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

We decided that the Plan does not have to waive the copayment for the echocardiography provided on June 8, 2020.
You asked the Plan to waive the copayment for the echocardiography. You say that you don't understand why the plan only paid $64.69 while charging you $150. You say that you budgeted 20% of the charges. 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 $150 copayment for each Medicare-covered radiological diagnostic service performed at an in-network physician's office or freestanding facility. You have been asked to pay a $150 copayment for the echocardiography. The echocardiography falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The echocardiography is considered an ultrasound of the heart. 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 echocardiography provided on June 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea bone replacement graft for ridge preservation (D7953) andguided tissue regeneration (D4266).You asked the Plan to pre-approvethe bone replacement graft and guided tissue regeneration. You say that the services are medically necessary.The Plan denied your request. The Plan says these services are notcovered.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 requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvea bone replacement graft for ridge preservation (D7953) and guided tissue regeneration (D4266).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for nail debridement provided on September 15, 2020.
You asked the Plan to waive the copayment for nail debridement. You say that you wanted a second opinion for an ingrown toenail. 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 $40 copayment for each Medicare-covered visit (medically necessary foot care). Covered services include diagnosis and the medical or surgical treatment of injuries and diseases of the feet. You have been asked to pay $33.56, which is less than the standard $40 copayment for nail debridement. Nail debridement falls within 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 for nail debridement provided on September 15, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for the canalith repositioning procedure provided on September 15, 2020.
You asked the Plan to waive the copayment for the canalith repositioning procedure. You say that you assumed the repositioning was part of the office visit. You say that you shouldn't owe a separate $35 copayment. The Plan denied your request. The Plan says that the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay a $35 copayment for each specialist visit. Covered services include medically necessary medical care or surgery services furnished in a physician's office, certified ambulatory surgical center, hospital outpatient department, or any other location. Covered services also include consultation, diagnosis, and treatment by a specialist. The Plan says you must pay a $35 copayment for an outpatient therapy service for the canalith repositioning procedure. Based on the Plan contract, however, you cannot be asked to pay more than $0 for the canalith repositioning procedure. The canalith repositioning procedure is considered a physician service, which would be included in the office visit copayment. Therefore, we decided that the Plan has to waive the additional $35 copayment for the canalith repositioning procedure provided on September 15, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe inpatient rehabilitation services received from May 5, 2020, to May 18, 2020.You asked the Plan to waive the copayment forthe inpatient rehabilitation services. You say that you would like this copayment waived and approved for payment.The Plan denied your request. The Plan says the copayment has applied 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). The enrollee's contractwith the Plan clearly says that enrollees must pay a $175 copayment per day for days 1-4 and a $0 copayment per day for additional days for inpatient hospital care. The enrollee has been asked to pay a total cost share of $700 ($175 copayment x +4 days). The services provided fallwithin the inpatient hospital care benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe inpatient rehabilitationservices received from May 5, 2020, to May 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the enrollee needs IRF services.The Plan denied your request. The Plan says the enrollee can safely receive services in other settings.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file andapply 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. Our physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for surgical repair of a hip fracture. Medical conditions are stable. There are no medical needs requiring inpatient admission. 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. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program.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.
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-approveacute inpatient rehabilitation facility (IRF) admission and services
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 10, 2019.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the claim was received past the allowed timeframe.
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 services provided was not filed until September 8, 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 the medical services provided on January 10, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lab services (84153) provided on August 6, 2020.You asked the Plan to payforthe lab services. 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 has network providers available who can provide 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 lab services (84153) provided on August 6, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on June 18, 2020.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you do not believe you should be held responsible for this bill because you saw 3 different dentists who did not know what the infection you had was. You also say that these dentists kept sending you to different dentists, and you ended up treating yourself. The Plan denied your request. The Plan says this service does not meet the frequency requirements of the Plan.
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, problem focused limited oral evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem focused limited oral evaluation (D0140) on May 15, 2020, and your problem focused limited oral evaluation (D0140) benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on June 18, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on April 4, 2020.
You asked the Plan to pay for the ambulance services. You say that this is a financial hardship. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on April 4, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on April 4, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BROVANA J7605.
You asked the Plan to pre-approve BROVANA J7605 (arformoterol). You say that you want the enrollee
treated with this drug. The Plan denied your request. The Plan says the enrollee has not first tried and had a
contraindication or intolerance to PERFOROMIST (formoterol).
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 BROVANA J7605 (arformoterol). Our
reviewer says that the drug is not medically necessary. Our physician reviewer found there is no evidence that
the enrollee is allergic to or intolerant of PERFOROMIST. There is no evidence that the enrollee has tried and
not responded PERFOROMIST. There is no documentation as to why PERFOROMIST would not be expected
to be safe and effective for the enrollee. Therefore, the requested BROVANA is not shown to be currently
medically necessary and reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of BROVANA J7605 (arformoterol) have not been met. Therefore, we decided
that the Plan does not have to pre-approve BROVANA J7605.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forgenetic testing (81120, 81121, 81173, 81201, 81210, 81235, 81270, 81272, 81275, 81293, 81310, 81311, 81314, 81321, 81400, 81401, 81401, 81402, 81403, 81403, 81404, 81404, 81405, 81405, 81406, 81406) provided August 6, 2020.You asked the Plan to pay forthe genetic testing. You say that the services were medically necessary.The Plan denied your request. The Plan says the services were reported with an inappropriate CPT codes. Genetic testing codes should not be unbundled.The Plan must follow Medicare rules. Medicare rules say that providersmust report services correctly. Providers must report services with the appropriate CPT code.We find that CPT codes 81120, 81121, 81173, 81201, 81210, 81235, 81270, 81272, 81275, 81293, 81310, 81311, 81314, 81321, 81400, 81401, 81401, 81402, 81403, 81403, 81404, 81404, 81405, 81405, 81406 & 81406 are not supported in the medical record. Specifically, Medicare rules require this genetic testing to be reported with CPT code 81479. 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 forgenetic testing (81120, 81121, 81173, 81201, 81210, 81235, 81270, 81272, 81275, 81293, 81310, 81311, 81314, 81321, 81400, 81401, 81401, 81402, 81403, 81403, 81404, 81404, 81405, 81405, 81406, 81406) provided August 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on August 11, 2020.
You asked the Plan to pay for the testing services. You say that the testing was ordered to determine if there was a more effective therapy to treat the enrollee's advanced cancer. The Plan denied your request. The Plan says providers must not unbundle services.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that the testing at issue was not billed using CPT code 81479. If a single procedure is performed, only one HCPCS/CPT code with one unit of service may be reported for the procedure. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on August 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe removal of an impacted tooth (D7240).You asked the Plan to pre-approvethe dental service. You say that the requested service is medically necessary.The Plan denied your request. The Plan says the removal of an impacted tooth is not listed as a covered service.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 requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvethe removal of an impacted tooth (D7240)
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvebreast implant surgery for the enrollee.You asked the Planto pre-approvethe surgery. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is considered to be cosmetic surgery.The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are coverable.  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 surgery. Our reviewer says that the requested surgery is not medically reasonable or necessary. Our reviewer found the enrollee is a 55 year old transgender male to female with well-documented gender dysphoria who has been undergoing female transitioning with hormonal therapy for approximately 2 years. Thus, based on her diagnosis and history, her external anatomy should be more consistent with a female than a male. Review of the photograph supports that she has had breast development that appears consistent with a relatively normal female contour. In this case, medical necessity has not been adequately defined in the medical documentation provided as reasoned above and as defined by Medicare. Thus, the procedure should be considered cosmetic enhancement of relatively normal female breasts and not medically necessary.We looked at this physician'sreview, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the surgery have not been met.Therefore, we decided that the Plandoes not haveto pre-approvebreast implant surgery for the enrollee
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forpsychotherapy services (90837) provided on February 29, 2020, through May 28, 2020.You asked the Plan to pay forthe psychotherapy services. You say that you would like reconsideration because these claims have been paid in the past and you have an established therapeutic relationship with this provider.The Plan denied your request. The Plan says this provider does not meet Medicare's standards of non-physician practitioners.The Plan must follow Medicare rules. Medicare rules say that Licensed Professional Counselors and Marriage Family Therapists are not eligible to enroll in Medicare.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the psychotherapy services have not been met. Specifically, this provider is a Licensed Professional Counselor and Marriage and Family Therapist. The services of this provider are not payable by Medicare or the Plan.Therefore, we decided that the Plan does not have to pay forpsychotherapy services (90837) provided on February 29, 2020, through May 28, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea gradient compression wrap (A6545).You asked the Planto pre-approvethe wrap. You say that this is medically necessary.The Plandenied your request. The Plansaysthere are no open wounds.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 wrap. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the rules are clear in that these stockings are not meant for lymphedema or edema. Ulcer(s) are necessary in order for this wrap to be indicated.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 wrap have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea gradient compression wrap (A6545)
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe surgical placement of an implant body (D6010 x 2) and prefabricated abutments (D6056 x 2).You asked the Plan to pre-approvethe surgical placement of implants and prefabricated abutments. You say that the requested dental services are medically necessary.The Plan denied your request. The Plan says surgical placement of an implant is not listed and therefore is not a covered service. The Plan says prefabricated abutment is not listed and therefore is not a covered service either.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 requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvethe surgical placement of an implant body (D6010 x 2) and prefabricated abutments (D6056 x 2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services provided on July 27, 2020, by a provider who
has opted out of Medicare.
You asked the Plan to pay for dental services. You say that you selected the provider from the Plan's list of
providers. The Plan denied your request. The Plan says the dental provider has opted out of Medicare.
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
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for dental
services provided on July 27, 2020, by a provider who has opted out of Medicare.