that the Plan has to pre-approveKeytruda for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe Rituximab injection provided on September 30, 2019.You asked the Plan to waive the coinsurance forthe injection. You say that you should not be responsible since you are approved for this medication through the foundation at no cost.The Plan denied your request. The Plan says that the coinsurance 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 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a 20% coinsurance for the injection. The injection 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 forthe Rituximab injection provided on September 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services (CPT 99051) provided to the enrollee on July 14, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says this code is not payable.The Plan must follow Medicare rules. Medicare rules say that a status indicator of "B" under the Physician Fee Schedule indicates that payment for covered services are always bundled into payment for other services not specified. We looked at the file and Medicare rules. Procedure code 99051is assigned a status indicator of "B" under the Physician Fee Schedule, which means that this is a bundled service. Payment for this service is bundled into payment for other services. No separate payment can be made for this service.Therefore, we decided that the Plan does not have to pay forthe services (CPT 99051) provided to the enrollee on July 14, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadditional mileage for the enrolle's routine transportation.You asked the Plan to pre-approveadditional miles. You say that the enrollee does not have access to care locally.The Plan denied your request. The Plan says the requested transportation exceeds 50 miles.Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The file shows that transportation over 50 miles was requested for the enrollee. We looked at your request, the records in the case file, and the rules. The plan only covers routine transportation for up to 50 miles per one-way trip. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approveadditional mileage for the enrollee's routine transportation
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe first intraoral periapical x-ray and two additional intraoral periapical x-rays provided on October 23, 2019.You asked the Plan to pay forthe intraoral periapical x-rays. You say that the provider said you needed x-rays because it had been two years since your last x-rays. You also say that you think this should be paid for because the provider's office requested them.The Plan denied your request. The Plan says these services are not covered 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 Plan only covers one set of bitewing x-rays per year. Periapical x-rays are not a covered benefit.Therefore, we decided that the Plan does not have to pay forthe first intraoral periapical x-ray and two additional intraoral periapical x-rays provided on October 23, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on September 9, 2019.
You asked the Plan to pay for drug tests. You say that you are appealing with records. The Plan denied your
request. The Plan says the denial of payment for these services is correct, because the documentation submitted
does not support the Place of Service (POS) code billed on this claim.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place
where the sample was taken is reported as the Place of Service (POS).
We looked at the file and Medicare rules. The record shows that the sample for this testing was taken in an
office setting, therefore the Place of Service (POS) code 81 - indicating an independent laboratory setting - is
not appropriate for 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 for drug testing provided on September 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forhealth club membership reimbursement towards your 2019 Wellness allowance.You asked the Plan to pay forhealth club membership. You say that you would like to know why you are not eligible for the fitness benefit for your tennis membership. You are getting much more exercise than most members by playing tennis two or three times a week.The Plan denied your request. The Plan says the benefit does not cover membership fees you pay to non-qualified health clubs or fitness facilities, including but not limited to martial arts centers, gymnastic facilities, county clubs, sports clubs, social clubs and for sports activities such as golf and tennis.The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers gym benefits onlyThe plan will reimburse up to $150 each calendar year towards your cost for membership in a qualified health club or fitness facility.The Plan's rules for coverage of gym benefits have not been met because reimbursement submitted was at a non-qualifyinghealth club..Therefore, we decided that the Plan does not have to pay forhealth club membership reimbursement towards your 2019 Wellness allowance
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on October 22, 2019.You asked the Plan to waive the copayment for the ambulance transport. The Plan denied your request. The Plan says that you were charged the appropriate cost-share and the claim paid 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 $245 copayment for each one-way Medicare-covered ground ambulance trip. You have been asked to pay a $245 copayment for the ambulance transport. The ambulance transport falls within the one-way Medicare-covered ground ambulance trip 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 ambulance transport provided on October 22, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveProlia (denosumab) injections.You asked the Planto pre-approvethe Prolia injections. You say that this treatment is needed to prevent fracture.The Plandenied your request. The Plansaysno other treatments have been tried. The Plan requires a trial of zoledronic acid before Prolia can be covered.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 injections. Our reviewer says that the requested medication is not considered 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 enrollee has not trialed the plan preferred drug 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 injections have not been met.Therefore, we decided that the Plandoes not haveto pre-approveProlia (denosumab) injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an alert system.
You asked the Plan to pre-approve an alert system. You say that you have fallen on several occasions without any help. The Plan denied your request. The Plan says the item is not a covered benefit.
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 available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve an alert system.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on October 9, 2019.
You asked the Plan to waive the copayment for the specialist office visit. You say should not have been charged the $40 copayment because this was your follow-up to a procedure. 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 $40 copayment per specialist office visit. You have been asked to pay a $40 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. Please note, there is no provision in the contract which indicates a copayment would be waived if performed as a follow-up to a procedure.
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 specialist office visit provided on October 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on August 10, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the physician services. The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan says the enrollee's primary care physician did not refer them for the services. The Plan also says that the services were not urgent or emergent.
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 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 office visit provided on August 10, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).
You asked the Plan to pre-approve a pneumatic compression device. You say that the device is needed. The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forlaboratory services (80053, 80061, 84439, 36415) provided  on September 5, 2019.You asked thePlan to waive the copayment forlab services. You say that you had the same lab work done before and never had a copay. You don't have a copay for lab work and need it explained.The Plan denied your request. The Plan says outpatient hospital services have a $70 copayment.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 $70 copayment for outpatient hospital services. You have been asked to pay a $56.43copayment for lab services. Thisservice falls within the outpatient hospital services benefit category. The allowableamount for yourservices is less than your$70 copayment. Therefore, you areonly responsible for the allowableamount of $56.43.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 enrolledin the Plan.Therefore, we decided that the Plan does not have to waive the copayment forlaboratory services (80053, 80061, 84439, 36415) provided on September 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran office visit and physician services provided on July 27,2019 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 approved for payment.The Plan denied your request. The Plan says no referral of prior authorization was obtained for the services in question.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 and physician services provided on July 27, 2019 by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora physician or other qualified health care professional services for outpatient cardiac rehabilitation; with continuouselectrocardiogram (ECG) monitoring (93798) from July 29, 2019 to August 30, 2019.You asked the Plan to waive the copayment fora physician or other qualified health care professional services for outpatient cardiac rehabilitation; with continuous (ECG) monitoring. You say that you were not made aware that this service was covered with this cost share under yourpolicy.The Plan denied your request. The Plan says cardiac rehabilitation services have a $25 copayment.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 $25 copaymentfor cardiac rehabilitation services. You have been asked to pay a $25 copayment for a physician or other qualified health care professional services for outpatient cardiac rehabilitation; with continuous (ECG) monitoring. This servicefalls within the cardiac rehabilitation services benefit category. The record shows you received services on 10 dates of service from July 29, 2019 to August 30, 2019 (10 x $25 = $250). 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 fora physician or other qualified health care professional services for outpatient cardiac rehabilitation; with continuous electrocardiogram (ECG) monitoring (93798) from July 29, 2019 to August 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe prophylaxis and periodic oral evaluation provided on November 11, 2019.You asked the Plan to pay forthe prophylaxis and periodic oral evaluation. You say that you did not realize that it had not been a year since your last cleaning. You also say you cannot afford to pay this.The Plan denied your request. The Plan says these services are payable once per calendar year. The Plan also says that you had already exhausted these 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, exams and cleanings are limited to once per year. The record shows that you received a cleaning and oral exam on January 11, 2019 and your exams and cleanings benefit was then exhausted.Therefore, we decided that the Plan does not have to pay forthe prophylaxis and periodic oral evaluation provided on November 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea PMD.You asked the Plan to pre-approvethe PMD. You say that you need this wheelchair to go places because you have a life and need to get around.The Plan denied your request. The Plan says the PMD you requested is not the most appropriate mobility device for you at this time.The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file shows that your condition can be improved by a walker, cane or manual wheelchair. This means that Medicare rules for coverage of a PMD have not been met.Therefore, we decided that the Plan does not have to pre-approvea PMD.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe chest x-ray rendered to the enrollee on October 16, 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 claim is a duplicate.The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied.The provider submitted a claim for procedure code 71045 (chest x-ray) under claim number "A". The Plan previously paid for this code for the date of service at issue under claim number "B". Therefore, we decided that the Plan does not have to pay forthe chest x-ray rendered to the enrollee on October 16, 2019.