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

We decided that the Plan does not have to waive the copayment for the duplex scan provided on January 15,
2020.
You asked the Plan to waive the copayment for the duplex scan. You say that you had an x-ray done. You say
that no additional tests were done. 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 $110
copayment for each Medicare-covered radiological diagnostic service, not including x-rays performed in an innetwork
physician's office or at a free-standing facility.
You have been asked to pay $108.05, which is less than the standard $110 copayment for the duplex scan. The
duplex scan falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit
category. The records show that a duplex scan was performed. 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 duplex scan provided on January 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the outpatient services provided Center from July 21, 2018 through July 27, 2018 and August 12, 2019 through August 13, 2019.
You asked the Plan to waive the coinsurance for the outpatient services. You say that you were informed that you overpaid. You say that you do not have to pay these bills. The Plan denied your request. The Plan says 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 40% coinsurance for out-of-network. Medicare Part B prescription drugs after you pay your $750 deductible, 40% coinsurance for out-of-network, outpatient hospital services and after you pay your $750 deductible, you pay 40% coinsurance for Medicare-covered outpatient surgery from an out-of-network provider.
You have been asked to pay a total of $3,185.78 for the outpatient services.
Date of Service
Service
Allowed Amount
Standard Coinsurance
Member Liability
July 21, 2018
Therapeutic Injections
$308.6
40%
$123.44
July 21, 2018
Chemotherapy Administration
$830.14
40%
$332.04
July 21, 2018
Part B Drugs
$4,150.40
40%
$1,660.15
July 27, 2018
Clinic Visit
$132.64
40%
$53.05
August 12, 2019- August 13, 2019
Tumor Ablation
$8,950.72
40%
$1,017.10
TOTAL:
$3,185.78
The Part B drugs fall within the "Medicare Part B prescription drugs" benefit category. The therapeutic injections, chemotherapy administration and clinic visit fall within the "Physician/Practitioner services, including doctor's office visits" benefit category. The tumor ablation 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 coinsurance for the outpatient services provided Center from July 21, 2018 through July 27, 2018 and August 12, 2019 through August 13, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam (D0120) and prophylaxis (D1110) provided on
February 12, 2020.
You asked the Plan to pay for the dental services. You say that you made multiple attempts to try and update
your address. You say that you were not notified that your dental coverage had been cancelled. You also say
that your Social Security check amount did not reflect a cancellation of services. The Plan denied your request.
The Plan says you did not have active dental coverage when you received the dental services. The Plan says
that the Annual Notice of Coverage that was sent out on September 25, 2019 explained that the supplemental
dental coverage was no longer available for 2020. The Plan also says that payment cannot be made for dental
services that you receive when you are not actively enrolled in a dental plan.
Medicare generally does not cover dental services. The Plan follows the same rule.
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid
for by Medicare. The record shows that the Plan sent out an Annual Notice of Coverage on September 25,
2019. Additionally, the record shows that you did not change your address on file with the Plan until after the
new year. Therefore, we decided that the Plan does not have to pay for the oral exam (D0120) and prophylaxis
(D1110) provided on February 12, 2020.
Your complaint about not being notified of the cancellation of your dental coverage is not a valid appeal for
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does
not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on December 15, 2018.
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 codes 37242, 75625, and 75726 are not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 37242 is occlusion of artery (other than hemorrhage or
tumor) with radiological supervision and interpretation, roadmapping, and imaging guidance. The definition of
code 75625 is aortography, abdominal, by serialography, radiological supervision and interpretation. The
definition of code 75726 is angiography, visceral, selective or supraselective (with or without flush aortogram),
radiological supervision and interpretation.
We find that CPT codes 37242, 75625, and 75726 are not supported in the medical record. Specifically, the
operative report does not include documentation of a vascular embolization to support code 37242, of an
abdominal aortography to support code 75625, or selective or supraselective visceral angiography to support
code 75726. Based on this information, we decided that Medicare rules for coverage of these services have not
been met. Therefore, we decided that the Plan does not have to pay for the surgical services rendered on
December 15, 2018.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT scan of the abdomen for the enrollee.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your
request. The Plan says the requested scan is not supported by evidence-based guidelines, nor is there evidence
that it is 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 was correct in denying the request to pre-approve the scan. Our reviewer says that the
requested scan is not medically reasonable or necessary. Our physician reviewer found the reason for the denial
by the plan has been based upon NCCN guidelines not supporting 6 month surveillance of the abdomen based
upon the clinical history, particularly Stage IIIA NSCLC. Personal review of the NCCN guidelines, NSCLC
Version 5.2020 pg NSCLC-16 indicates surveillance of the abdomen every 6 months is not supported absent an
abnormal finding in the abdomen on prior exams in a patient having finished definitive therapy 1/4/18 and in
whom no clinical or lab findings are suspicious for tumor recurrence or metastatic disease.
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 not been met. Therefore, we decided that the Plan does not have
to pre-approve CT scan of the abdomen for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda.
You asked the Plan to pre-approve Keytruda. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the requested drug is not medically necessary.
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 the
documentation does not support that the requested drug is medically reasonable or necessary. Our physician
reviewer found the requested use of Keytruda is FDA-approved for the enrollee's diagnosis, however, for firstline
treatment (in combination with pemetrexed and platinum chemotherapy) of metastatic nonsquamous
NSCLC in patients with no EGFR or ALK genomic tumor aberrations. The documentation states that
Foundation testing was sent but no results are given. Therefore, the enrollee does not meet criteria for the
requested drug.
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 not been met. Therefore, we decided that the Plan does not have
to pre-approve Keytruda.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on January 13, 2020 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that you spend winters in the state and you had to see a doctor. You say that when you just had Medicare you never received a bill and it was covered. The Plan denied your request. The Plan says the member's primary care physician did not refer these services. The Plan says that no prior authorization was 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 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 physician services provided on January 13, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an Inogen G5 Portable Oxygen System purchased on January 21, 2020.
You asked the Plan to pay for the portable oxygen concentrator. You say that the rented tank is cumbersome and you breathe better due to the portability of the machine. The Plan denied your request. The Plan says only rented oxygen equipment is eligible for coverage.
The Plan must follow Medicare rules. The rules say that only rented oxygen equipment is eligible for coverage.
We looked at the file and Medicare rules. Purchased oxygen equipment is statutorily non-covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the portable oxygen concentrator have not been met. Therefore, we decided that the Plan does not have to pay for an Inogen G5 Portable Oxygen System purchased on January 21, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments for the occupational therapy visits provided
from August 1, 2019 to August 30, 2019.
You asked the Plan to reduce the copayments for the occupational therapy visits. You say that you were told
that you would have a $10 copayment at an outpatient clinic. 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 for occupational therapy at an in-network outpatient hospital.
You have been asked to pay a $40 copayment for each of the occupational therapy visits. The occupational
therapy visits fall within the "Outpatient rehabilitation services" benefit category. The record shows you were
billed by an outpatient hospital facility.
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 reduce the copayments for the occupational therapy visits provided from August 1,
2019 to August 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the office visit provided on December 5, 2019.
You asked the Plan to waive the coinsurance for the office visit. You say that you met your maximum out-of-pocket prior to the visit. You say that you should be reimbursed. The Plan denied your request. The Plan says 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 15% coinsurance for services obtained from a specialist. You have been asked to pay $12.62, which is less than the standard15% coinsurance for the office visit because you met your maximum out-of-pocket. The office visit falls 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 coinsurance for the office visit provided on December 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for chemotherapy provided from January 30, 2020 to February 13, 2020.
You asked the Plan to waive the coinsurance for chemotherapy. You say that you received chemotherapy infusions and disagree with 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 20% coinsurance for Medicare Part B prescription drugs. You received chemotherapy on January 30, 2020. Therefore, you are responsible to pay $452.60, which is less than the 20% coinsurance amount. You received chemotherapy on February 13, 2020. Therefore, you are responsible to pay $1,123.70, which is less than the 20% coinsurance amount. The total amount you owe is: $1,576.30.
You have been asked to pay the total coinsurance amount of $1,576.30 for chemotherapy. Chemotherapy 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 chemotherapy provided from January 30, 2020 to February 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids (V5181) purchased December 19, 2019.
You asked the Plan to pay for the hearing aids. You say that there has been considerable deterioration in your
hearing and a new hearing aid was recommended. There is no copayment for a maximum of 2 hearing aid
devices. You are requesting only 1. The Plan denied your request. The Plan says the benefit maximum has been
exhausted and no additional refund is due.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays a
maximum benefit of $2000 for 2 hearing aid devices every 36 months. The plan has paid the $2,000 benefit
maximum.
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for
the hearing aids (V5181) purchased December 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services (99325, 11043) provided on October
28, 2019.
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The
Plan denied your request. The Plan says the services were not emergent or preauthorized. Network providers
were available.
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 item/service 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 physician services (99325, 11043) provided on October 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lithotripsy provided on December 13, 2019.
You asked the Plan to waive the copayment for lithotripsy. You say that you disagree with 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 $150 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You have been asked to pay a $150 copayment for lithotripsy. Lithotripsy 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 lithotripsy provided on December 13, 2019.
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 the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a SNF. In this case, the enrollee is mostly moderate/minimal assist for functional transfers and activities of daily living (ADL's) and a less intensive, longer duration of therapy will allow for measurable gains to be attained within a predicted period. 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 Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health services (90837 and 90791) provided on January 21, 2020 through February 3, 2020.
You asked the Plan to pay for the outpatient mental health services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this provider is not eligible in the Medicare program.
The Plan must follow Medicare rules. Medicare rules say that Licensed Professional Counselors are not eligible to enroll in Medicare. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the outpatient mental health services have not been met. Specifically, the record indicates that this provider is a Licensed Professional Counselor. Licensed Professional Counselors are not eligible in the Medicare program. Therefore, we decided that the Plan does not have to pay for outpatient mental health services (90837 and 90791) provided on January 21, 2020 through February 3, 2020.