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

We decided that the Plan does not have to waive the copayment for the emergency care provided from December 18, 2020, through December 19, 2020.
You asked the Plan to waive the copayment for the emergency care. You say that you were admitted for emergency care and discharged on December 19, 2020. You state you received a huge bill for a test that you cannot pay and would like for the services to be paid. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 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 the emergency care from December 18, 2020, through December 19, 2020. You were asked to pay a $90 copayment for the emergency care. Your 2020 EOC states that enrollees must pay a $90 copayment for emergency services. 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 emergency care provided from December 18, 2020, through December 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a neurostimulator (E0745) provided October 1, 2020.
You asked the Plan to pay for the neurostimulator. You say that the device was medically necessary. The Plan denied your request. The Plan says the documentation does not support the item billed.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid proof of delivery. The record did not include any itemized shipping receipt.
The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a neurostimulator (E0745) provided October 1, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the blepharoplasty of the upper eyelids.
You asked the Plan to pre-approve the blepharoplasty of the upper eyelids. You say that this request is medically necessary because your eyelids hang over your eyes. The Plan denied your request. The Plan says the coverage criteria have not been met.
The Plan follows Medicare rules. Medicare rules say that blepharoplasty surgery is subject to the criteria listed 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 the blepharoplasty of the upper eyelids. Our reviewer says that the requested surgery does not meet coverage criteria. Our physician reviewer found in this case, the medical records do not indicate a margin reflex distance of 2.0 mm or less. The submitted
photograph is uncalibrated and also does not satisfy this requirement. The elements of the coverage rule are not satisfied The requested service cannot be recommended. 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 blepharoplasty of the upper eyelids have not been met. Therefore, we decided that the Plan does not have to pre-approve the blepharoplasty of the upper eyelids.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer placement (22869).
You asked the Plan to pre-approve the interspinous spacer placement. You say that the procedure is medically necessary. The Plan denied your request. The Plan says this procedure is experimental and non-covered.
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 interspinous spacer placement. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the literature shows that the long-term safety and efficacy has not been established for the requested procedure. 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 interspinous spacer placement have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous spacer placement (22869).
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for endoscopic services provided on June 8, 2020.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says that the records do not support the billed 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.
The file shows that the enrollee received a flexible transoral esophagogastroduodenoscopy (43238), an endoscopic retrograde cholangiopancreatography (ECRP) (43276), and an endoscopic catheterization of the biliary ductal system (74328). 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 pay for the services provided. Our physician reviewer found that the enrollee has a diagnosis of painless jaundice with common bile duct stenosis. Procedure reports include ERCP with stent exchange and upper endoscopic ultrasound that identified a 24mm pancreatic head mass in association with severe stenosis of the intrapancreatic portion of the common bile duct. This lesion was fine needle biopsied, and adenocarcinoma was histologically identified. The available medical records in the case file support the billing of 43238, 43276, and 74328. 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 services provided have been met. Therefore, we decided that the Plan has to pay for endoscopic services provided on June 8, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99223) provided December 9, 2020.
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The
Plan denied your request. The Plan says the documentation does not support the billed services.
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is
due and the amount of payment.
We looked at the file and Medicare rules. Insufficient records were provided to support the services billed. The
plan made multiple requests for additional records and none were received. Based on this information, we
decided that Medicare rules for coverage of the physician services have not been met. Therefore, we decided
that the Plan does not have to pay for physician services (99223) provided December 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the telemedicine services provided on February 2, 2021, by a
non-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 a non-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 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 telemedicine services provided on February 2,
2021, by a non-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging, spinal canal and contents (72148) provided February 3, 2021.
You asked the Plan to waive the copayment for the MRI. You say that you received a bill from the provider, and you are appealing for the balance of the copayment. The Plan denied your request. The Plan says the claim was processed with the correct copayment applied.
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 $250 copay for Medicare covered diagnostic radiology services. You have been asked to pay $20 for the MRI. The invoice shows that you paid $185.84. You still owe the remaining $20. The MRI falls within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the magnetic resonance imaging, spinal canal and contents (72148) provided February 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).
You asked the Plan to pre-approve radiofrequency ablation (RFA). You say that the requested radiofrequency ablation (RFA) is medically necessary. The Plan denied your request. The Plan says the requested radiofrequency ablation (RFA) 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 radiofrequency ablation (RFA). Our reviewer says that the requested radiofrequency ablation (RFA) is not medically necessary. Our physician reviewer found the enrollee has chronic low back pain. She is morbidly obese. She is status post L4-L5 laminectomy, discectomy and L2-L5 spinal fusion. She also has fibromyalgia. She has tried physical therapy, Chiropractic, and acupuncture. She has had SI joint injections with good effect. The request is for RFA of the lateral sacral branches. This is considered an experimental/investigational procedure because of the wide variation in efficacy reported in the literature. Therefore, the request is considered not medically reasonable or 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 radiofrequency ablation (RFA) have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (82542, 80307, 80299) provided on November 4, 2020 by an out of network (OON) provider.
You asked the Plan to pay for OON drug testing. You say that most in-network providers cannot perform this testing. The Plan denied your request. The Plan says this testing was not authorized.
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 drug testing (82542, 80307, 80299) provided on November 4, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on October 26, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says prior authorization was not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider on October 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Flexitouch pneumatic compression device (E0652, E0667) for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says there is no swelling in the abdomen or trunk documented.
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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the records do not clearly document lymphedema of the chest, trunk, or abdomen. There is no clear documentation of a failure of at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Flexitouch pneumatic compression device (E0652, E0667) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a shoulder-arm brace (L3960) provided on September 26, 2020.
You asked the Plan to pay for a shoulder-arm brace. You say that the requested item was a necessity for the enrollee's care. The Plan denied your request. The Plan says rules for durable medical equipment have not been met.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid proof of delivery for the supplies provided in this case. Specifically, the record does not include an itemized billing/shipping invoice to verify the billed supplies. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a shoulder-arm brace (L3960) provided on September 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 standard power wheelchair (K0823).
You asked the Plan to pre-approve a Group 2 standard power wheelchair. You say that the requested item is a medical necessity for you. The Plan denied your request. The Plan says rules for power mobility devices have not been met.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 Group 2 standard power wheelchair. Our reviewer says that the requested item is not medically necessary. Our physician reviewer found that the provided medical records do not indicate that you have a mobility deficit that impairs the performance of mobility related activities of daily living within the home. You were evaluated by a Plan consultant who observed you ambulating within the home. You indicated that the requested device was to facilitate community
travel. The elements of the coverage criteria are not satisfied. 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 Group 2 standard power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 2 standard power wheelchair (K0823).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiovascular-respiratory risk assessment testing/panels
(CPT code 81286, 81407, 81408, 81479) provided to the enrollee on September 4, 2020, by an out-of-network
provider.

You asked the Plan to pay for the laboratory testing. You say that the claim should be paid. The Plan denied
your request. The Plan says this service is not covered.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the laboratory testing have not been met. Medicare denies coverage
for all cardiovascular risk assessment testing/panels, except the basic lipid panel, for symptomatic patients with
suspected or documented cardiovascular disease. Therefore, we decided that the Plan does not have to pay for
cardiovascular-respiratory risk assessment testing/panels (CPT code 81286, 81407, 81408, 81479) provided to
the enrollee on September 4, 2020, by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a hereditary cardiovascular screening (81185, 81401, 81404, 81405, 81406, 81479) provided on October 29, 2020.

You asked the Plan to pay for a hereditary cardiovascular screening. You say that this is supported by the medical records. The Plan denied your request. The Plan says this is not covered.

The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular (CV) risk assessment panels, except the basic lipid panel, for symptomatic (with signs and symptoms) patients with suspected or documented CV disease because panel testing is not specific to a given patient's lipid abnormality or disease. 

We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not covered. Based on this information, we decided that Medicare rules for coverage of a hereditary cardiovascular screening have not been met. Therefore, we decided that the Plan does not have to pay for a hereditary cardiovascular screening (81185, 81401, 81404, 81405, 81406, 81479) provided on October 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve consultation and treatment to be provided by an out of network provider.
You asked the Plan to pre-approve consultation and treatment with an out of network provider. You say that the enrollee is requesting a second opinion at the out of network facility. The Plan denied your request. The Plan says the services must be provided by network providers.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve consultation and treatment to be provided by an out of network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for physical therapy visits (97110, 97116, 97530, 97163) provided on January 16, 2021, to January 26, 2021.
You asked the Plan to waive the coinsurance for physical therapy visits. You say that you were misled when you signed up for this plan. You also say that you received a card showing you did not have any coinsurance for January. The Plan denied your request. The Plan says the coinsurance you are being charged is correct.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for each outpatient rehabilitation service.
You have been asked to pay a 20% coinsurance for each physical therapy visit. The EOC confirms that 20% is the required coinsurance for this service. The records show you had four (4) physical therapy visits. For your visit on January 16, 2021, the allowed amount of the claim is $227.66, resulting in a coinsurance obligation of $45.53. For your visit on January 19, 2021, the allowed amount of the claim is $128.03, resulting in a coinsurance obligation of $25.60. For your visit on January 21, 2021, the allowed amount of the claim is $98.31, resulting in a coinsurance obligation of $19.66. For your visit on January 26, 2021, the allowed amount of the claim is $98.31, resulting in a coinsurance obligation of $19.66. Your total cost-share is $110.45 ($45.53 + $25.60 + $19.66 + $19.66 = $110.45). There is no evidence within the record that the services at issue are subject to waiver of a coinsurance. Physical therapy visits fall within the outpatient rehabilitation 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 coinsurance for four (4) physical therapy visits (97110, 97116, 97530, 97163) provided on January 16, 2021, to January 26, 2021.
Your complaint about potentially receiving misinformation from a Plan is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.