Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit and hearing test provided on February 24, 2021.

You asked the Plan to waive the copayment for the office visit and hearing test. You say that you are being double charged. 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 $40 copayment for specialist physician services and a $40 copayment for Medicare-covered diagnostic hearing and balance evaluations.

You have been asked to pay a $40 copayment for the office visit and a $40 copayment for the hearing test. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The hearing test falls within the "Hearing services" benefit category. Diagnostic tests are considered a separate 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 for the office visit and hearing test provided on February 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the podiatry services provided on January 20, 2020 to March 17, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the podiatry services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services received were neither emergent nor urgent and prior authorization was not obtained to seek out-of-network care.
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 the podiatry services provided on January 20, 2020 to March 17, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the aspiration and/or injection of large joint or joint capsule (20610) provided January 20, 2021.
You asked the Plan to waive the copayment for the aspiration and/or injection of large joint or joint capsule. You say that you do not believe you should be charged for surgery services. The Plan denied your request. The Plan says the claim has 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 $150 copayment for Medicare-covered surgery.
You have been asked to pay a $150 copayment for the aspiration and/or injection of large joint or joint capsule. This service falls within the Medicare-covered surgery benefit category. This service is classified as a surgery 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 for the aspiration and/or injection of large joint or joint capsule (20610) provided January 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on December 11, 2020.

You asked the Plan to waive the copayment for the office visit. You say that there is no copayment during COVID, but the copayment is continually denied. You say that the explanation of benefits says you do not need to pay the copayment. 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 $20 copayment for provider and professional services at an in-network primary care physician's office.

You have been asked to pay a $20 copayment for the office visit. 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 copayment for the office visit provided on December 11, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.
You asked the Plan to pre-approve the Vertiflex procedure. You say that this request is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this procedure is considered experimental/investigational.
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 Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found The Vertiflex device is experimental. More research is needed to show safety and efficacy of the device before coverage can be considered. 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 Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the patient is motivated to improve and will tolerate the three hours of therapy required of acute rehabilitation. The Plan denied your request. The Plan says that the enrollee has no complex medical needs that require intensive rehabilitation.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for cauda equine
syndrome and had lumbar decompression surgery. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services (99205) provided on December 10, 2020.
You asked the Plan to pay for the outpatient visit. You say that the services were medically necessary. The Plan denied your request. The Plan says there were network providers 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 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 for outpatient services (99205) provided on December 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the SNF stay provided from December 7, 2020, through December 31, 2020.

You asked the Plan to waive the copayment forthe SNF stay. You say that the stay had to be extended because you caught COVID. You say that you needed more physical therapy, oxygen,and nursing care to regain strength to be dismissed.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 $0 per day, days 1-20 and $178 per day, days 21-100 for each in-network SNF Stay.

You have been asked to pay a total of $4,450 for the SNF stay.

The SNF stay falls within the "Skilled nursing facility (SNF) 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 SNF stay provided from December 7, 2020, through December 31, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forthe computed tomography (CT) scan of thoracic spine, without contrast, (72128), and the CT of lumbar spine, without contrast, (72131) provided on June 17, 2020.You asked the Plan to pay forthe imaging services. You say that the services are medically necessary.The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay forthe computed tomography (CT) scan of thoracic spine, without contrast, (72128), and the CT of lumbar spine, without contrast, (72131) provided on June 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit with a chiropractor provided on June 4, 2020.You asked the Plan to pay forthe office visit with a chiropractor. You say that the enrollee was not aware this service was not covered.The Plan denied your request. The Plan says excluded from Medicare coverage is any service other than manual manipulation for the treatment of subluxation 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 service at issue is not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay forthe office visit with a chiropractor provided on June 4, 2020
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe x-ray provided by an out-of-network provide on November 18, 2020.You asked the Plan to pay forthe x-ray. You say that you were not informed the doctor did not accept your insurance. You say that you cannot afford to make these payments.The Plan denied your request. The Plan says services provided by an out-of-network provider are not covered.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 requirethe Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay forthe x-ray provided by an out-of-network provide on November 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the topical administration of aminolevulinic acid provided on December 15, 2020. 

You asked the Plan to waive the coinsurance for the topical administration of aminolevulinic acid. You say that a mistake was made in charging you a copayment for a procedure that should have been fully covered. You say that the Plan should pay the dermatologist.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 20% coinsurance for other Part B covered drugs.

You have been asked to pay $76.58, which is 20% of the allowed amount for the topical administration of aminolevulinic acid. The allowed amount is $382.91 (20% x $382.91 = $76.58). The topical administration of aminolevulinic acid 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 the topical administration of aminolevulinic acid provided on December 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a reverse total shoulder arthroplasty for the enrollee.

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The
Plan denied your request. The Plan says that records do not show the additional level of damage in the
enrollee's shoulder to warrant a reverse procedure.

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 these services. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. The enrollee is being
treated for right glenohumeral osteoarthritis. She presented with right shoulder pain. Exam of the right shoulder
(from 3/23/21) reveals flexion 170, external rotation 60, abduction 170, and internal rotation L3. Strength is 4
out of 5 in external rotation, supraspinatus and subscapularis. Neer's, Hawkin's, Whipple's, SLAP test, and
Speed's are all positive. CT scan noted moderate to severe right glenohumeral joint degenerative changes;
intra-articular loose bodies in the subscapularis recess measuring slightly greater than 1cm; mild right
acromioclavicular joint degenerative changes. She is noted to have tried and failed conservative treatment
measures. However, the most recent exam findings from 5/18/21 are noted to be for the left shoulder. (The
prior right shoulder exam findings (from late March 2021) were however noted/factored in.) The provided right
shoulder imaging does not demonstrate evidence of an irreparable rotator cuff tear, despite the relatively severe
and painful right shoulder arthrosis. The requested procedure has been found in peer-reviewed literature to be
an effective treatment modality when there is evidence of cuff tear arthropathy and irreparable rotator cuff
tears, including with pseudoparalysis (preserved deltoid contraction but loss of active elevation). Significant
issues with active elevation and other literature-documented indications (especially including an irreparable
rotator cuff tear) are not evident on the medical documentation provided for review. Our physician reviewer
found that the enrollee's condition does not meet criteria for coverage of these services.

We looked at this physician's review, the file, and Medicare rules. 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 pre-approve a reverse total shoulder arthroplasty for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 24, 2020 billed with codes 99215 and 94760.

You asked the Plan to pay for the medical services. You say that this should be paid.The Plan denied your request. The Plan says coverage was approved for code 99215 on a prior claim, and no separate payment is allowed for 94760 when billed with another payable 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. The rules also say that duplicate claims will be denied. 

In this case, the Plan has shown that a previous claim was paid on December 15, 2020 with the charge for code 99215 being applied to the enrollee's deductible. As such, the second claim for this service is duplicate and correctly denied. Regarding code 94760, this has a status indicator of "T" on the Physician Fee Schedule. This means that the code is only paid if there are no other services payable under the Physician Fee Schedule billed on the claim. Otherwise, payment is bundled with the other service. Based on this information, we decided that Medicare rules for coverage of the medical services have not been met.Therefore, we decided that the Plan does not have to pay for the medical services provided on September 24, 2020 billed with codes 99215 and 94760.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy provided from February 5, 2019, to November 20, 2019.

You asked the Plan to pay for the psychotherapy. You say that your policy provided coverage for the services which are out-of-network. The Plan denied your request. The Plan says the provider is a mental health counselor and not eligible to participate in Medicare.

The Plan follows Medicare rules. Medicare rules say that no Medicare payment may be made for items or services provided directly by a physician or practitioner who is not eligible to enroll in Medicare. 

The provider is not qualified to receive payment under Medicare or the benefit plan. Therefore, we decided that the Plan does not have to pay for psychotherapy provided from February 5, 2019, to November 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam provided on February 5,
2021.

You asked the Plan to waive the copayment for the eye exam. You say that you requested an annual routine
exam which is covered 100% with no copayment. This routine exam was not the result of a medical condition
and you should not have been billed. 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 $30
copayment for each specialist's office visit.

You have been asked to pay a $30 copayment for the eye exam. The eye exam falls within the "Vision services
(Medicare-covered)" benefit category. The records show a medical eye exam 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 eye exam provided on February 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit provided on December 2, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe office visit. You say that you were not told the provider was out of network. You say you cannot afford to pay this bill and it is not your fault. The Plan denied your request. The Plan says the provider is out-of-network.Medicare rules say that plans can require enrollees to get care fromnetwork 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 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 office visit provided on December 2, 2020 by an out of network (OON) provider.