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

We decided that the Plan does not have to waive the copayment for the respiratory test provided on February 24, 2020. 
 
You asked the Plan to waive the copayment for the respiratory test. You say that you were not aware that there would be any charges associated with your routine physical. You say the copayment should be waived. The Plan denied your request. The Plan says the claim was reprocessed and you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment per visit for laboratory tests, non-radiological tests, flat film x-rays, and ultrasounds.  
 
You have been asked to pay a $20 copayment for the respiratory test. The respiratory test falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the respiratory test provided on February 24, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health services provide on January 6, 2020
to January 20, 2020 by an out of network (OON) provider.
You asked the Plan to pay for outpatient mental health services. You say that the member never told you that
she changed her Plan coverage. 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 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 outpatient mental health services provide on
January 6, 2020 to January 20, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for complete upper denture (D5110) and complete lower denture (D5120) provided December 23, 2019.
You asked the Plan to pay for the dental services. You say that you received a bill from your provider and you think you should not have to pay it because you were told by plan representatives that the dentures would be covered 100%. The Plan denied your request. The Plan says the annual maximum has been met and these services exceeds the annual maximum.
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 there is an annual maximum of $2,000. You must pay any amount over the $2,000 annual maximum. You have been asked to pay $337 for the dental services. The services fall within the dental 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 pay for complete upper denture (D5110) and complete lower denture (D5120) provided December 23, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation.
You asked the Plan to pre-approve the radiofrequency ablation. You say that you would like reconsideration because this service is medically necessary. The Plan denied your request. The Plan says radiofrequency ablation of sacroiliac joint is investigational.
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 radiofrequency ablation. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found radiofrequency ablation of the lateral sacral branches is considered experimental/ investigational because of the wide variation in efficacy in the peer-reviewed literature. 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 radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for vision care provided on February 14, 2020 by an out of
network (OON) provider.
You asked the Plan to pay for vision care. You say that the nursing facility as your provide to examine the
patient. The Plan denied your request. The Plan says the member's primary care physician did not refer these
services. The Plan says that 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 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 vision care provided on February 14, 2020 by an
out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for an inpatient hospital stay provided on January 2, 2020. 
 
You asked the Plan to waive the copayments for an inpatient hospital stay. You say that you disagree with the charges because your primary care provider prescribed a medication that interfered with another medication. 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 $195 copayment each day for days 1-7 for inpatient hospital care. 
 
You received an inpatient hospital stay on January 2, 2020. Therefore, you are responsible to pay the $195 copayment.  
 
The total amount you owe is: $195.   
 
You have been asked to pay a $195 copayment for an inpatient hospital stay. An inpatient hospital stay falls 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 copayments for an inpatient hospital stay provided on January 2, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy visits for the enrollee.
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary to address the enrollee's pain. The Plan denied your request. The Plan says wearing a shoe lift does not require the unique skills of a physical therapist.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 additional visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the records provided do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or for physical therapy and occupational therapy, by or under the supervision of a therapist. 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 additional visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy visits for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME and related supplies provided on December 3, 2019.
You asked the Plan to waive the coinsurance for DME and related supplies. You say that you were not informed the cost prior to receiving the supplies and cannot use the supplies. 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 20% coinsurance for DME and related supplies. You received DME and related supplies on December 3, 2019. The total allowed amount is $162.60 and 20% of that is $32.52. You have been asked to pay the total coinsurance amount of $32.52 for DME and related supplies. DME and related supplies fall within the DME and related supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for DME and related supplies provided on December 3, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. You say that you would like reconsideration because this drug is
medically necessary. The Plan denied your request. The Plan says the member does not meet step therapy
exception criteria.
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 Prolia. Our reviewer says that the
member has not tried and failed a trial of zoledronic acid. Our physician reviewer found the documentation
does not support that Zoledronic acid would likely be less effective, and/or would likely have adverse effects
for the enrollee in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to
pre-approve Prolia.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on January 2, 2020. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the charges because your primary care provider prescribed a drug that interacted with another drug that you are on. 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 $150 copayment for ambulance services.  
 
You have been asked to pay a $150 copayment for ambulance services. Ambulance services fall within the ambulance 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 copayment for ambulance services provided on January 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for 3 flaps (15734x3) provided on November 13, 2019.
You asked the Plan to pay for the 3 flaps. You say that you would like reconsideration based on the records
submitted. The Plan denied your request. The Plan says the documentation submitted does not support the
service 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.
In this case, the CPT Code Manual definition of code 15734x3 is muscle, myocutaneous, or fasciocutaneous
flap; trunk.
We asked our coder 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 3 flaps. Our reviewer says that CPT code 15734x3 does
not meet criteria for billing or reimbursement consideration. Our reviewer found the operative report did not
include documentation of 3 flaps.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the 3 flaps have not been met. Therefore, we decided that the Plan does not
have to pay for 3 flaps (15734x3) provided on November 13, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered provided from February 6, 2020 to February 7, 2020.
You asked the Plan to pay for the self-administered drugs. You say that these drugs were given to you during and after a procedure. The Plan denied your request. The Plan says these drugs 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 provided from February 6, 2020 to February 7, 2020.
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on
February 12, 2020.
You asked the Plan to waive the copayment for the specialist office visit. You say that you should not be
responsible for the copayment because the service is a part of your pre-op for your surgery. The Plan denied
your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50
copayment for each in-network specialist visit for Medicare-covered services.
You have been asked to pay a $50 copayment for the specialist office visit. The specialist office visit falls
within the "Physician/Practitioner services, including doctor's office visits" benefit category. Please note, there
is no provision in the contract which indicates a copayment would be waived if performed as a pre-operative
service to a surgical procedure.
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 specialist office visit provided on February 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyewear purchased on February 19, 2020.
You asked the Plan to pay for the eyewear. You say that you are appealing for reconsideration of the denied
charges. The Plan denied your request. The Plan says you exhausted your maximum benefit allowance.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case.
We looked at the file and the Plan's rules. You exhausted your maximum benefit allowance, because the plan
paid $300 toward your eyeglasses. Your EOC states, the Plan pays up to a total of $300 every twelve (12)
months for eyeglasses, frames, lenses or contact lenses from participating network providers. Any costs you
pay above this allowance will not count toward your maximum out-of-pocket amount. Therefore, we decided
that the Plan does not have to pay for the eyewear purchased on February 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing facility services that you provided on November 12, 2019.
You asked the Plan to pay for the nursing facility services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 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 nursing facility services that you provided on November 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 14, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says nonemergent,
non-urgent services with out-of-network providers require prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
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 physician's services provided on November 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on December 23, 2019 by an out of network (OON) provider.
You asked the Plan to pay for skilled nursing services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the member's referring assisted living facility is out-of-network. The Plan says that 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 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 skilled nursing services provided on December 23, 2019 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided to the enrollee on August 13, 2019.
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says that no additional payment is due.
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules state that that Medicare secondary payment amounts are determined by a formula and are the lowest of: 1) Excess of the actual charge minus the primary payment; 2) The amount Medicare would pay if the services were not covered by a primary payer; 3) The higher of the Medicare payment amount or the primary payers allowable charge minus the amount actually paid by the primary payer. The breakdown of Medicare secondary payment is as follows: 1) $655 (actual charge) minus $524 (amount paid by primary) equals $131 2) Amount Medicare would pay $443.42 times 0.8 equals $354.74 (this is the amount Original Medicare would pay, the allowed times 80% coinsurance) 3) $524 (the higher between the Medicare amount and the primary payers allowable) minus $524 (the amount the primary payer paid) equals $0. Medicare will pay the lowest of these amounts. The lowest amount is $0. Therefore, we decided that the Plan does not have to pay for the ambulance services provided to the enrollee on August 13, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections (64493, 64494).
You asked the Plan to pre-approve facet joint injections. You say that the services are necessary. The Plan
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that facet joint injections are covered when specific
criteria is met.
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 facet joint injections. Our reviewer says
that the services are not medically necessary. Our physician reviewer found in this case, there is no
documentation of facet mediated pain. The review has determined that the enrollee does not meet the coverage
criteria.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan
does not have to pre-approve facet joint injections (64493, 64494).