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

We decided that the Plan does not have to waive the coinsurance for the ultrasound rendered on December 15, 2020.
You asked the Plan to waive the coinsurance for these services. You say that you believe this is copayment stacking. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance up to a maximum of $75 per day for Medicare-covered diagnostic radiology services.
Review of the file shows that you received an ultrasound on December 15, 2020. You have been asked to pay a 20% coinsurance up to a maximum of $75 per day for these services, for a total of $26.27. These services fall within the Medicare-covered diagnostic radiology services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the ultrasound rendered on December 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services provided by a
participating provider on January 26, 2021.
You asked the Plan to waive the copayment for specialist services. You say that you do not agree with this
copayment. The Plan denied your request. The Plan says the correct copayment 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 $35
copayment for physician/practitioner services/specialist visit.
You have been asked to pay a $35 copayment for specialist services. The correct copayment has been applied
to the services that were provided. Specialist services fall within the physician/practitioner services/specialist
visit 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 specialist services provided by a
participating provider on January 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on July
17, 2020.

You asked the Plan to pay for the cardiovascular risk assessment panel. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the services rendered are not payable.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered. Cardiovascular disease screening tests are only covered for certain
indications.

The laboratory services at issue in this appeal were requested solely for screening purposes. While Medicare
covers cardiovascular disease screening tests for certain indications, the documentation does not support that
the enrollee met criteria for the services rendered. Therefore, we decided that the Plan does not have to pay for
the cardiovascular risk assessment panel provided on July 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel.

You asked the Plan to pay for the cardiovascular risk assessment panel. 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 payable.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. Cardiovascular disease screening tests are only covered for certain indications.

The laboratory services at issue in this appeal were requested solely for screening purposes. While Medicare covers cardiovascular disease screening tests for certain indications, the documentation does not support that the enrollee met criteria for the services rendered. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment panel.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluations (D0150) and the topical
application of fluoride varnish (D1206) received January 12, 2021.

You asked the Plan to pay for the comprehensive oral evaluation and the fluoride varnish. You say that you
were not told that the fluoride varnish would no longer be covered this year. The Plan denied your request. The
Plan says the requested services either exceed benefit frequency or are not covered under your supplemental
benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit or exceed the benefit frequency. Fluoride varnish is not listed as a
covered benefit. The Plan has submitted evidence that you last received a covered comprehensive oral
evaluation on September 9, 2019. Therefore, we decided that the Plan does not have to pay for the
comprehensive oral evaluations (D0150) and the topical application of fluoride varnish (D1206) received
January 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care provided on January 12, 2021 by an out of network (OON) provider.
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 the services were rendered by an out-of-network provider without 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 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 nursing facility care provided on January 12, 2021 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Freestyle Libre therapeutic continuous glucose monitor.
You asked the Plan to pre-approve the Freestyle Libre therapeutic continuous glucose monitor. You say that the request is medically necessary. The Plan denied your request. The Plan says there was no documentation or evidence that the preferred products on the Plan's formulary would not be as effective for the member's condition.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least 3 daily injections. Based on this information, we decided that Medicare rules for coverage of the Freestyle Libre therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve the Freestyle Libre therapeutic continuous glucose monitor.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular radiofrequency ablation (64624).

You asked the Plan to pre-approve genicular radiofrequency ablation. You say that this request is medically necessary. The Plan denied your request. The Plan says the requested service is considered experimental and unproven.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 genicular radiofrequency ablation. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found you are a 61-year-old woman who has chronic bilateral knee pain. The requested service is considered an experimental/investigational procedure. It is the subject of ongoing clinical trials. Therefore, the request is considered not medically reasonable or 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 genicular radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular radiofrequency ablation (64624).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer device placement (22869).
You asked the Plan to pre-approve the interspinous spacer device placement. You say that the procedure is medically necessary. The Plan denied your request. The Plan says this device is investigational and is not covered.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 interspinous spacer device placement. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found interspinous process spacer devices remain experimental for use in spinal surgery. More research is needed to show safety and efficacy of the devices. 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 interspinous spacer device placement have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous spacer device placement (22869).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve epidural steroid injection (62323) with moderate conscious sedation (99152, 99153).
You asked the Plan to pre-approve the epidural steroid injection. You say that you have clinical documentation available to show the medical necessity of this service. The Plan denied your request. The Plan says after reviewing the information provided, the enrollee's condition does not meet medical necessity criteria.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 epidural steroid injection. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the imaging study provided demonstrates L3-4: minimal left neural foraminal stenosis, stable. and L4-5: subtle degenerative grade 1 anterolisthesis, mildly worse. Mild bilateral subarticular recess stenosis, stable bilaterally. Minimal bilateral neural foraminal stenosis, stable bilaterally. This does not demonstrate central disc herniation or severe degenerative disc disease or spinal stenosis. The elements of the coverage determination are not satisfied. In the absence of approval for the procedure, the request for CPT 99152 and 99153 is moot and also not recommended. 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 epidural steroid injection have not been met. Therefore, we decided that the Plan does not have to pre-approve epidural steroid injection (62323) with moderate conscious sedation (99152, 99153).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the MRI provided on October 5, 2020.
You asked the Plan to waive the copayment for the MRI. You say that you have never received any bills until
recently. The Plan denied your request. The Plan says you have been asked to pay 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 $0
copayment - 20% coinsurance for each Medicare-covered radiological diagnostic service, not including x-rays,
performed in an in-network a physician's office or at a freestanding facility (such as a radiology center or
medical clinic).
You have been asked to pay $68.72 for the MRI. The MRI falls within the "Outpatient Diagnostic Tests and
Therapeutic Services and Supplies" benefit category. The allowed amount is $343.59. ($343.59 x 20% =
$68.72).
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 MRI provided on October 5, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept ablation procedure (C9752).
You asked the Plan to pre-approve the Intracept ablation procedure. You say that the services are medically necessary. The Plan denied your request. The Plan says this procedure is experimental and is non-covered.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 Intracept ablation procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Intracept procedure remains experimental at this time. More research is needed to show safety and efficacy of the Intracept procedure for back pain treatment. 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 Intracept ablation procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept ablation procedure (C9752).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mastectomy sleeve.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that a mastectomy sleeve (L8010) is denied as noncovered. We looked at the file and Medicare rules. The requested mastectomy sleeve is not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve a mastectomy sleeve.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the predictive screening testing provided on August 31, 2020.
You asked the Plan to pay for the predictive screening testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
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 predictive screening testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the predictive screening testing provided on August 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Shingrix vaccine received on January 4, 2021.
You asked the Plan to pay for the Shingrix vaccine. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Shingrix 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 Shingrix vaccine. Therefore, we decided that the Plan does not have to pay for the Shingrix vaccine received on January 4, 2021.
Benefits for the Shingrix 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting from October 5, 2020, to October 9, 2020.
You asked the Plan to pay for the self-administered drug. You say that you were not supposed to have an arthroscopy. You say that another provider did it anyways. You say that as a result you were in the hospital for 5 days with heart difficulties and a paralyzed diaphragm. You also say that you should not be charged for anything. The Plan denied your request. The Plan says the drugs you received are considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drugs you received are not covered under Medicare Part B.
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 pay for the self-administered drugs provided in an outpatient setting from October 5, 2020, to October 9, 2020.
Benefits for the self-administered drug 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve extracoronal provisional splinting (D4321).
You asked the Plan to pre-approve the dental service. You say that this service is necessary to save your tooth. The Plan denied your request. The Plan says this service is not covered by Medicare or by the Plan's supplemental dental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve extracoronal provisional splinting (D4321).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on June 2, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
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 laboratory services provided on June 2, 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 psychotherapy services provided on November 18, 2019 by an out of network (OON) provider.

You asked the Plan to pay for the psychotherapy 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 payable.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the psychotherapy services provided on November 18, 2019 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 office visit provided by an out of network provider on November 10, 2020.
You asked the Plan to pay for the office visit. You say that you disagree with the amount paid by the plan. The Plan denied your request. The Plan says the claim was processed correctly per your plan 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 while you may receive care from out-of-network providers, the out-of-pocket costs may be higher. Review of the file shows that you say you paid the total amount owed of $145 to the provider. The plan allowed amount was $73.23. This means that the plan is only obligated to reimburse you that amount. Any difference in the amounts for services received by an out-of-network provider may be the enrollee's responsibility. You have been asked to pay the difference for the office visit. The office visit falls within the 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 pay for the office visit provided by an out of network provider on November 10, 2020.