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

We decided that the Plan does not have to pay for genetic testing (81455) provided December 15, 2020.

You asked the Plan to pay for genetic testing. You say that the services were medically necessary. The Plan
denied your request. The Plan says this is not a covered service.

The Plan must follow Medicare rules. Medicare rules say that CPT code 81455 is not covered.

We looked at the file and Medicare rules. The CPT code billed is not covered under Medicare. Based on this
information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we
decided that the Plan does not have to pay for genetic testing (81455) provided December 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on November 19, 2020.

You asked the Plan to pay for drug testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing 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 documentation submitted shows that the sample for this testing was taken in an office setting, therefore the 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on November 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and therapeutic activities provided from February 1, 2021, to February 19, 2021.
You asked the Plan to pay for the chiropractic office visit and therapeutic activities. You say that you called the Plan about your benefits and were told you were fully covered. The Plan denied your request. The Plan says the services at issue are not listed as covered under the chiropractic benefit in the EOC.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the office visit and therapeutic activities provided from February 1, 2021, to February 19, 2021.
Please note, your appeal contained other dates of service. The Plan is handling them separately.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa (J7323).

You asked the Plan to pre-approve Euflexxa. You say that Euflexxa is medically necessary. The Plan denied your request. The Plan says a trial of Orthovisc and Monovisc is required before alternatives can be considered.

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 necessary. Our physician reviewer found the record does not show a trial of the plan preferred drugs or any reason they would be unsafe or ineffective 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa (J7323).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on December 18, 2020.

You asked the Plan to pay for lab test. You say that this test is highly beneficial in predicting response to treatment and improving clinical outcomes. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this testing was not ordered or approved by the enrollee's treating physician.

The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem. 

The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on December 18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81291, 81407, 81408, 81439) provided October 22, 2020.
You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan denied your request. The Plan says the genetic testing performed is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular risk assessment testing / panels, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular-respiratory disease. We looked at the file and Medicare rules. The service performed was a cardiovascular risk panel. 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 (81291, 81407, 81408, 81439) provided October 22, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for arthroplasty provided from July 23, 2020, to July 30, 2020.
You asked the Plan to waive the coinsurance for arthroplasty. You say that this was not an outpatient surgical procedure and you did not know that the provider was out-of-network. 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 50% coinsurance for out-of-network outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You received arthroplasty at an out-of-network provider from July 23, 2020, to July 30, 2020. The record shows that this was an outpatient surgical procedure. Therefore, you are responsible to pay your share of the out-of-network cost-sharing charges. The total allowed amount is $11,749.28 and 50% of that is $5,874.62.
You have been asked to pay the total coinsurance amount of $5,874.62 for arthroplasty. Arthroplasty 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 arthroplasty provided from July 23, 2020, to July 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for dialysis services (90970) provided April 23, 2019 to April 27, 2019.
You asked the Plan to pay for the dialysis services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim was not filed timely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the dialysis services was not filed until December 20, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for dialysis services (90970) provided April 23, 2019 to April 27, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services provided on October 22, 2020, by a provider who had opted out of Medicare.
You asked the Plan to pay for surgical services. You say that the services at issue were a necessity for the enrollee's care. The Plan denied your request. The Plan says the provider at issue had opted out of Medicare during the date of service.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who had opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for surgical services provided on October 22, 2020, by a provider who had opted out of Medicare.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the periodic oral evaluation, panoramic x-ray, prophylaxis, and topical application of fluoride, excluding varnish provided on February 16, 2021 by an OON provider.
You asked the Plan to pay more for the periodic oral evaluation, panoramic x-ray, prophylaxis, and topical application of fluoride. You say that the documentation sent to you by the Plan says there is no copay for services rendered by OON providers. The Plan denied your request. The Plan says the total liability amount of $143.25 was applied correctly. The Plan also says that the member liability is a contractual obligation under the Plan and cannot be waived.
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, you are responsible for the difference between the billed amount and allowed amount for dental services received OON. Therefore, we decided that the Plan does not have to pay more for the periodic oral evaluation, panoramic x-ray, prophylaxis, and topical application of fluoride, excluding varnish provided on February 16, 2021 by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Injectafer 750mg/15ml.
You asked the Plan to pre-approve Injectafer. You say that Injectafer is medically necessary. The Plan denied your request. The Plan says a trial of Infed or Venofer is required before alternatives can be considered.
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 Injectafer. Our reviewer says that Injectafer is not medically necessary. Our physician reviewer found the record shows no trial of the plan preferred drugs or any reason they would be unsafe or ineffective 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 Injectafer have not been met. Therefore, we decided that the Plan does not have to pre-approve Injectafer 750mg/15ml.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an impression and custom preparation of oral surgical splint (21085) and a lower jaw bone graft (21215).
You asked the Plan to pre-approve the impression and custom preparation of oral surgical splint and lower jaw bone graft. You say that the enrollee's current resorptive pattern creates a functional deformity. You also say that failure to treat this enrollee could potentially result in chronic soft tissue problems, pneumatization of the sinuses, digestive, and metabolic problems, and many more health issues. The Plan denied your request. The Plan says these services are not covered.
Medicare generally does not cover dental services. The Plan follows the same rule. 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 impression and custom preparation of oral surgical splint and lower jaw bone graft. Our reviewer says that this treatment is dental in nature, and therefore, does not meet the criteria for coverage. Our physician reviewer found according to the rules of coverage, Medicare does not cover any treatment involving the care, filling, extraction or replacement of the teeth or the supporting structures of the teeth. Our reviewer also found that that the proposed treatment is related to the teeth and supporting structures of the teeth (alveolar bone).
The services you are asking the Plan to pre-approve 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. Therefore, we decided that the Plan does not have to pre-approve an impression and custom preparation of oral surgical splint (21085) and a lower jaw bone graft (21215).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the evoked potential study rendered on November 27, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the appropriate place of service (POS) code. We looked at the file and Medicare rules. The file shows that procedure code 95939 (central motor evoked potential study) was billed with POS code 15 for a mobile setting; however, the services were rendered in a facility setting. 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 evoked potential study rendered on November 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more than the benefit allowance for eyeglasses provided on February 16, 2021.

You asked the Plan to pay more than the benefit allowance for the eyeglasses. The Plan denied your request. The Plan says the claim processed with the correct eyewear allowance of $250 under your Plan.

Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

We looked at the file and the Plan's rules. The file shows the Plan paid the correct eyewear allowance of $250. Therefore, we decided that the Plan does not have to pay more than the benefit allowance for eyeglasses provided on February 16, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81479) provided December 21, 2020.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the service at issue is not a covered service.

The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular disease.

We looked at the file and Medicare rules. The service performed was a cardiovascular risk assessment. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81479) provided December 21, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided on March 3, 2021.

You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you were not aware that you would owe such a high amount for your cancer treatments and cannot afford 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 Medicare Part B drugs on March 3, 2021. The total allowed amount is $10,636.08 and 20% of that is $2,127.22.

You have been asked to pay the total coinsurance amount of $2,127.22 for Medicare Part B drugs. Medicare Part B drugs fall 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 Medicare Part B drugs provided on March 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the laboratory services provided on
March 2, 2021 and March 9, 2021.

You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to the services provided.

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 $15 copayment for Medicare-covered lab services completed in an outpatient hospital.

You have been asked to pay $30 ($15 copayment x 2 days) for the Medicare-covered lab services provided in an outpatient hospital. 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 laboratory services provided on March 2, 2021 and March 9, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81201, 81317, 81404) provided October 15, 2020.

You asked the Plan to pay for the genetic testing. You say that the services were medically necessary.The Plan denied your request. The Plan says the service cannot be paid as billed.

The Plan must follow Medicare rules. Medicare rules say that to report a CGP, service providers should use CPT code 81479.

We looked at the file and Medicare rules. The panel was billed using separate unbundled codes. 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 (81201, 81317, 81404) provided October 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram (93000), the influenza vaccine (90682), the administration of the influenza vaccine (G0008), routine venipuncture (36415), and the annual wellness visit (G0439) rendered by the out of network (OON) provider on January 27, 2020.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without 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 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 for the electrocardiogram (93000), the influenza vaccine (90682), the administration of the influenza vaccine (G0008), routine venipuncture (36415), and the annual wellness visit (G0439) rendered by the out of network (OON) provider on January 27, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation (A0425, A0429) received March 22, 2021.
You asked the Plan to waive the copayment for the ambulance transportation. You say that the ambulance was called against your will. The Plan denied your request. The Plan says the correct cost share applied to the claim.
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 $200 copayment for Ambulance Services. You have been asked to pay a $200 copayment for the ambulance transportation. The ambulance transportation falls within the Ambulance 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 for the ambulance transportation (A0425, A0429) received March 22, 2021.