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

We decided that the Plan does not have to pay for the pelvic ultrasound (76856) provided by an out of network (OON) provider.

You asked the Plan to pay for the pelvic ultrasound. You say that you would like the Plan to pay for the services. The Plan denied your request. The Plan says 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 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 pelvic ultrasound (76856) provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment or the allowed amount for the contrast material
(Q9967) used for a Computed Tomography (CT) scan (74177).

You asked the Plan to adjust the copayment or the allowed amount for the contrast material (Q9967). You say
that you do not understand why the Plan's allowed amount for the contrast material is so low when the provider
billed a greater amount. The Plan denied your request. The Plan says the cost-share was 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 $200
copayment for CT scans and 20% coinsurance for Medicare Part B drugs or medical supplies.

The Plan is charging a $200 copayment for the CT scan, and $0.02 (The Plan's allowed amount is $0.12 x 20%
= $0.02) for the contrast material. CT scans are subject to a $200 copayment, and contrast materials, which can
be considered a Medicare Part B drug or a medical supply, require 20% coinsurance. 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 copayment or the allowed amount for the contrast material (Q9967) used for a Computed
Tomography (CT) scan (74177).

Please note: Your complaint about the Plan's allowed amount for a service and the amount you were
reimbursed is not a valid appeal for medical coverage. This 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.

From the provided record, it appears that you paid $540 directly to the provider for the CT scan and contrast
material on the date of service. The Plan's allowed amount for the CT scan (74177) is $317.23 and the Plan's
allowed amount for the contrast material is $0.12, for a total allowed amount of $317.35 for both services. You
were correctly charged a total copayment of $200.02 for the CT scan and contrast material, and you were
reimbursed $117.33 which amounts to the total allowed amount for these services ($200.02 + $117.33 =
317.35).

Since you paid $540 out of pocket at the time of the service, this leaves $222.65 unaccounted for. Based on
your appeal request, it appears that you believe this amount was not returned to you because the Plan's allowed
amount for the contrast material is less than the amount the provider billed.

Your complaint about the Plan's allowed amount for provided services and obtaining reimbursement for direct
payment from a plan-contracted provider are grievances that must be answered by the Plan. Medicare does not
permit us to make a decision about these types of complaints.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.

You asked the Plan to pay for the ambulance services. You say that you had shortness of breath. 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. 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.
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 the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 you were admitted for osteomyelitis of the left foot. Your medical problems are 
stable. The documentation does not support that you require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. The documentation does not support that you require an 
intensive rehabilitation therapy program. Your care needs can be met at a lower 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 periodic oral evaluation and prophylaxis.

You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that the same services were covered in 2019. You also say that the provider advised that their relationship with the Health Plan did not change between 2019 and 2020. The Plan denied your request. The Plan says services performed by a privately contracted provider 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.

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 periodic oral evaluation and prophylaxis provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services (99202, 98940, 72100, 72040) 
provided on October 22, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for OON chiropractic services. You say that you tried to obtain authorization, but the 
Plan's system was down. The Plan denied your request. The Plan says these services were not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the chiropractic services (99202, 98940, 72100, 
72040) provided on October 22, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services (99211) you received.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the chiropractic services (99211) you received.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says there is a requirement that the cancer improves after receiving sorafenib.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found Keytruda cannot be approved as first-line therapy for hepatocellular carcinoma.

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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse the wellness allowance for the 2020 Plan year. 
 
You asked the Plan to reimburse the wellness allowance. You say that this should be covered. The Plan denied 
your request. The Plan says that the facility is not a qualified health club. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan reimburses you up to 
$150 each calendar year towards your cost for membership in a qualified health club or fitness facility.  
 
The Plans rules for coverage of gym benefits have not been met because the facility is not a qualified health 
club or fitness facility and the Plan will not pay for sports activities such as golf and tennis Therefore, we 
decided that the Plan does not have to reimburse the wellness allowance for the 2020 Plan year.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing.

You asked the Plan to pay for the Guardant360 testing. You say that you would like reconsideration because the diagnosis from Guardant360 enabled the ordering provider to determine the optimal treatment pathway for the member. The Plan denied your request. The Plan says there is a more appropriate code to describe the services provided.

The Plan must follow Medicare rules. Medicare rules say that the Guardant360 testing is covered when certain criteria are met. One unit of CPT code 81479 is used to report this testing.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Guardant360 testing have not been met. Specifically, this claim was not billed with the appropriate CPT code for Guradant360 testing. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for wound debridement.

You asked the Plan to waive the copayments for wound debridement. You say that you thought that you would only owe a $40 copayment. 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 $350 copayment for outpatient surgery, including services provided at hospital outpatient facilities.

You received wound debridement at an outpatient hospital facility. Wound debridement is considered an outpatient surgical procedure. Therefore, you are responsible to pay a $350 copayment per each date of service. The total amount you owe is: $350 (copayment) x 2 (wound debridement services) = $700.

You have been asked to pay the total copayment amount of $700 for wound debridement. Wound debridement 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 copayments for wound debridement.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve a Xiaflex, .09 mg vial. 
 
You asked the Plan to pre-approve Xiaflex. You say that it is medically necessary. The Plan denied your 
request. The Plan says that the conditions needed to approve Xiaflex have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Xiaflex. Our reviewer says that Xiaflex 
is medically necessary. Our physician reviewer found the provided documentation supports that the Xiaflex is 
safe and effective for the enrollee. The reviewer found that Xiaflex is indicated for the treatment of Peyronie's 
disease with a palpable plaque and curvature deformity of at least 30 degrees at the start of therapy. Therefore, 
the reviewer found that the requested Xiaflex injections are medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Xiaflex have been met. Therefore, we decided that the Plan has to pre-approve a 
Xiaflex, .09 mg vial.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the aspiration and/or injection of large joint or joint capsule (20610).

You asked the Plan to waive the copayment for these services. You say that you would not have had this done if you realized the cost. The Plan denied your request. The Plan says that the copayment 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 $295 copayment for Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers.

You have been asked to pay two separate $295 copayments for these services. These services fall within the Outpatient Surgery and Other Medical 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 the aspiration and/or injection of large joint or joint capsule (20610).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.

You asked the Plan to pre-approve these services. You say that you need the scan to continue your course of treatment. The Plan denied your request. The Plan says the services are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the requested PET scan is with axumin for staging prostate cancer. The use of axumin is used for suspected recurrence of prostate cancer with rising prostate specific antigen (PSA), not for staging. The services are not reasonable or medically necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the chemotherapy drug services.

You asked the Plan to waive the cost share for the services provided. The Plan denied your request. The Plan says the cost share was applied according to your 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 20% of the cost for Part B covered chemotherapy drugs.

The file shows that the total cost was $34,173.43 for the services provided. Twenty percent of the total cost is $6834.69. You were charged $6700, which allowed you to meet the maximum out-of-pocket amount for 2020. The services provided fall within the Medicare Part B prescription drugs 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 share for the chemotherapy drug services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on April 20, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are 
available 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 services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on April 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99204) provided on August 14, 2020, by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you would like the Plan to cover the OON office 
visit. The Plan denied your request. The Plan says the office visit was provided by an OON provider without 
getting a referral prior to the visit. 
 
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 office visit (99204) provided on August 14, 
2020, by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for facility services (99053) provided on September 8, 2020. 
 
You asked the Plan to pay for facility services. You say that these services should be covered. The Plan denied 
your request. The Plan says payment for this service is bundled into the payment for other services. 
 
The Plan must follow Medicare rules. Medicare rules say that payment for covered services with a status code 
of B is always bundled into payment for other services not specified. 
 
We looked at the file and Medicare rules. The service at issue has a status code of B and is not separately 
payable. Based on this information, we decided that Medicare rules for coverage of facility services have not 
been met. Therefore, we decided that the Plan does not have to pay for facility services (99053) provided on 
September 8, 2020.