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

We decided that the Plan has to hold you harmless for the routine physical examination provided on August 6, 2020.
You asked the Plan to hold you harmless for the routine physical. You say that you were not told by your doctor that he would be doing another physical. You were just told to return for follow-up. You were not aware that this would not be covered. The Plan denied your request. The Plan says that you were covered for an annual physical provided in February 2020. Since this was exhausted, the second physical provided in August is not covered by the plan.
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. In this case, we find that there is coverage under the Plan for two separate preventive visits once per year. You were provided with a routine physical in February. The records from this visit show that you were told to return for a follow-up at that time. There is no indication that you were informed that this would be a second routine physical or that you would be financially responsible for the cost.
We find that you had no reasonable expectation in returning for this follow-up that this would be a noncovered visit. As such, we find this visit is considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for the routine physical examination provided on August 6, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions (CPT Code 11200) provided on December 23, 2019.
You asked the Plan to pay for the services. You say that this procedure is not cosmetic. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. It appears that you were treated for the condition of intertrigo under the abdominal excess skin apron and had a benign skin tag in the groin treated incidentally. It does not appear that the skin tag was treated to improve the functioning of a malformed body member or for therapeutic purposes related to any disease process. This would appear to be a cosmetic procedure to improve on appearance and not done for medical necessity. Therefore, we decided that the Plan does not have to pay for removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions (CPT Code 11200) provided on December 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forremoval of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions (CPT Code 11200) provided on July 28, 2020.You asked the Plan to pay forthe services. You say that you are appealing for reconsideration of the denied charges.The Plan denied your request. The Plan says the Medicare rules have not been met.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. It does not appear that the skin tag was treated to improve the functioning of a malformed body member or for therapeutic purposes related to any disease process.Therefore, we decided that the Plan does not have to pay forremoval of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions (CPT Code 11200) provided on July 28, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveDesvenlafaxine Succinate ER 50mg.You asked the Planto pre-approvethe drug. You say that this is medically necessary.The Plandenied your request. The PlansaysMedicare says Part B programs can only provide limited benefits for prescription drugs.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plandoes not haveto pre-approveDesvenlafaxine Succinate ER 50mg
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hymovis (J7322).
You asked the Plan to pre-approve Hymovis. The Plan denied your request. The Plan says the information
submitted does not meet the Plan's medical necessity guidelines for coverage.
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 Hymovis. Our reviewer says that
Hymovis is not medically reasonable and necessary for the enrollee. Our physician reviewer found the enrollee
has trialed viscosupplemental Orthovisc, but has not trialed treatment with Monovisc. Step therapy, as outlined
by the Plan, requires both Monovisc and Orthovisc be trialed first. Our reviewer found that the documentation
does not outline contraindications or reason Monovisc was not considered.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Hymovis have not been met. Therefore, we decided that the Plan does not have
to pre-approve Hymovis (J7322).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveArmour Thyroid 60 mg tablets.You asked the Plan to pre-approveArmour Thyroid. You say that this drug is medically necessary for the enrollee's condition.The Plan denied your request. The Plan says this medication falls under Part D coverage, but member has no Part D pharmacy benefit.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveArmour Thyroid 60 mg tablets.Benefits for Armour Thyroidmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe initial 15 minutes of deep sedation (D9222) and the additional 15 minutes of deep sedation (D9223) provided on May 16, 2020.You asked the Plan to pay forthe deep sedation. You say that you are not able to have 20 minutes or oral surgery while being awake. You also say that more should be paid on your tooth extraction.The Plan denied your request. The Plan says medical necessity has not been documented.Medicare generally does not cover dental services. However, the Plan offers adental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the deep sedation when the services are medically necessary and reasonable. We asked our physician reviewer to carefully reviewthe case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the deep sedation. Our reviewer says that the deep sedation is not medically necessary. Our physician reviewer found there was no medical condition noted that would preclude the use of a local anesthetic alone for the procedure. The reviewer found that the documentation that was provided does not meet the criteria for coverage for deep sedation for the surgical extraction of tooth # 19. Therefore, the reviewer found that the deep sedation is not medically reasonable and necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the deep sedation have not been met.Therefore, we decided that the Plan does not have to pay forthe initial 15 minutes of deep sedation (D9222) and the additional 15 minutes of deep sedation (D9223) provided on May 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the office services on May 5, 2020, by an out-of-network provider.
You asked the Plan to waive the deductible for the office visit. You say that you did not know that out-of-network providers were being used. 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 the office services provided on May 5, 2020, by an out-of-network provider. At the time of services rendered you had not met your $1,000 deductible; therefore, you have been asked to pay $42.40 for the services to apply to your deductible. Your EOC states, "Your deductible is $1,000. This is the amount you have to pay out-of-pocket before the Plan will pay their share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost for most of your covered services. Once you have paid your deductible, the Plan will begin to pay their share of the costs for covered medical services and you will pay your share (your copayment or coinsurance amount) for the rest of the calendar year." 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 deductible for the office services on May 5, 2020, by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forthe acute inpatient hospital care provided from September 17, 2019, through September 20, 2019.You asked the Plan to pay foracute inpatient hospital care. You say that the stay was medically necessary.The Plan denied your request. The Plan says that the stay is 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 tocarefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found given the age, comorbidities, and acuity of illness it was reasonable to expect that greater than two (2) midnights would be required. The patient needed home oxygen arranged, likely.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met.Therefore, we decided that the Plan has to pay forthe acute inpatient hospitalcare provided from September 17, 2019, through September 20, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on October 8, 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 screening tests are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The tests at issue in this appeal were requested solely for screening purposes. Medicare does not cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on October 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for IV tubing extension (S1015) and infection control supplies (S8301) provided on March 10, 2020.
You asked the Plan to pay for the IV tubing and infection control supplies.. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT codes S1015 and S8301 have a status indicator of I and are not valid for Medicare purposes.
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 S1015 and S8301 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT codes S1015 and S8301 have a status indicator of I. This means that CPT codes S1015 and S8301 are not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the IV tubing and infection control supplies. have not been met. Therefore, we decided that the Plan does not have to pay for IV tubing extension (S1015) and infection control supplies (S8301) provided on March 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an ultrasound and a copayment office visitprovided by an out-of-network provider on January 7, 2020.You asked the Plan to waive the copayment foran ultrasound and an office visit. You say that you did not know the provider was out-of-networkThe Plan denied your request. The Plan says the correct coinsurance and copayment have been applied.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 40% coinsurance and a $75 copayment for outpatient diagnostic tests/radiological diagnostic services/out-of-network and physician/practitioner services/specialist/out-of-network. You have been asked to pay a 40% coinsurance of the allowed amount for an ultrasound. The total allowed amount is $141.58. The amount you are being asked topay for an ultrasound is $56.63 ($141.58 x 40% = $56.63). You have been asked to pay a $75 copayment for an office visit. The total amount you are being asked to pay is $134.60 ($59.60 + $75 = $134.60). An ultrasound falls within the outpatient diagnostictests/radiological diagnostic services/out-of-network and an office visit falls within thephysician/practitioner services/specialist/out-of-network 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 an ultrasound and a copayment office visit provided by an out-of-network provider on January 7, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for injections provided by a participating provider on June 15, 2020, to July 13, 2020.
You asked the Plan to waive the coinsurance for injections. You say that if you would have known that these injections were so expensive you wouldn't have gotten the injections. The Plan denied your request. The Plan says the correct coinsurance has been applied.
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 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a 20% coinsurance of the allowed amount for injections. The total allowed amount is $5,952.92. The total amount you are being asked to pay is $1,190.60 ($5,952.92 x 20% = $1,190.60). Injections 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 coinsurance for injections provided by a participating provider on June 15, 2020, to July 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on June 24, 2020, by an OON provider.You asked the Plan to pay fora physician home visit. You say that the rendered services were medically necessary.The Plan denied your request. The Plan says rules for payment have not been met.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 June 24, 2020, by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing forthe services provided on July 13, 2020.You asked the Plan to waive the cost-sharing forthe services. 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 2020EOC 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 hand x-ray, office services and a methylprednisolone acetate, 40 mg injection on July 13, 2020. You are asked to pay a $20 copayment for the x-ray, a $20 copayment for the injection services and 20% coinsurance for the medication. Your EOC states that enrollees must pay a $20 copayment per visit for laboratory tests, non-radiological diagnostic tests, flat film x-rays, and ultrasounds and 20% coinsurance of the total cost for Medicare-covered Part B prescription drugs, including chemotherapy drugs. 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 forthe services providedon July 13, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on April 22, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation indicates that the specimen was obtained in an office setting POS 11. Also, the laboratory results submitted indicate the specimen was collected on April 22, 2020 and received by the lab on April 24, 2020. Therefore, the billed code cannot be verified.
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 claim cannot be paid as billed due to an issue with the POS code reported. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on April 22, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for PT provided on August 10, 2020, by an in-network provider.
You asked the Plan to waive the copayment for the PT. You say that when you were informed you could go to PT you asked to make sure that your insurance would pay for it. 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 physical therapy provided on August 10, 2020, by an in-network provider. You are asked to pay a $35 copayment for the PT. Your EOC states, "enrollees must pay a $35 copayment for each in-network Medicare-covered therapy visit. Covered services include: physical therapy." 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 PT provided on August 10, 2020, by an in-network provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary visit (99336) provided on July 29, 2020 by an out of network (OON) provider.
You asked the Plan to pay for domiciliary visit. You say that you provided medically necessary services in good faith. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services rendered by an out-of-network provider.
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 for the domiciliary visit (99336) provided on July 29, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home health services provided to the enrollee.


You asked the Plan to pay for home health services. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says CPT code G0299 is not payable under the Physician Fee Schedule.

The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.

We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, this claim does not include the required Q code.Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee.