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

We decided that the Plan does not have to pre-approve thrombolytic venous therapy (37212, 36010, 37187, 75820, and 76937).
You asked the Plan to pre-approve thrombolytic venous therapy. You say that the requested thrombolytic venous therapy is medically necessary. The Plan denied your request. The Plan says the requested thrombolytic venous therapy is not medically necessary.
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 thrombolytic venous therapy. Our reviewer says that the requested thrombolytic venous therapy is not medically necessary. Our physician reviewer found the enrollee has had a deep vein thrombosis (DVT) in the right leg since prior to December 2019. The thrombus is limited to the femoral and popliteal vein with a patent common femoral vein. The thrombus was described as subacute versus chronic as far back as December 2019 and had a history of DVT in that leg even prior. There is no documentation of acute iliac venous thrombosis. There is inadequate documentation that the benefits of thrombolytic therapy outweigh the risks for the current situation. Based on the documentation provided, coverage 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 thrombolytic venous therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve thrombolytic venous therapy (37212, 36010, 37187, 75820, and 76937).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) and an ankle-foot orthosis (L1971) provided to the enrollee on August 29, 2019. You asked the Plan to pay for the orthosis. 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 for a lumbar-sacral orthosis (L0650) and an ankle-foot orthosis (L1971) provided to the enrollee on August 29, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the prophylaxis and periodic oral evaluation provided on October 8, 2019.
You asked the Plan to pay more for the prophylaxis and periodic oral evaluation. You say that you called customer service prior to your appointment and were advised that the service would be covered with no copayment. You also say that you were never told that you had a $500 maximum. The Plan denied your request. The Plan says your benefit was 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 Plan offers a $500 annual dental benefit maximum. The contract says that after your annual deductible benefit maximum has been met, you are responsible for the full charges of any additional dental services. The record shows that you met the annual deductible benefit on October 8, 2019 and your annual deductible benefit was then exhausted.
Claim
Date of Service
CPT Code
Total Claimed
Total Allowed
Total Paid
Cost Share
Paid Date
Applied to Max
191493903700
5/28/19
D0120
D0274
D1110
$406
$104
$104
$0
5/30/19
$104
191863801000
7/3/19
D0140
D0220
D0230
D2335
$1,428
$460
$382
$78
7/12/19
$382
192834020700
10/8/19
D0120
D1110
$271
$179
$14
$165
10/11/19
$14
Total
$500
Therefore, we decided that the Plan does not have to pay more for the prophylaxis and periodic oral evaluation provided on October 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an out-ofnetwork
provider from December 11, 2018, to December 30, 2018.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network
deficiency for the 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 has network providers
available who can provide 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 medical services provided by an out-of-network provider
from December 11, 2018, to December 30, 2018.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay foran office visit (99213) provided on July 22, 2019.You asked the Plan to pay foran office visit.. Her office said everything was clear for you to go to your appointment.The Plan denied your request. The Plan says that the services were not emergent and were not authorized. You must receive care from network providers in order for the plan to cover the care. The exceptions to this are emergent/urgent situations when you are unable to use a network provider, or if you need specialized care that network providers are not able to provide.Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are consideredapproved by the plan unless notice is provided that the services will not be covered.The plan follows these rules.You were referred for an office visit The file does not show that the plan provided notice that an office visit would not be covered. Under Medicare rules, this means an office visit is considered approved by the plan.In addition, the Plan has not provided any evidence (such as a billing statement showing a $0 balance) to corroborate their narrative that you will not be charged by the non-contracted provider for these services. The Plan case narrative on its own does not substantiate the denial and we must find in your favor.Therefore, we decided that the Plan has to pay foran office visit (99213) provided on July 22, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the remote ECG recording provided on August 5, 2019.
You asked the Plan to waive the copayment for the remote ECG recording. You say that this was done over the phone. You say that the Plan should pay the bill. 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 $35 copayment for diagnostic procedures and tests by an in-network specialist's office. You have been asked to pay $25.39, which is less than the standard $35 copayment for the remote ECG recording. The remote ECG recording falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The ECG recording is considered a remote physician 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 remote ECG recording provided on August 5, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approvea positron emission tomography (PET) scan (78816).You asked the Plan to pre-approvea PET scan. You say that this is needed to detect any cancer in your lower body.The Plan denied your request. The Plan says that this is not medically necessary because you have had four PET scans.The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a PET scan. Our reviewer says that this is medically necessary. Our physician reviewer found while guidelines typically allow up to 3 PET scans for each cancer diagnosis, there are some exceptions allowed including special circumstances when follow-up of prior PET scans are critical for patient care. In this particular case, the requested PET would be your fourth scan, but the tumor recurrence and residual tumor previously treated were best evaluated with PET scans and not on clinical grounds. These recurrent tumors required extensive surgical excision and reconstruction. Thus, the requested PET would be the best procedure to evaluate you with prior sub clinical tumor metastases and recurrence.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a PET scan have been met.Therefore, we decided that the Plan has to pre-approvea positron emission tomography (PET) scan (78816).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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the specialist office visit and the ultrasound provided on September 11, 2019.
You asked the Plan to waive the copayments for the specialist office visit and the ultrasound. You say that you were not informed by the facility that there would be copayment for the ultrasound and for the specialist office 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 $50 copayment for each specialist visit for Medicare-covered benefits and a $225 copayment for Medicare-covered diagnostic radiological services (such as CT scans and MRIs). You have been asked to pay a $50 copayment for the specialist visit and a $25 copayment for the ultrasound, which is less than the standard copayment. The specialist office visit falls within the "Physician/Practitioner services including doctor's office visits" benefit category. The ultrasound falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows the services were billed separately by two different providers.
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 specialist office visit and the ultrasound provided on September 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a cardiovascular stress test and does not have to waive the coinsurance for a Medicare Part B injection provided on August 9, 2019.
You asked the Plan to waive the copayment for a cardiovascular stress test and to waive the coinsurance for a Medicare Part B injection. You say that you paid the $100 copayment and disagree with the additional charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 copayment for non-radiological diagnostic services. Your contract with the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs. You received a cardiovascular stress test on August 9, 2019. Therefore, you are responsible to pay the $25 copayment. You received a Medicare Part B drug on August 9, 2019. The allowed amount is $20.79 and 20% of that is $4.16. The total amount you owe is: $29.16.
You have been asked to pay the total amount of $29.16 for a cardiovascular stress test and a Medicare Part B injection. A cardiovascular stress test falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. A Medicare Part B 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 a cardiovascular stress test and does not have to waive the coinsurance for a Medicare Part B injection provided on August 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a drug test provided on May 30, 2019 by out of network provider
You asked the Plan to pay for a drug test. You say that you provide these services in good faith. You say that these services were requested from a referring provider. The Plan denied your request. The Plan says no prior authorization was obtained 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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for a drug test provided on May 30, 2019 by out of network provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the catheters provided on October 1, 2019.
You asked the Plan to waive the coinsurance for the catheters. You say that catheters are not durable medical
equipment. The Plan denied your request. The Plan says that the claim processed 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 Durable medical equipment (DME) and related supplies.
You have been asked to pay a 20% coinsurance for the catheters. The catheters fall within the Durable medical
equipment (DME) and related 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 coinsurance
for the catheters provided on October 1, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the physical and occupational therapy services rendered to you from July 10, 2019 to August 5, 2019.
You asked the Plan to waive the coinsurance for these services. You say that you needed guidance from a physical therapist. The Plan denied your request. The Plan says the coinsurance was 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% of the Medicare-allowed amount for point-of-service coverage.
Review of the file shows that you received outpatient rehabilitation services from an out-of-network provider from July 10, 2019 to August 5, 2019. You have been asked to pay 20% of the Medicare-allowed amount for these services. These services fall within the point-of-service coverage 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 physical and occupational therapy services rendered to you from July 10, 2019 to August 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture services provided on September 13, 2019.
You asked the Plan to pay for the acupuncture services. You say that these treatments make you feel well. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. The services at issue in this appeal are acupuncture services. Therefore, we decided that the Plan does not have to pay for the acupuncture services provided on September 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for osteogenesis stimulator, electrical, non-invasive, other than spinal applications (CPT Code E0747) on June 24, 2019.
You asked the Plan to waive the coinsurance for the DME. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was 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). Review of the file show that you received an osteogenesis stimulator on June 24, 2019. The Plan paid $2564.44 (80%); therefore, you are liable for $651.33 (20%). 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 osteogenesis stimulator, electrical, non-invasive, other than spinal applications (CPT Code E0747) on June 24, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 17, 2019 by an out-of-network provider.
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 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 requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on June 17, 2019 by an out-of-network provider.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve a transthoracic echocardiogram (TTE) with Doppler and stress TTE 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says that the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has increased coronary risk, atypical chest pain and a normal electrocardiogram. In this setting of intermediate pretest probability, interpretable ECG and ability to exercise, exercise echocardiography is considered appropriate by current guidelines. The services are reasonable and medically necessary. 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 been met. Therefore, we decided that the Plan has to pre-approve a transthoracic echocardiogram (TTE) with Doppler and stress TTE
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for vision care services provided to the enrollee on September 11, 2019 by an out-of-network provider. 
 
You asked the Plan to pay for vision care services. You say that the claim should be paid. The Plan denied your request. The Plan says the enrollee does not have out-of-network benefits. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for vision care services provided to the enrollee on September 11, 2019 by an out-of-network provider.