Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision services you received.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider does not
participate with your vision plan.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers these services when provided by an in-network provider.

We looked at the file and the Plan's rules. The documentation shows that you were provided the vision services
by a provider who does not participate with your vision plan. Out-of-network routine vision care is not covered
under your Plan. Based on this information, we decided that the Plan's rules for coverage of the services have
not been met. Therefore, we decided that the Plan does not have to pay for the vision services you received.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a duplex scan.

You asked the Plan to pay for the duplex scan. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.

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 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 a duplex scan.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit provided by an out-of-network provider.

You asked the Plan to pay for the home visit. You say that the enrollee was in an assisted living facility, so the doctor was not responsible for getting authorization. You say that the claim should be processed for reimbursement. The Plan denied your request. The Plan says this provider is not a network provider with the Plan.

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 home visit provided by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an epidural provided on October 29, 2020.
You asked the Plan to waive the copayment for an epidural. You say that you would like the copayment to be
reduced to $90. 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 $600
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory
surgical centers.
The record shows that you received an epidural at an outpatient hospital facility on October 29, 2020. An
epidural injection is considered an outpatient surgical procedure. Therefore, you are responsible to pay the
$600 copayment.
You have been asked to pay a $600 copayment for an epidural. An epidural falls within the outpatient surgery,
including services provided at hospital outpatient facilities and ambulatory surgical centers 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 epidural provided on October 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for onabotulinumtoxina injections (CPT code(s) J0585JW and J0585) provided from March 3, 2020, through October 13, 2020, by an in-network provider.

You asked the Plan to waive the coinsurance for the injections. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says the claims were 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 onabotulinumtoxina injections (Current Procedural Terminology (CPT) code(s) J0585JW and J0585) from March 3, 2020, through October 13, 2020. You are asked to pay 20% coinsurance for the injections. The JW modifier does mean provider discarded that amount, however they are still allowed to be billed and paid according to Medicare rules. The health plan contract says that enrollees must pay 20% coinsurance for each in-network Medicare-covered Part B drug. Please note that coinsurance may vary due to the units of injection provided on that date of 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 coinsurance for onabotulinumtoxina injections (CPT code(s) J0585JW and J0585) provided from March 3, 2020, through October 13, 2020, by an in-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services (85025, 80076, G0471, P9604) provided on
September 22, 2020, by an OON provider.
You asked the Plan to pay for the lab services. You say that these services were medically necessary and the
skilled nursing facility where this enrollee resides is contracted with this provider. The Plan denied your
request. The Plan says they only cover out of network services in limited circumstances. The services provided
were not urgent or pre-approved.
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 lab services (85025, 80076, G0471, P9604)
provided on September 22, 2020, by an OON provider.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the F1CDx? test provided on October 1, 2020.
You asked the Plan to pay for the F1CDx? test. The Plan denied your request. The Plan says that the provider
is not a Medicare certified provider and the health plan cannot make payment to a provider who does not accept
assignment from Medicare.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract
provider are considered approved by the plan unless notice is provided that the services will not be covered.
The Plan follows these rules.
The enrollee was referred for the F1CDx? test by a contract provider. The file does not show that the Plan
provided notice that the F1CDx? test would not be covered prior to rendering the test. Under Medicare rules,
this means the F1CDx? test is considered approved by the Plan. Therefore, we decided that the Plan has to pay
for the F1CDx? test provided on October 1, 2020.
Additionally, the opt-out rule is only applicable to providers that are considered physicians by Medicare rules.
Facilities or labs are not subject to opting out of Medicare and this laboratory is an active HHS certified lab.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for lumbar-sacral orthosis (CPT code L0637) provided on November 19, 2020, by an in-network provider.
You asked the Plan to waive the coinsurance for the orthosis. You say that you were told by an associate in the provider's office that your responsibility would be $40. You state you did not need the brace and only wore the brace for two days. 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 lumbar-sacral orthosis (CPT code L0637) on November 19, 2020 from an in-network provider. You have been asked to pay 20% coinsurance of the allowed amount for durable medical equipment. The allowed amount is $1371.22. The total you owe is $177.48 ($1371.22 x 20% = $274.24). The health plan contract says that enrollees must pay 20% coinsurance for in-network Medicare-covered DME and related supplies. 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 lumbar-sacral orthosis (CPT code L0637) provided on November 19, 2020, by an in-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF admission.
You asked the Plan to pre-approve the SNF admission. You say that you would like reconsideration because
SNF admission is medically necessary. The Plan denied your request. The Plan says you are unable to
participate in therapy.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is 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 SNF admission. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found you do not require skilled nursing or
therapy services on a daily basis.
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 SNF admission have not been met. Therefore, we decided that the Plan does
not have to pre-approve SNF admission.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute setting.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that you would like reconsideration because the IRF admission is medically necessary. The Plan denied your request. The Plan says the member can safely receive necessary care in an alternate setting.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 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 there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care.

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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dentures.

You asked the Plan to pay for the dentures. The Plan denied your request. The Plan says the benefit limit has been reached.

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 services are subject to a benefit limitation. The Plan covers dental services up to $2,500 per calendar year. The records show that the benefit limit was reached on the date of service in question. You are responsible for any amount over the $2,500 benefit limit. Therefore, we decided that the Plan does not have to pay for the dentures.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia 60 mg/ml syringe.
You asked the Plan to pre-approve Prolia. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says step therapy criteria has 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 Prolia. Our reviewer says that step therapy criteria has not been satisfied. Our physician reviewer found the enrollee has osteoporosis but has not had an osteoporosis fracture. The enrollee has no symptoms of gastroesophageal reflux, no gait disturbance, and no seizures in several years. The enrollee has not tried and failed and does not have a contraindication to the plan's required step therapy drug. The documentation does not support that the enrollee is currently receiving the requested drug. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia 60 mg/ml syringe.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for diabetic supplies.

You asked the Plan to waive the coinsurance for diabetic supplies. You say that the device does not work properly so you should not be responsible for the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for diabetic services and supplies.

You received diabetic supplies on October 30, 2020. The total allowed amount is $489.34 and 20% of that is $97.86.

You have been asked to pay the total coinsurance amount of $97.86 for diabetic supplies. Diabetic supplies fall within the diabetes self-management training, diabetic 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 coinsurance for diabetic supplies.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care.

You asked the Plan to pay for the acute inpatient hospital care. The Plan denied your request. The Plan says inpatient care was not medically necessary.

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 pay for the acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the record does not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights.

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 acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0483).

You asked the Plan to pay for drug testing. You say that this code is supported. The Plan denied your request. The Plan says the record does not show that 22 or more drug classes were tested.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

In this case, the CPT Code Manual definition of code G0483 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed.

We find that CPT code G0483 is not supported in the medical record. Specifically, the record does not show that at least 22 drug classes were tested. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (G0483).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided by an out of network (OON) provider.

You asked the Plan to pay for the lab services. You say that these services were medically necessary. The Plan denied your request. The Plan says they only cover services that are provided out-of-network in limited circumstances. The lab services were not urgent or pre-approved and could have been provided in-network.

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 lab services provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME and related supplies.

You asked the Plan to waive the coinsurance for DME and related supplies. You say that you cannot afford the
charges. The Plan denied your request. The Plan says the claims were processed correctly, and you are being
charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20%
coinsurance for DME and related supplies.

You received DME and related supplies. The total allowed amount is $458.46 and 20% of that is $91.70.

You have been asked to pay the total coinsurance amount of $91.70 for DME and related supplies. DME and
related supplies fall within the DME and related supplies benefit category. This means that you have been
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have
to waive the coinsurance for DME and related supplies.