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

We decided that the Plan does not have to pay forthe radiologic examination provided on August 19, 2020 by an out of network provider.You asked the Plan to pay forthe radiologic examination. You say that you did not realize you were out of network.The Plan denied your request. The Plan says you did not request prior authorization.Medicare rules saythat plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the 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 forthe radiologic examination provided on August 19, 2020 by an out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe X-ray of chest (71045) provided on August 12, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe X-ray of chest. You say that you thought you were in-Network with the Plan.The Plan denied your request. The Plan says prior authorization was not requested.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe X-ray of chest (71045) provided on August 12, 2020 by an out of network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for immunotherapy service provided on August 13, 2020.
You asked the Plan to waive the copayment for specialist visit. You say that this cost-share was not on the Evidence of Coverage or Annual Notice of Change for 2020. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $35 copayment for specialist visit. You have been asked to pay the allowed amount of $10.36, which is less than the $35 copayment for specialist visit. Specialist 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 copayment for immunotherapy service provided on August 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for vitamin D testing (82306) provided on May 7, 2020.
You asked the Plan to pay for vitamin D testing. You say that this was medically necessary. The Plan denied
your request. The Plan says this was not indicated.
The Plan must follow Medicare rules. Medicare rules say that vitamin D testing is indicated only for the
conditions listed above.
We looked at the file and Medicare rules. The record does not show that the enrollee had a covered indication
for this testing. Based on this information, we decided that Medicare rules for coverage of vitamin D testing
have not been met. Therefore, we decided that the Plan does not have to pay for vitamin D testing (82306)
provided on May 7, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rythmol caplets.
You asked the Plan to pre-approve Rythmol caplets. You say that the enrollee has been taking Rythmol since July 24, 2018, and needs to continue using this drug. The Plan denied your request. The Plan says this medication does not fall under the members Part B benefits.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Rythmol caplets.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the emergency room visit provided on May 28, 2020.
You asked the Plan to reduce the copayment for the emergency room visit. You say that you should not be charged another emergency room visit copayment. You say the most you should be charged is $35 for a specialist visit. 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 $90 copayment for emergency care. You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. The medical record shows you were seen and treated in the emergency room.
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 copayment for the emergency room visit provided on May 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81404, 81405, 81406, 81407, 81408)
provided March 26, 2020.
You asked the Plan to pay for the genetic testing. You say that the testing was medically necessary. The Plan
denied your request. The Plan says this type of testing is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular
risk assessment panels.
We looked at the file and Medicare rules. The genetic testing performed is not a covered service. Based on this
information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore,
we decided that the Plan does not have to pay for genetic testing (81404, 81405, 81406, 81407, 81408)
provided March 26, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eylea for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your
request. The Plan says step therapy guidelines were not followed.
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 drug. Our reviewer says that the
requested drug is not medically reasonable or necessary. Our physician reviewer found the requested
medication is subject to step therapy. Step therapy is a type of prior authorization for drugs that begins
medication for a medical condition with the most preferred drug therapy and progresses to other therapies only
if necessary, promoting better clinical decisions. The plan requires a trial of Avastin before they will approve
the requested drug. In this case, the enrollee has not tried and failed the required drug. There is no
documentation provided indicating that the Plan's required drugs would likely be less effective and/or likely
have adverse effects for the enrollee. 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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Eylea for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran X-ray provided on August 17, 2020.You asked the Plan to waive the copayment foran X-ray. You say that you were misdiagnosed and the proper test was not ordered.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 $55 copayment for X-rays. You have been asked to pay a $55 copayment for an X-ray. An X-ray 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 X-ray provided on August 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forpodiatry services provided on May 8, 2020.You asked the Plan to waive the copayment forpodiatry services. You say that you feel that the charges might be fraudulent.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 $20 copayment for podiatry services. The medical records show that you received podiatry services on May 8, 2020. Therefore, you are responsible to pay the $20 copayment. You have been asked to pay a $20 copayment for podiatry services. Podiatry services fallwithin the podiatry services 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 forpodiatry services provided on May 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the erectile vacuum pump purchased on March 12, 2020.
You asked the Plan to pay for the pump. You say that you have had a post radical prostatectomy resulting in
erectile dysfunction and your need for an erectile pump. The Plan denied your request. The Plan says that this
is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that vacuum erection devices (L7900) and related
accessories (L7902) are statutorily non-covered.
We looked at the file and Medicare rules. The item at issue is a vacuum erection device. This item is not
covered by Medicare. Therefore, we decided that the Plan does not have to pay for the erectile vacuum pump
purchased on March 12, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 10, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says nonemergent, non-urgent services with out-of-network providers require prior 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 did not pre-approve the
physician's services. 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 physician's services provided on October 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for arthrocentesis and does not have to waive
the coinsurance for a Medicare Part B drug injection provided on December 19, 2019.
You asked the Plan to waive the copayment for arthrocentesis and to waive the coinsurance for a Medicare Part
B drug injection. You say that you were not informed that you would owe such a high fee for the shot. 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 $35
copayment for specialist visits. Your contract with the Plan also clearly says that you must pay 20%
coinsurance for Medicare Part B prescription drugs.
You received arthrocentesis on December 19, 2019. Therefore, you are responsible to pay the $35 copayment.
You received a Medicare Part B drug on December 19, 2019. The allowed amount is $1,212.77 and 20% of
that is $242.55.
The total amount you owe is: $277.55.
You have been asked to pay the total amount of $277.55 for arthrocentesis and a Medicare Part B drug
injection. Arthrocentesis falls within the physician/practitioner services, including doctor's office visits benefit
category. A Medicare Part B drug 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 copayment for arthrocentesis and does not have to waive the
coinsurance for a Medicare Part B drug injection provided on December 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider from October 7, 2019, to October 11, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services are available in-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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the 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 the enrollee by an out-of-network provider from October 7, 2019, to October 11, 2019
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for diabetic supplies on April 22, 2020.
You asked the Plan to pay for the diabetic supplies. You say that the diabetic supplies should be covered. The
Plan denied your request. The Plan says that the services were billed by another provider, so the services were
denied.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The plan did not adequately support their decision on why the standard diabetic
testing supplies were not supported, just the Continuous Glucose Monitor. Therefore, we decided that the Plan
has to pay for diabetic supplies on April 22, 2020.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee on July 15,
2020.
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your
request. The Plan says there was no valid authorization 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 had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for home health services provided to the enrollee on
July 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on July 10, 2020.You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says this service requires prior authorization.Medicare rules say that plans can require enrollees to getcare 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 did not pre-approve the 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 subsequent nursing facility care provided on July 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the LTACH services are medically necessary.The Plan denied your request. The Plan says coverage criteria have not been met.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee can remain at the current hospital until such time no acute services are required. The enrollee can then be transferred to a lower level of care for any ongoing needs.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 LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from August 21, 2019, to August 24, 2019.
You asked the Plan to waive the copayment for the inpatient hospital care. You say that you were not aware you would be charged a copayment for the services you received. The Plan denied your request. The Plan says the copayment processed correctly in this case.
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 $275 copayment per day for days 1-6 for inpatient hospital care. You have been asked to pay a total cost share of $825 for the three days of inpatient hospital care you received ($275 copayment x 3 days). The services provided falls within the inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from August 21, 2019, to August 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for advance care planning services (CPT 99497) provided to the
enrollee on May 9, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says the information submitted does not support this level of service.
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 99497 is "advance care planning, including the
explanation and discussion of advance directives, such as standard forms, by the phys; first 30 minutes, F2F
with the patient."
We asked our coding 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 services. Our reviewer says that the
services at issue in this case were not supported by the medical records. Our coding reviewer found the
documentation submitted did not include counseling of advance care planning, as well as, time spent
counseling advance care planning. The records should include documentation of the explanation and
discussion with the enrollee to verify this service was performed.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not
have to pay for advance care planning services (CPT 99497) provided to the enrollee on May 9, 2020.