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

We decided that the Plan does not have to waive the copayments for an electrocardiogram (93000) and cardiology visit (99214) provided December 1, 2020.
You asked the Plan to waive the copayments for the electrocardiogram and cardiology visit. You say that the copayment was lower in the past and was not applied correctly. The Plan denied your request. The Plan says the correct copayment was applied per the 2020 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). Your contract with the Plan clearly says that you must pay a $35 copayment for specialist visits, and a $20 copayment for diagnostic tests. You have been asked to pay $35 for the cardiology visit, and the Medicare allowable amount of $18.34 for the electrocardiogram. The cardiology visit is included in the specialist visits benefit category. The electrocardiogram is a diagnostic test. 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 an electrocardiogram (93000) and cardiology visit (99214) provided December 1, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services (A0425, A0426)
provided on November 17, 2020.
You asked the Plan to waive the copayment for the ambulance services. You say that you were told by the
provider of the ambulance services that you would not be responsible for payment. The Plan denied your
request. The Plan says you were charged this cost sharing 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 $185
copayment for each ambulance trip. You had 1 ambulance trip. The Plan charged you $185 for these 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 ambulance services (A0425, A0426) provided on
November 17, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on January 23, 2021.
You asked the Plan to pay for the ambulance services. 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 January 23, 2021. 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 January 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for interrogation device evaluation provided on January 21, 2021.
You asked the Plan to waive the copayment for interrogation device evaluation(s), (remote) up to 30 days; subcutaneous cardiac rhythm monitor system, including analysis of recorded heart rhythm data, analysis, review(s) and report(s) by a physician or other qualified health care professional (93298). You say that this monthly evaluation was always covered in full. The Plan denied your request. The Plan says you were charged this copayment 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 Outpatient diagnostic tests. You have been asked to pay a $28.46 copayment for interrogation device evaluation (93298). The evaluation falls within the Outpatient diagnostic tests benefit category. The Medicare allowed amount is less than your required copayment. 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 interrogation device evaluation provided on January 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital services.
You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there is no clinical documentation of unstable comorbidities that significantly increase risk or require more than 24 hours of postoperative monitoring.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 inpatient hospital services. Our reviewer says that inpatient hospital services are not medically reasonable and necessary. There is no clinical rationale for the inpatient hospital services. You are medically stable and the procedure is not considered an inpatient procedure. The record does not show that the physician reasonably expects that your necessary hospital care will span two midnights. Our physician reviewer found that your condition does not meet criteria for coverage of inpatient hospital 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 inpatient hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient hospital services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on June 29, 2020.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on June 29, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the echocardiogram and myocardial perfusion imaging (MPI) rendered on November 20, 2020 to November 23, 2020.
You asked the Plan to waive the copayments for these services. You say that you didn't see the doctor so there should be no copayment. The Plan denied your request. The Plan says the copayments were 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 $50 copayment for basic radiological services at a specialist's office.
Review of the file shows that you received an echocardiogram on November 20, 2020. You have been asked to pay a $50 copayment for these services. These services fall within the basic radiological services at a specialist's office benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
The file shows that you received MPI on November 23, 2020. You have been asked to pay a $50 copayment for these services. These services fall within the basic radiological services at a specialist's office benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
The total amount you have been asked to pay for these services is $100. 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 echocardiogram and myocardial perfusion imaging (MPI) rendered on November 20, 2020 to November 23, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ultrasound guided breast biopsy (19081) provided October 23, 2020.

You asked the Plan to waive the copayment for the diagnostic services. You say that you were mislead into thinking your copayment was $40 not $200. You can't afford $200 and would not have had the process done if you knew it was $200. The Plan denied your request. The Plan says the claim was processed and the correct copayment was applied per the Evidence of Coverage.

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 $200 copay for advanced imaging services in an outpatient hospital facility for Outpatient diagnostic tests and therapeutic services and supplies.

You have been asked to pay $200 copay for advanced imaging services in an outpatient hospital facility for the diagnostic services. the diagnostic services 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 ultrasound guided breast biopsy (19081) provided October 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient (92014) provided on December 8, 2020, by an out of network (OON) provider.

You asked the Plan to pay for the medical eye exam. You say that you were told the provider is in the Plan's network. The Plan denied your request. The Plan says the provider is not contracted with the Plan, there was no authorization on or participating referring provider file, and upon confirmation from your past calls, no misinformation given by the health plan prior to the date of service in question.

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 ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient (92014) provided on December 8, 2020, by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound provided on October 8, 2020.

You asked the Plan to waive the copayment for the ultrasound. You say that your doctor requested a sonogram. You say you had breast cancer in 2000, and you do not understand the cost share applied to the code. The Plan denied your request. The Plan says you have been asked to pay 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 $160 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in an in-network physician's office or at a free-standing facility (such as a radiology center or medical clinic). For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the standard $160 copayment for the ultrasound.

You have been asked to pay a $99.43 copayment for the ultrasound. The ultrasound 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 ultrasound provided on October 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the debridement services (11042) provided on October 6, 2020 and October 13, 2020.

You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to the services provided.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges. 

You have been asked to pay $650 ($325 copayment x 2 procedures) for the outpatient surgery services provided. 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 debridement services (11042) provided on October 6, 2020 and October 13, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One for the enrollee.

You asked the Plan to pre-approve Synvisc-One. You say that this is medically necessary. The Plan denied your request. The Plan says that there is no indication our preferred agent would likely be less effective, and/or cause adverse effects for the member.

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 Synvisc-One. Our reviewer says that Synvisc-One is not medically reasonable and necessary for the enrollee. The patient has not tried and failed Monovisc. There is no indication that Monovisc would likely be less effective and/or likely have adverse effects for the patient. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Synvisc-One. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on November 4, 2020.

You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that CGP testing must be reported with one unit of CPT 81479 and the appropriate DEX Z-Code. 

We looked at the file and Medicare rules. The requested CGP testing was billed with multiple CPT code 81599. Per the applicable article, this testing must be reported with CPT 81479 and the appropriate DEX Z-Code. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on November 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the intravenous infusion services
(96365 x 5) and the breast biopsy (19083) provided from November 4, 2020, through December 3, 2020.

You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to the services provided.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $75 copayment for Medicare-covered surgery or other services at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges.

You have been asked to pay $450 ($75 copayment x 6) for the Medicare-covered services provided at an outpatient hospital. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the intravenous infusion services (96365 x 5) and the breast biopsy (19083) provided from November 4, 2020, through December 3, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to adjust the cost sharing for the left total knee arthroplasty surgery (27447), x-ray (73560), and the implantable device (C1776) provided on December 3, 2020.

You asked the Plan to adjust the cost sharing. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the cost sharing has been applied correctly to the services provided.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that enrollees must pay a $100 copayment for an outpatient surgery or procedure at an in-network outpatient hospital facility or ambulatory surgical center. Enrollees pay a $10 copayment for x-rays and diagnostic procedures and tests. Additionally, enrollees pay a 20% coinsurance for prosthetic devices. 

You have been asked to pay $983 which includes a $100 copayment for the outpatient surgery, a $10 copayment for the x-ray, and $873 coinsurance ($4,364.99 x 20%) for the prosthetic device provided. 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 adjust the cost sharing for the left total knee arthroplasty surgery (27447), x-ray (73560), and the implantable device (C1776) provided on December 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the BDX-XL2 assay provided on August 28, 2020.

You asked the Plan to pay for the BDX-XL2 assay. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the enrollee does not meet criteria.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We looked at the file and Medicare rules. Medicare covers a BDX-XL2 assay when the above criteria are met. In this case, the file shows that the enrollee's lung nodule diameter measured 48 mm and the enrollee's pre-test information was 92% risk of malignancy. The provider noted the follow up CT scan was highly suspicious for malignancy given worsened appearance. Based on this information, Medicare coverage criteria have not been met. Therefore, we decided that the Plan does not have to pay for the BDX-XL2 assay provided on August 28, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MRI of the lumbar spine.

You asked the Plan to pre-approve the MRI. You say that you would like reconsideration because this imaging is needed for the treatment of the member's back pain. The Plan denied your request. The Plan says this service is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that MRIs 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 the MRI. Our reviewer says that the notes do not record the member having tried a formal 6 week trial of physical therapy and weight loss efforts which would be required before considering any imaging. Our physician reviewer found There was no signs or symptoms suggestive of a red flag diagnosis and there was no planned procedure to justify MRI at this time. 

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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve the MRI of the lumbar spine.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on September 1, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the physician 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 provided were neither emergent nor urgent and prior authorization was not obtained to provide 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 physician services provided on September 1, 2020 by an out of network (OON) provider.