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

We decided that the Plan does not have to pay for the tetanus vaccine provided on October 12, 2020.

You asked the Plan to pay for the vaccine. You say that your provider considered it necessary for your health. The Plan denied your request. The Plan says preventative tetanus immunizations are covered through your drug plan.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The Plan follows the same rules. 

The records do not show that you were injured or directly exposed to any illness related to the vaccine. Therefore, we decided that the Plan does not have to pay for the tetanus vaccine provided on October 12, 2020.

Benefits for the vaccine may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office services (CPT code 99213) provided on December 23, 2020.
You asked the Plan to waive the copayment for the office services. You say that you received a letter from the plan saying to get the physical and the provider would not do the physical over the phone. 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 a follow-up visit on December 23, 2020. You were asked to pay a $10 copayment for the office services. Your 2020 EOC states that enrollees must pay a $10 copayment for each
covered visit or consultation in an outpatient location with your PCP or other primary care provider. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the office services (CPT code 99213) provided on December 23, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing charges for outpatient hospital services and outpatient rehabilitation services provided on January 30, 2021.

You asked the Plan to waive the cost-sharing charges for outpatient hospital services and outpatient rehabilitation services. You say that this was an emergency surgery and you had no control over it. 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 $300 deductible for outpatient hospital services. Your contract with the Plan also clearly says that after the $300 deductible has been met, enrollee's must pay 10% coinsurance for outpatient hospital services. Your contract with the Plan also clearly says that enrollee's must pay a $35 copayment for per each outpatient rehabilitation service, per day.

You received outpatient hospital services on January 30, 2021. The record shows that you had paid $0 toward the $300 deductible prior to receiving the services. Therefore, you are responsible to pay the $300 deductible. Now that the deductible has been met, you are also responsible to pay 10% coinsurance on the difference between the allowed amount and the amount that applied toward the deductible. $4,881.30 (allowed amount) - $300 (deductible) = $4,581.30 and 10% of that is $458.13.

You received two types of outpatient rehabilitation services on January 30, 2021. Therefore, you are responsible to pay a $35 copayment per each outpatient rehabilitation service type. The total amount you owe is: $70.

The total amount you owe is: $300 + $458.13 + $70 = $828.13.

You have been asked to pay the total amount of $828.13 for outpatient hospital services and outpatient rehabilitation services. Outpatient hospital services fall within the outpatient hospital services benefit category. Outpatient rehabilitation services 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 cost-sharing charges for outpatient hospital services and outpatient rehabilitation services provided on January 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 64483) provided on June 11, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed incorrectly.

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 CPT code 64483-TC is not supported. Specifically, CPT code 64483 is assigned a PC/TC indicator of "0". This means that the concept of PC/TC does not apply since physician services cannot be split into professional and technical components. Modifier TC cannot be used with this code. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (CPT 64483) provided on June 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established
patient (D0150) and intraoral - complete series of radiographic image (D0210) provided January 19, 2021.

You asked the Plan to pay for the comprehensive dental exam and complete intraoral x-rays. You say that you
do not agree with the denial. The Plan denied your request. The Plan says these services were previously
covered within the 3-year timeframe and therefore the services at issue are not covered.

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. The Plan covers the
comprehensive dental exam and complete intraoral x-rays when the services are medically necessary and
reasonable.

We looked at the file and Medicare rules. The Plan provided documentation showing that coverage was provided for a comprehensive dental exam and complete intraoral x-rays on April 8, 2019. Based on this information, we decided that the Plan's rules for coverage of the comprehensive dental exam and complete intraoral x-rays have not been met. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) and intraoral - complete series of radiographic image (D0210) provided January 19, 2021.

Your complaint about how services are covered by your Plan and potentially confusing information provided by the 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-preferred brand test strips.

You asked the Plan to pre-approve the requested items. You say that the plan-approved test strips are not
accurate. The Plan denied your request. The Plan says a provider statement shows the preferred formulary test
strips can be used.

Medicare rules say that plans may specify brands and as preferred. The Plan follows the same rules.

The requested brand of diabetic supplies in this case is not a preferred brand with the Plan. The Plan has
preferred brands available for the items at issue in this appeal. We found no exception that would require the
Plan to pre-approve non-preferred items. Therefore, we decided that the Plan does not have to pre-approve nonpreferred
brand test strips.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane.

You asked the Plan to pre-approve Durolane. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says step therapy criteria have not been met.

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 Durolane. Our reviewer says that the enrollee is a 74-year-old female with a history of osteoarthritis of the right knee. The Plan requires a trial of Visco-3, Gel-One, Orthovisc, Synvisc or Synvisc One before they will approve the requested drug. In this case, the has not patient tried and failed the required drug(s). There is no documentation provided indicating that the Plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Durolane have not been met. Therefore, we decided that the Plan does not have to pre-approve Durolane.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services provided on December 7, 2020.
You asked the Plan to waive the copayment for lab services. You say that you disagree with the charges. The Plan denied your request. The Plan says the copayment 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 $10 copayment for Medicare-covered lab services.
You have been asked to pay a $10 copayment for lab services. Lab services fall 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 lab services provided on December 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the four gingival irrigations (D4921 x4) provided on
December 16, 2020.
You asked the Plan to pay for the gingival irrigations. You say that this provider is in-network. The Plan denied
your request. The Plan says this service is not a covered benefit.
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 pay for the four
gingival irrigations (D4921 x4) provided on December 16, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services provided to the enrollee on October 16, 2020, by an out-of-network provider.
You asked the Plan to pay for the psychotherapy services. You say that you rendered treatment to the enrollee in good faith that the service will get reimbursed. You state the service was provided with no adequate time frame to obtain authorization for the service. The Plan denied your request. The Plan says the provider did not make attempts to verify the enrollee's correct insurance, eligibility, or authorization requirements prior to rendering non-emergent services. The Plan states there is no evidence of plan directed care and the enrollee was not receiving skilled services or inpatient services during this time. The Plan states the provider did not provide good cause for why prior authorization was not requested.
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 psychotherapy services provided to the enrollee on October 16, 2020, by an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound care services provided on February 11, 2021, by
an OON provider.
You asked the Plan to pay for the wound care services. You say that the services were provided prior to
obtaining authorization to avoid delay in care. The Plan denied your request. The Plan says these services were
rendered by a non-participating provider. The Plan also says that 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 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 wound care services provided on February 11,
2021, by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the chest x-ray (CPT code 71046) provided on June 5, 2020, by an in-network provider.
You asked the Plan to waive the copayment for the chest x-ray. 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 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 a chest x-ray on June 5, 2020, by an in-network. You were asked to pay a $25 copayment for the chest x-ray. Your 2020 EOC states that enrollees must pay a $25 copayment for each in-network Medicare-covered X-ray 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 chest x-ray (CPT code 71046) provided on June 5, 2020, by an in-network provider.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the ambulance transportation provided on December 7, 2020.

You asked the Plan to pay for the ambulance transportation. The Plan denied your request. The Plan says that the services should have been billed with the "-QL" modifier.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The submitted records do not show that the enrollee was pronounced dead on the scene. Life-saving efforts were provided during the ambulance transport. As the enrollee was still considered to be alive during transport, the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the ambulance transportation provided on December 7, 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Triluron injections (J7332).

You asked the Plan to pre-approve the Triluron injections. You say that the Triluron injections are medically necessary. The Plan denied your request. The Plan says a trial of Orthovisc and Monovisc is required before alternatives can be considered.

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 the Triluron injections. Our reviewer says that the Triluron injections are not medically necessary. Our physician reviewer found the records show no trial of the plan preferred drugs. The records do not show any reason the plan preferred drugs would be unsafe or ineffective. 

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 Triluron injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Triluron injections (J7332).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the total hip arthroplasty (27130) and computer-assisted
surgical navigational procedure for musculoskeletal procedures (20985) provided on November 3, 2020.

You asked the Plan to pay for the surgical services. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says a facility claim has not been received by the
Plan and the authorization obtained by the provider was for outpatient facility and professional services.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

We find that CPT codes 27130 and 20985 are not supported in the record. Specifically, this claim was billed
with Place of Service code 21 indicating inpatient services. The record indicates that the Plan has not received a
facility claim for inpatient services and the authorization was for outpatient and physician services.
Additionally, the documentation submitted does not clearly support that the member was admitted inpatient on
the billed date of service. There is a more appropriate place of service code for the services billed. Based on
this information, we decided that Medicare rules for coverage of the surgical services have not been met.
Therefore, we decided that the Plan does not have to pay for the total hip arthroplasty (27130) and computer assisted
surgical navigational procedure for musculoskeletal procedures (20985) provided on November 3,
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Volara System.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that high frequency chest wall oscillation devices are covered only for patients with cystic fibrosis, bronchietasis, or certain neuromuscular diseases. The record does not show that the enrollee has cystic fibrosis, bronchiectasis, or a covered neuromuscular disease. This means that the enrollee does not have a medical condition for which a high frequency chest wall oscillation device can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve a Volara System.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI provided on January 2, 2021, and an office visit provided on January 18, 2021.
You asked the Plan to waive the copayment for an MRI and an office visit. You say that you disagree with the charges. The Plan denied your request. The Plan says the copayment 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 $300 copayment for other outpatient diagnostic tests, including a magnetic resonance imaging (MRI). Your contract with the Plan also clearly says that you must pay a $5 copayment for a PCP office visit/other health care professionals. You have been asked to pay a $305 copayment for an MRI and office visit ($300 + $5). An MRI falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. An office visit falls within the physician/practitioner services, including doctor's office visits, benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an MRI provided on January 2, 2021, and an office visit provided on January 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the steroid injection provided on January
20, 2021.
You asked the Plan to waive the copayment for the steroid injection. You say that the enrollee should have
been told the copay amount before receiving the injection. The Plan denied your request. The Plan says the
enrollee was 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). The enrollee's contract with the Plan clearly says that enrollees
must pay a $350 copayment for Outpatient Surgery.
The enrollee has been asked to pay a $320.06 copayment for the steroid injection. The steroid injection falls
within the Outpatient Surgery benefit category. The allowable amount was less than your copayment. 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 for the steroid injection provided on January 20, 2021.