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

We decided that the Plan does not have to waive the copayment for the gastroenterology visit you had on June 15, 2021.

You asked the Plan to waive the copayment for the gastroenterology visit. You say that this visit was required prior to your screening colonoscopy. You do not think you should have to pay a copayment for this. 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 $45 copayment for visits with a specialist. 

You have been asked to pay a $45 copayment for the gastroenterology visit. There is no provision in your Evidence of Coverage that states that office visits prior to a colonoscopy are free of charge. 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 gastroenterology visit you had on June 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home infusion supplies.
You asked the Plan to pre-approve the supplies. You say that you have had two hospitalizations. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that disposable drug delivery systems are non-covered items. The requested supplies are statutorily not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve home infusion supplies.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a breast ultrasound provided on May 6, 2021.
You asked the Plan to waive the copayment for a breast ultrasound. You say that you feel that this should be included as part of a breast mammogram screening. 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 $110 copayment for ultrasounds. You received a breast ultrasound on May 6, 2021. A breast ultrasound is not included in breast cancer screenings. Therefore, you are responsible to pay the allowed amount of $60.56, which is less than the $110 copayment.
You have been asked to pay $60.56 for a breast ultrasound. A breast ultrasound 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 a breast ultrasound provided on May 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the arthrocentesis procedure and injectable drugs you received at an outpatient hospital facility on April 21, 2021.

You asked the Plan to waive the cost sharing for the arthrocentesis procedure and injectable drugs. You say that you feel this bill is too high. The Plan denied your request. The Plan says you were charged this cost sharing 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 $400 copayment for outpatient surgery in a hospital and 20% coinsurance for Medicare Part B drugs. 

You have been asked to pay a $400 copayment for the arthrocentesis procedure and 20% coinsurance for the injectable drugs. The arthrocentesis procedure falls within the outpatient surgery in a hospital benefit category.The injectable drugs fall in the Medicare Part B drug benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost sharing for the arthrocentesis procedure and injectable drugs you received at an outpatient hospital facility
on April 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.

You asked the Plan to pre-approve foot orthotics. You say that you need these for heel pain and plantar fasciitis. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services coded 99100 provided on February 12, 2021.
You asked the Plan to pay for the anesthesia 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 separately payable.
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 99100 is anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure). We find that CPT code 99100 is not supported in the medical record. Specifically, this code has a status code of "B." A status code of B means that payment for this code is always bundled into payment for other services not
specified and no separate payment can be made. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services coded 99100 provided on February 12, 2021.
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 May 14, 2021.

You asked the Plan to waive the coinsurance for DME and related supplies. You say that you cannot use the device and feel that you shouldn't have to pay for it. 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 May 14, 2021. The total allowed amount is $87.50 and 20% of that is $17.50.

You have been asked to pay the total coinsurance amount of $17.50 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 May 14, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cardiac rehabilitation.

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 medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary cardiac rehab programs. The services must be provided in a doctor's office or an outpatient hospital setting. 

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 records show that you have a history of coronary artery disease (CAD) and had heart surgery. You have no current symptoms of chest pain or significant shortness of breath related to cardiac disease. There are no signs or symptoms of congestive heart failure on exam. The most recent nuclear stress test and echocardiogram showed normal function. You also completed a fully supervised phase II cardiac rehab program and three months of a phase III cardiac rehab without any recurrent symptoms. The cardiac rehab is therefore 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 cardiac rehabilitation.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Evenity (J3111).
You asked the Plan to pre-approve Evenity. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says step therapy rules for the requested drug have not been 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 Evenity. Our reviewer says that the requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the Plan requires a trial of a preferred drug, Forteo or Tymlos, before they will approve the requested drug. In this case, the enrollee has not tried and failed a required drug. There is no documentation provided indicating that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Evenity (J3111).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the epidural injection procedure you had at an outpatient hospital facility on May 5, 2021.

You asked the Plan to waive the copayment for the epidural injection procedure. You say that you don't think this procedure should be considered surgery and you think the cost is too high. 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 $250 copayment for outpatient procedures and services at an outpatient hospital facility. 

You have been asked to pay a $250 copayment for the epidural injection procedure. The epidural injection procedure falls within the outpatient procedures and services at an outpatient hospital facility 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 epidural injection procedure you had at an outpatient hospital facility on May 5, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the pelvic ultrasound services you had on March 19, 2021.

You asked the Plan to waive the coinsurance for the pelvic ultrasound. You say that you have never had to pay this before and you cannot afford this. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for radiological diagnostic services.

You have been asked to pay 20% coinsurance for the pelvic ultrasound. The pelvic ultrasound falls within the radiological diagnostic 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 pelvic ultrasound services you had on March 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the magnetic resonance imaging (MRI) of the lower extremity you had on January 8, 2021, the MRI of the spine you had on January 31, 2021, the knee brace you received on March 2, 2021, and the arthrocentesis procedure and Synvisc injection you received on March 15, 2021.

You asked the Plan to waive the cost sharing for the MRIs, the knee brace, the arthrocentesis procedure, and the Synvisc injection. You say that had you known you would be responsible for these charges, you would not have received the services. You said that you cannot afford these amounts. The Plan denied your request. The Plan says you were charged this cost sharing correctly. The Plan says that for the MRIs, since the allowed amounts for these two services ($220.91 and 134.64) are less than your copayment obligation, you are responsible for the full allowed amount for these services.

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 $275 copayment for diagnostic radiology (other than CT scans), 20% coinsurance for prosthetic devices, 20% coinsurance for Medicare Part B drugs, and a $40 copayment for physician specialist services. 

You have been asked to pay a $275 copayment for each of the MRIs, 20% coinsurance for the knee brace, a $40 copayment for the arthrocentesis procedure, and 20% coinsurance for the Synvisc injection. The MRIs, fall within the diagnostic radiology benefit category. The knee brace falls in the prosthetic benefit category. You had the arthrocentesis procedure in a specialist's office, so this service falls in the specialist services benefit category. Finally, Synvisc is considered a Medicare Part B drug. This means that you have been asked to pay the correct amounts 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 for the magnetic resonance imaging (MRI) of the lower extremity you had on January 8, 2021, the MRI of the spine you had on January 31, 2021, the knee brace you received on March 2, 2021, and the arthrocentesis procedure and Synvisc injection you received on March 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound exam of the pelvis (76856) and the transvaginal ultrasound (76830) rendered by the out-of-network (OON) provider on April 26, 2021.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the ultrasound exam of the pelvis (76856) and the transvaginal ultrasound (76830) rendered by the out-of-network (OON) provider on April 26, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on May 21, 2020.

You asked the Plan to pay for the ambulance services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the enrollee enrolled in hospice from May 21, 2020 through May 22, 2020. The Plan says, per Medicare guidelines, the provider should bill Original Medicare for the services rendered on May 21, 2020.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on May 21, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services (90837) rendered by the out-of-network (OON) provider from March 3, 2021, through May 17, 2021.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue.
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the psychotherapy services (90837) rendered by the out-of-network (OON) provider from March 3, 2021, through May 17, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Colorectal Screening and Fecal hemoglobin (Cologuard Test) (CPT code 81528), for the enrollee.
You asked the Plan to pre-approve the test. You say that you are helping the enrollee to get an approval for Cologuard testing. You state this is to help guide the enrollee in their decision about another colonoscopy. You state the enrollee has a family history of colon cancer and has a precancerous polyp that is seen every colonoscopy including the one that was done seven (7) years ago. The Plan denied your request. The Plan says the Medicare rules have not been 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 the test. Our physician reviewer found the available record does not support that the enrollee meets NCD requirements for Medicare coverage of Cologuard. Specifically, the enrollee neither meets age 50-85 criteria, nor can the enrollee be considered average risk for developing colorectal cancer. In addition, Cologuard has an insufficient sensitivity at 42% for detecting advanced precancerous lesions. As such, it does not appropriately fulfill the enrollee's intended identification of polyps for colonoscopic removal. 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 test have not been met. Therefore, we decided that the Plan does not have to pre-approve Colorectal Screening and Fecal hemoglobin (Cologuard Test) (CPT code 81528), for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve destruction by neurolytic agent, genicular nerve
branches including imaging guidance, when performed (CPT code 64624) for the enrollee.
You asked the Plan to pre-approve the service. You say that this is for the treatment of knee pain. The Plan
denied your request. The Plan says the service is considered experimental and 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 service. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found knee genicular nerve ablation is experimental. More research is needed to show safety and
efficacy.
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 service have not been met. Therefore, we decided that the Plan does not
have to pre-approve destruction by neurolytic agent, genicular nerve branches including imaging guidance,
when performed (CPT code 64624) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary visit provided on March 31, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the domiciliary visit. You say that it is the hospital facility's responsibility to obtain authorization which should cover the rendering physician's medical treatment. You say the service was medically necessary. 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 domiciliary visit provided on March 31, 2021, by an out-of-network (OON) provider.