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

We decided that the Plan does not have to reduce the copayment for the ultrasound provided on January 28, 2020.
You asked the Plan to reduce the copayment for the ultrasound. You say that according to your Evidence of Coverage, you should only have a $30 copayment. The Plan denied your request. The Plan says you have been charged 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 $155 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a free-standing facility. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $155 copayment for the ultrasound.
You have been asked to pay a $131.35 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 reduce the copayment for the ultrasound provided on January 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code A4550 provided on December 31, 2019.
You asked the Plan to pay for CPT A4550. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says CPT code A4550 remains unsupported as it is an unbundled service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. Medicare specifically says that CPT code A4550 is always bundled into payment for other services not specified. Based on this information, we decided that Medicare rules for coverage of CPT A4550 have not been met. Therefore, we decided that the Plan does not have to pay for CPT code A4550 provided on December 31, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient hospital services provided from December 2, 2019 to December 4, 2019.
You asked the Plan to pay for the outpatient hospital services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. Medicare says that all therapy services with HCPCS/CPT code(s) in the 97000-97799 series must include the corresponding therapy modifier, GP or GO. In this case, the provider billed CPT code 97161 without the GP modifier. Based on this information, we decided that Medicare rules for coverage of the outpatient hospital services have not been met. Therefore, we decided that the Plan does not have to pay for the outpatient hospital services provided from December 2, 2019 to December 4, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz FX.You asked the Plan to pre-approve Supartz FX. You say that the requested Supartz FX is medically necessary.The Plan denied your request. The Plan says they were unable to make a determination within the allotted time frame.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 Supartz FX. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found the enrollee has a diagnosis of Unilateral primary osteoarthritis of the left knee. The Plan requires a trial of Orthovisc and Monovisc first before they will approve the requested drug, Supartz FX. The documentation in the case file does not support that Monovisc and Orthovisc (Hyaluronic acid) have been tried and failed. The documentation does not support that Monovisc and Orthovisc (Hyaluronic acid) would likely be less effective, and/or would likely have adverse effects for the enrollee in this case.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Zostavax vaccine provided on February 19, 2020
You asked the Plan to pay for the shingles vaccine. You say that the benefits booklet states immunizations are
covered. The Plan denied your request. The Plan says the shingles vaccine is not covered under your Part B
benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine.
The Plan follows the same rules.
Records do not show that you have been injured or directly exposed to any illness related to the shingles
vaccine. Therefore, we decided that the Plan does not have to pay for the Zostavax vaccine provided on
February 19, 2020
Benefits for the shingles 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: Favorable

We decided that the Plan has to pay for dialysis services, supplies, and drugs provided from February 1, 2019 to February 4, 2019.You asked the Plan to pay for dialysis services, supplies, and drugs. You say that the Plan's denial of this claim is incorrect.The Plan denied your request. The Plan says that the denial of payment for these services and supplies is correct, because this provider is not eligible for Medicare coverage.The Plan must follow Medicare rules. Medicare rules say that for a provider or supplier to receive payment for services furnished to a Medicare beneficiary, the provider must be enrolled in the Medicare program. We looked at the file and Medicare rules. This provider is enrolled in the Medicare program and is eligible for receive payment for Medicare-covered items and services. Based on this information, we decided that Medicare rules for coverage of dialysis services, supplies, and drugs have been met.Therefore, we decided that the Plan has to pay for dialysis services, supplies, and drugs provided from February 1, 2019 to February 4, 2019.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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on November 14, 2019.You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.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 laboratory services provided on November 14, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Atezolizumab.
You asked the Plan to pre-approve Atezolizumab. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Atezolizumab. Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found the enrollee has recurrent stage IV ER/PR negative HER2 negative breast cancer. The requested use of Atezolizumab is not FDA-approved as a monotherapy. The requested drug is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. Therefore, the enrollee does not meet criteria for 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 Atezolizumab have not been met. Therefore, we decided that the Plan does not have to pre-approve Atezolizumab.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on November 22, 2019.
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 procedure code 29826 is not supported.
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 29826 is arthroscopy, shoulder, surgical; decompression
of subacromial space with partial acromioplasty, with coracoacromial ligament (ie, arch) release, when
performed (List separately in addition to code for primary procedure).
We find that CPT code 29826 is not supported in the medical record. Specifically, there is no documentation of
a surgical shoulder arthroscopy. Based on this information, we decided that Medicare rules for coverage of
these services have not been met. Therefore, we decided that the Plan does not have to pay for the surgical
services rendered on November 22, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe non-covered ambulance mileage provided on October 17, 2019.You asked the Plan to pay forthe non-covered ambulance mileage (A0888). You say that at no time did anyone say there was a mileage limit.The Plan denied your request. The Plan says payment for A0888 is not covered by Medicareor the Plan.Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. We looked at the file and Medicare rules. The enrollee was not transported to the nearest appropriate facility. Based on this information, we decided that Medicare rules for coverage of the non-covered ambulance mileage (A0888) have not been met.Therefore, we decided that the Plan does not have to pay forthe non-covered ambulance mileage provided on October 17, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe malignant growth removal procedure provided on January 27, 2020.You asked the Plan to waive the copayment forthe malignant growth removal procedure. You say that this procedure was done in the doctor's office. You feel like you should not be charged. The Plan denied your request. The Plan says you have been charged 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 $265 copayment for surgery services at an in-network outpatient hospital. You have been asked to pay a $225 copayment for the malignant growth removal procedure which is less than the standard copayment amount. The malignant growth removal procedure falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows you were billed by the 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 forthe malignant growth removal procedure provided on January 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on January 27, 2020 by an out of network (OON) provider.You asked the Plan to pay foroffice visit. You say that the enrollee presented to your office due to a referral from their dermatologist.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and the referring provider is also out-of-network 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 has network providers available who can provide 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 forthe medical services provided on January 27, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, prophylaxis, and amalgam provided on January 7, 2020 by an OON provider.You asked the Plan to pay for the periodic oral evaluation, prophylaxis, and amalgam. The Plan denied your request. The Plan says the services must be rendered at a participating dental office. The Plan also says that the treating provider is not a participating provider with your dental plan.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered when they are received OON.Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, prophylaxis, and amalgam provided on January 7, 2020 by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on February 3, 2020.You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the laboratory services.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 laboratory services provided on February 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded 80307 and G0482 provided on January 7, 2020.You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not supported by the documentation.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 codes 80307 and G0482 are not supported in the medical record. Specifically, the documentation submitted did not include lab results of drug test, presumptive, any number of drug classes, any number of devices or procedures; therefore, code 80307 cannot be verified. Also, the documentation submitted did not include lab results of drug test, definitive, 15-21 drug classes; therefore, code G0482 cannot be verified. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met.Therefore, we decided that the Plan does not have to pay for the drug testing coded 80307 and G0482 provided on January 7, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel-One.
You asked the Plan to pre-approve Gel-One. You say that the requested Gel-One is medically necessary. The Plan denied your request. The Plan says the enrollee must try and fail Orthovisc and Monovisc first.
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 Gel-One. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found the enrollee has a diagnosis of Bilateral primary osteoarthritis of the knees. The Plan requires a trial of Monovisc and Orthovisc first before they will approve the requested drug, Gel-One. The documentation does not support that the enrollee has tried and failed Orthovisc and Monovisc. The documentation does not support that Monovisc and Orthovisc (Hyaluronic acid) would likely be less effective, and/or would likely have adverse effects for the enrollee in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Gel-One.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the vehicle wheelchair lift and cover provided on December 3, 2019 and December 5, 2019.
You asked the Plan to reimburse you for the vehicle wheelchair lift and cover. You say that the vehicle wheelchair lift was medically necessary. The Plan denied your request. The Plan says vehicle wheelchair lifts are not primarily medical in nature and therefore not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Also, the item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to reimburse you for the vehicle wheelchair lift and cover provided on December 3, 2019 and December 5, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for PT provided from January 31, 2020 to February 14, 2020.
You asked the Plan to waive the copayments for PT. You say that you would like the Plan to cover 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 a $30 copayment for outpatient mental health care. You received PT from January 31, 2020 to February 14, 2020 for a total of 4 visits. Therefore, you are responsible to pay a $30 copayment per each visit. The total amount you owe is: $30 (copayment) x 4 (PT visits) = $120. You have been asked to pay the total copayment amount of $120 for PT. PT falls within the outpatient mental health care 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 copayments for PT provided from January 31, 2020 to February 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on December 9, 2019.
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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a
physician.
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation.
Based on this information, we decided that Medicare rules for coverage of these services have not been met.
Therefore, we decided that the Plan does not have to pay for the drug testing rendered on December 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services coded S9328 provided from July 9, 2019 to November 21, 2019.
You asked the Plan to pay for the home infusion therapy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not a covered benefit.
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 S9328 is home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem. We find that CPT code S9328 is not supported in the medical record. Specifically, code S9328 has a status code of "I". A status code of I means that these services are not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy services coded S9328 provided from July 9, 2019 to November 21, 2019.