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

We decided that the Plan does not have to waive the copayment for the emergency room services provided on February 6, 2021.

You asked the Plan to waive the copayment for the emergency room services. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received emergency care on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.

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 $90 copayment for Emergency care. 

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received emergency room services on February 6, 2021. You have been asked to pay a $90 copayment for the emergency room services. The emergency room services fall within the Emergency 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 copayment for the emergency room services provided on February 6, 2021.

The Qualified Independent Contractor (QIC) read your letter and knows that you may have a quality of care concern. The QIC cannot address quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement Organization for further review.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic breast ultrasound provided on December 18, 2020.

You asked the Plan to waive the copayment for Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete (76641). You say that your doctor orders this test as a preventative measure. The Plan denied your request. The Plan says you were charged this copayment 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 $110 copayment for Outpatient Diagnostic Tests. 

You have been asked to pay a $110 copayment for Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete (76641). Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete (76641) falls within the Outpatient Diagnostic Tests 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 diagnostic breast ultrasound provided on December 18, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane.
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 step therapy requirement is not met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has osteoarthritis. She has not tried and failed the Plan's required drugs, Orthovisc and Monovisc. The records do not show that the required drugs would be contraindicated or less effective; therefore, Durolane is 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 Durolane.
Appeal type: Transportation
Decision: Unfavorable

We decided the Plan does not have to pay for air ambulance transport provided on July 17, 2020.You asked the Plan to pay for this claim as billed. You say that this service should be covered by the Plan.The Plan denied your request. The Plan says this claim cannot be paid as billed due to the incorrect modifier submitted. Maximus overturned the Plans denial for medical necessity. The Plan states that this claim was denied administratively and not for medical necessity. The Plan states the claim must be resubmitted without the "GZ" modifier to allow payment under Medicare guidelines.The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case the claim cannot be paid as submitted due to an error with the modifier submitted. The Plan has attempted to communicate the need for a corrected claim. Medicare billing criteria were not met. Therefore, we decided that the Plan does not have to pay for air ambulance transport provided to the enrollee on July 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation, detailed and extensive oral evaluation, complete series of intraoral x-rays, panoramic x-ray, tooth molds, bite analysis, TMD therapy services, and splint provided from December 15, 2020, to December 23, 2020.

You asked the Plan to pay for the consultation, detailed and extensive oral evaluation, complete series of intraoral x-rays, panoramic x-ray, tooth molds, bite analysis, TMD therapy services, and splint. You say that you believe these services would be covered under your medical insurance. The Plan denied your request. The Plan says these services are not covered.

The Plan must follow Medicare rules. The rules say that Medicare covers treatment for TMJ syndrome only when the condition or symptom is medical in nature. The treatment must also be medically 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 pay for the consultation, detailed and extensive oral evaluation, complete series of intraoral x-rays, panoramic x-ray, tooth molds, bite analysis, TMD therapy services, and splint. Our reviewer says that without medical documentation the claim cannot be supported. Our physician reviewer found the documentation is insufficient to support a billed diagnosis of TMJ disorder. Our reviewer found that there are no medical records other than a radiology report indicating some degenerative changes in the joint. Our physician reviewer also found that there are no records documenting any clinical findings other than your own statement.

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 consultation, detailed and extensive oral evaluation, complete series of intraoral x-rays, panoramic x-ray, tooth molds, bite analysis, TMD therapy services, and splint have not been met. Therefore, we decided that the Plan does not have to pay for the consultation, detailed and extensive oral evaluation, complete series of intraoral x-rays, panoramic x-ray, tooth molds, bite analysis, TMD therapy services, and splint provided from December 15, 2020, to December 23, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One.

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 step therapy requirement is not met.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria.

The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has osteoarthritis. She has not tried and failed the Plan's required drugs, Orthovisc and Monovisc. The records do not show that the required drugs would be contraindicated or less effective; therefore, Synvisc-One is 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 Synvisc-One.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a wound repair (12013) provided June 14, 2020.

You asked the Plan to pay for the wound repair. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.

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 12013 is not supported in the medical record. Specifically, insufficient clinical documentation was provided to support the CPT code billed. Based on this information, we decided that Medicare rules for coverage of the wound repair have not been met. Therefore, we decided that the Plan does not have to pay for a wound repair (12013) provided June 14, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cardiac catherization.
You asked the Plan to pre-approve the cardiac catheterization. You say that you would like reconsideration because you are in danger and this procedure is urgent. The Plan denied your request. The Plan says the requested procedure is not medically necessary.
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 cardiac catheterization. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found your positron emission tomography scan did not show evidence of ischemia. Your cardiologists had jointly determined that repeat catheterization for Percutaneous Coronary Intervention of the circumflex artery was not indicated at this time based on those findings and the current clinical situation.
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 cardiac catheterization have not been met. Therefore, we decided that the Plan does not have to pre-approve cardiac catherization.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Ketamine therapy provided from September 22, 2020, to October 15, 2020 provided by a medical spa.

You asked the Plan to pay for the Ketamine therapy. You say that your psychiatrist recommended the infusions at a medical spa, and you were told they were covered. The Plan denied your request. The Plan says the medical spa does not work with insurance and does not code, bill, or diagnose medical issues.

The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered Medicare items or services, a provider or supplier must be enrolled in the Medicare program. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Ketamine therapy have not been met. Therefore, we decided that the Plan does not have to pay for the Ketamine therapy provided from September 22, 2020, to October 15, 2020 provided by a medical spa.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Levothyroxine Sodium for the enrollee.

You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under 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 pre-approve Levothyroxine Sodium for the enrollee.

Benefits for this 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 implants (D6010) for teeth # 4, 7, 10, 12, 20, 22, 27, and 29.
You asked the Plan to pre-approve the implants. You say that you fell and knocked out some of your teeth. You say that you went to your appointment and were not told that you were there for tooth implants. You say that your gums are bleeding, and your teeth break when you are brushing your teeth. You also say that you are having a hard time eating. The Plan denied your request. The Plan says implants are not listed as covered services.
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 implants (D6010) for teeth # 4, 7, 10, 12, 20, 22, 27, and 29.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) provided on January 27, 2021, and January 28, 2021.You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral x-rays. You say that you would like to appeal these services.The Plan denied your request. The Plan says these services exceed the frequency limitation in your benefit 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, comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) are each limited to one procedure every three plan years. The record shows that you received a comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) on December 20, 2019 and your comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) benefits have been exhausted.Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) provided on January 27, 2021, and January 28, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient psychiatric hospital services provided to the enrollee from December 9, 2019 to December 12, 2019.

You asked the Plan to pay for the inpatient psychiatric hospital services. You say that these services were medically necessary. The Plan denied your request. The Plan says that there were no medical problems or post-acute withdrawal symptoms that required inpatient treatment.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient psychiatric hospital services. Our reviewer says that the inpatient psychiatric hospital services were not medically reasonable and necessary for the enrollee in this case. It was not expected this enrollee would improve in a reasonable period of time as he did not have dangerousness to self or others, auditory or visual hallucinations, delusions and was not showing any behavioral issues. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care as he did not have dangerousness to self or others, perceptual disturbance including delusions, auditory or visual hallucinations. This enrollee did not appear to require inpatient mental health treatment as he was not a danger to himself or others and was cooperative and compliant. It did not appear that active treatment was taking place. It did not appear that the services were reasonably expected to improve the patient's condition or for the purpose of diagnosis. Our physician reviewer found that the enrollee's condition did not meet Medicare criteria for the inpatient psychiatric hospital services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the inpatient psychiatric hospital services have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient psychiatric hospital services provided to the enrollee from December 9, 2019 to December 12, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the cataract surgery provided on November 3, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the cataract surgery. You say that you were told you would not need authorization. The Plan denied your request. The Plan says no prior authorization was obtained.
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 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 cataract surgery provided on November 3, 2020 by an out of network (OON) provider.
Appeal type: Drugs
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 enrollee has tried nonsteroidal anti-inflammatory
drugs (NSAIDs), cortisone injection, bracing, physical therapy, and home strengthening exercise. The Plan
denied your request. The Plan says the conditions needed to approve this drug 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 Gel-one. Our reviewer says that Gelone
is not medically reasonable and necessary for the enrollee. Our physician reviewer found based on the
medical records provided there is no documentation that the Gel-One is medically reasonable and necessary for
the enrollee, as records do not clearly document that radiographic examination of the right knee confirms the
diagnosis of osteoarthritis. Our reviewer found that there is no documentation that the Gel-One is safe and
effective for the enrollee, as records do not clearly document that radiographic examination of the right knee
confirms the diagnosis of osteoarthritis. Our physician reviewer also found that the records do not clearly
document that radiographic examination of the right knee confirms the diagnosis of osteoarthritis with bone
spurs in the knee joint, sclerosis in bone adjacent to the knee or joint space narrowing.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for the inpatient rehabilitation services provided January 4, 2021 to January 14, 2021.

You asked the Plan to waive the co-payment for the inpatient services. You say that you were at one facility and half-way through treatment you were sent to another. You are being charged 2 separate copay of $1,850. You feel you should only be charged 1 copay because it was a continuation of treatment. The Plan denied your request. The Plan says the claim was processed with the correct co-payment applied per the Evidence of Coverage.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $370 co-payment per day for days 1-5 $0 co-payment after day 5.

You have been asked to pay $1,850.00 for the inpatient services. The inpatient services fall within the Inpatient
hospital 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 co-payment for the inpatient rehabilitation
services provided January 4, 2021 to January 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the first 15 minutes of intravenous moderate (conscious) sedation/analgesia (D9239) and each subsequent 15 minute increment of intravenous moderate (conscious) sedation/analgesia (D9243).

You asked the Plan to pre-approve the intravenous moderate (conscious) sedation/analgesia services. You say that you believe these services should be approved for coverage. The Plan denied your request. The Plan says these services 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 pre-approve the first 15 minutes of intravenous moderate (conscious) sedation/analgesia (D9239) and each subsequent 15 minute increment of intravenous moderate (conscious) sedation/analgesia (D9243).