Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forapplication of multi-layer compression system; leg (below knee), including ankle and foot) provided from August 28, 2019 through August 30, 2019.You asked the Plan to waive the copayment forthe services. You say that the services were processed under the outpatient surgery benefit and they should be processed under the outpatient therapeutic services and supplies benefit.The Plan denied your request. The Plan says the claims were processed accordingly with your 2019 EOC benefits.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 provider billed procedure code 29581 in the amount of $579.00 on each dates of service. The allowed amount for procedure code 29581 is $132.47. Since the allowed amount of $132.47 is less than the outpatient hospital benefit's copayment of $295.00, the plan applied the lesser amount of $132.47 as your copayment on each of the dates of service. 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 forapplication of multi-layer compression system; leg (below knee), including ankle and foot) provided from August 28, 2019 through August 30, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sclerotherapy injections for the enrollee.You asked the Plan to pre-approve the injections. You say that this is medically necessary.The Plan denied your request. The Plan says Medicare would not expect to see more than three sclerotherapy sessions per leg. 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 injections. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support the medical necessity of treatments in question. Apparently there are/were procedures performed or scheduled in the date rage from 12/3/19 to 05/3/20. There are no notes provided as to what was performed or what the response was. There is no reflux described in the GSV bilaterally other than at the junctions. It is not clear what truncal veins have been treated or are slated for treatment. The health plan has approved 2 sessions of (or of additional) sclerotherapy. There is no documentation in the medical record that would suggest this is not satisfactory. There is no documentation in the medical record that approved procedures have been performed but failed.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 injections have not been met.Therefore, we decided that the Plan does not have to pre-approvesclerotherapy injections for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe medical services to be provided by an out of network (OON) provider.You asked the Plan to pre-approvespecialist consultation. You say that you have a rare medical condition and are requesting a second opinion visit.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and you can be treated within the Plan network.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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.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. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvethe medical services to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drugs and medicaments (D9630 x 2), and the localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue (D4381) for teeth # 18 and 19 provided on October 17, 2019.You asked the Plan to pay forthe 2 drugs and medicaments, and the localized delivery of antimicrobial agents for teeth # 18 and 19. The Plan denied your request. The Plan says the drugs and medicaments, and the localized delivery of antimicrobial agents are not listed as covered services.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 drugs and medicaments, and the localized delivery of antimicrobial agents are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe drugs and medicaments (D9630 x 2), and the localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue (D4381) for teeth # 18 and 19 provided on October 17, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the WATS 3D (brush) biopsy testing provided to the enrollee on July 18, 2019.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is an experimental/investigational service.
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 pay for the testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the service under review is included in specialty society guidelines for the screening and surveillance of Barrett's esophagus. However, the enrollee's history, endoscopic features, and conventional biopsies fail to support a high suspicion of Barrett's dysplasia in her situation to warrant the WATS 3D assay. 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for the WATS 3D (brush) biopsy testing provided to the enrollee on July 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup, including any pins when requiredand first intraoral periapical x-ray provided on June 21, 2019 and June 26, 2019.You asked the Plan to pay forthe core buildup and first intraoral periapical x-ray. The Plan denied your request. The Plan says core buildup is not a covered benefit. The Planalsosays that benefits for the first intraoral periapical x-ray had been satisfied and the frequency limitation had been exceeded.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, core buildup, including any pins when required, is not among those covered under this benefit.  The contract says that intraoral x-rays are limited to one procedure per calendar year. The record shows that you received a first intraoral periapical x-ray on June 19, 2019 and your intraoral x-rays benefit was then exhausted.Therefore, we decided that the Plan does not have to pay forthe core buildup, including any pins when required and first intraoral periapical x-ray provided on June 21, 2019 and June 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for oxygen concentrator (CPT Code E1390) provided to the enrollee on March 7, 2019 by an out-of-network provider.You asked the Plan to pay forthe oxygen concentrator. You say that the durable medical equipment is medically necessary.The Plan denied your request. The Plan says there was no authorization.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan 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 foroxygen concentrator (CPT Code E1390) provided to the enrollee on March 7, 2019 by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on October 10, 2019.You asked the Plan to pay forthe orthoses. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on October 10, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvedecompression of the lumbar spinal cord (63056) to be provided by an out of network (OON) provider.You asked the Plan to pre-approvedecompression of the lumbar spinal cord. You say that the services are necessary.The Plan denied your request. The Plan says there are in-network providers that are able to provide this service. Therefore, coverage criteria has not been met.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.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. We found no exception that would require thePlan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvedecompression of the lumbar spinal cord (63056) to be provided by an out of network (OON) provider
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lab services provided on July 18, 2019.You asked the Plan to pay forthe lab services. The Plan denied your request. The Plan says the testing is not a Medicare benefit for the diagnoses listed on the claim.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The test at issue in this appeal, the lab services, was requested for screening purposes. There were insufficient records provided to show the results of this testing would be used to determine a specific diagnosis or determine a specific treatment strategy for disease or illness present in the enrollee at the time of service. Medicare does not cover the tests for screening purposes.Therefore, we decided that the Plan does not have to pay forthe lab services provided on July 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe periodic oral evaluation (D0120) and the prophylaxis (D1110) provided on August 21, 2019.You asked the Plan to reimburse you forthe dental service. You say that the services should be covered as 2 cleanings per year are covered.The Plan denied your request. The Plan says the maximum benefit has been exhausted.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 maximum benefit of $1,000 has been exceeded. Therefore, we decided that the Plan does not have to reimburse you forthe periodic oral evaluation (D0120) and the prophylaxis (D1110) provided on August 21, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveEuflexxa for the enrollee.You asked the Plan to pre-approveEuflexxa. You say that this is medically necessary.The Plan denied your request. The Plan says that they did not receive documentation supporting the medical necessity for a step therapy exception.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 Euflexxa. Our reviewer says that Euflexxa is not medically reasonable and necessary for the enrollee in this case. The provided medical recordsdo not indicate that the enrollee has tried and failed Monovisc and Orthovisc or that they would likely be less effective and/or likely have adverse effects for the enrollee. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Euflexxa.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met.Therefore, we decided that the Plan does not have to pre-approveEuflexxa for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the endoscopy provided on November 22, 2019.You asked the Plan to waive the copayment forthe endoscopy. You say that you were in and out in an hour and a half. You say that the cost is out of control.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 $450 copayment for each visit to an in-network ambulatory surgical center for Medicare-covered services.You have been asked to pay a $450 copayment for the endoscopy. The endoscopy 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 forthe endoscopy provided on November 22, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the ED visits provided on August 9, 2019 and August 10, 2019.
You asked the Plan to waive the copayments for the ED visits. You say that the injections were administered improperly which results in two trips to the emergency room. You say that the costs are a hardship. The Plan denied your request. The Plan says the copayments 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 $90 copayment for emergency care. You have been asked to pay a $90 copayment for each ED visit. The total amount you owe is $180 ($90/visit x 2 visits = $180). The ED visits falls within the "Emergency 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 copayments for the ED visits provided on August 9, 2019 and August 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the office visits provided on August 24, 2019 and September6, 2019.You asked the Plan to waive the copayments forthe office visits. You say that the doctor did nothing for you. You say that you shouldn't owe a copayment.The Plan denied your request. The Plan says the copayments 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 $30 copayment for in-network specialist visits. You have been asked to pay a $30 copayment for each office visit. The total amount you owe is $60 ($30/visit x 2 visits = $60). The office visitsfallwithin 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 copayments forthe office visits provided on August 24, 2019 and September 6, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services provided on July 30, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe laboratory services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services rendered are not a covered benefit.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 forthe laboratory services provided on July 30, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says the enrollee has not met the step therapy requirements.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 Prolia. Our reviewer says that Prolia is not medically reasonable and necessary. Our physician reviewer found that this appeal considers the request for Prolia for the treatment of age related osteoporosis without pathologic fracture. The enrollee has not trialed zoledronic acid. Step therapy, as outlined by the plan, requires this be trialed first. The documentation does outline contraindications or reasons this medication was not considered. Without the support of the documentation, Prolia is not approved as step criteria are not 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 Prolia have not been met.Therefore, we decided that the Plan does not have to pre-approveProlia.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided on October 5, 2019.You asked the Plan to waive the copayment foran ultrasound. You say that the first ultrasound was poor quality and 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 toits enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 copayment for ultrasounds. You have been asked to pay a $10 copayment for an ultrasound. An ultrasound 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 foran ultrasound provided on October 5, 2019.Your quality of care concerns have been handled separately by the health plan. Medicare does not permit us to make a decision on this type of complaint.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forbilateral elbow orthoses (L3761) provided to the enrollee on May 10, 2019.You asked the Plan to pay forthe orthoses. You say that the records support Medicare coverage.The Plan denied your request. The Plan says there was not a claim in the member's history from the prescribing provider on the date of service or in the last six (6) months prior to the date of the service.The Plan must follow Medicare rules. Medicare rules say thatthe information in the patient's medical record mustadequately support the medical necessity for the item, and if not the supplier is liable. A review of the file does not show information from the treating physician concerning the patient's diagnosis and need for the elbow orthoses. Therefore, we decided that the Plan does not have to pay forbilateral elbow orthoses (L3761) provided to the enrollee on May 10, 2019.