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

We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869, 22870).

You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested treatment is experimental/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 a Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the role of the requested device in the management of spinal stenosis is still uncertain. The procedure is considered experimental/investigational at this point. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex procedure (22869, 22870).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for infusion supplies (A4221, A4222) provided from May 2, 2020, to May 5, 2020.
You asked the Plan to pay for infusion supplies. You say that these items were provided in good faith. The Plan denied your request. The Plan says there is not an order for these items.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.
The record does not contain a valid physician order for the supplies provided in this case. The record shows
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we
decided that the Plan does not have to pay for infusion supplies (A4221, A4222) provided from May 2, 2020,
to May 5, 2020
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance service, basic life support,
emergency transport (A0429) provided March 25, 2021
You asked the Plan to waive the copayment for the ambulance services. You say that you took an unnecessary
trip by ambulance due to confusion at the hospital and don't believe you should be responsible for the cost. The
Plan denied your request. The Plan says the copayment 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 $330
copayment for each covered, one-way ambulance trip by ground or water.
You have been asked to pay a $330 copayment for the ambulance services. This service falls 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 the ambulance
service, basic life support, emergency transport (A0429) provided March 25, 2021
Your complaint about confusion and misinformation at the hospital is not a valid appeal for medical coverage.
This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to
make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for telehealth services provided by a
participating provider on January 18, 2021.
You asked the Plan to waive the copayment for telehealth services. You say that you only had a phone call.
You say that you never went into the facility. 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/telehealth/specialist.
You have been asked to pay a $35 copayment for telehealth services. The correct copayment has been applied
to the services that were provided. Telehealth services fall within the physician/practitioner
services/telehealth/specialist 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 telehealth
services provided by a participating provider on January 18, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab testing (87633) provided January 13, 2021.

You asked the Plan to pay for the lab testing. You say that the lab services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.

The Plan must follow Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary. 

We looked at the file and Medicare rules. The records did not include a valid physician order for the lab test. Based on this information, we decided that Medicare rules for coverage of the lab testing have not been met. Therefore, we decided that the Plan does not have to pay for lab testing (87633) provided January 13, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency department visit provided
on April 29, 2021.

You asked the Plan to waive the copayment for emergency department visit (99284, 71045). You say that you
do not have copayments for emergency care or blood work. 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 $90
copayment for Emergency Care.

You have been asked to pay a $90 copayment for emergency department visit (99284). emergency department
visit (99284) falls 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 department visit provided on April 29, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular genetic testing provided on February 6, 2021.
You asked the Plan to pay for the cardiovascular genetic testing. The Plan denied your request. The Plan says screening tests are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The testing at issue in this appeal, the cardiovascular genetic testing, was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the cardiovascular genetic testing provided on February 6, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on March 8, 2021.

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 testing is not billed correctly.

The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. 

We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on March 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory services (80053, 80061) provided on April 28, 2021.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the services provided.

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 $15 copayment for Medicare-covered laboratory services completed in an outpatient hospital.

You have been asked to pay a $15 copayment for the Medicare-covered laboratory services provided at an outpatient hospital. 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 laboratory services (80053, 80061) provided on April 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Econazole Nitrate cream.

You asked the Plan to pre-approve Econazole Nitrate cream. You say that the enrollee has tried other drugs with no improvement. The Plan denied your request. The Plan says this drug is not covered under the enrollee's Part B drug benefit.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Econazole Nitrate cream.

Benefits for Econazole Nitrate cream 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 pre-approve an Intracept procedure (Intraosseous Neuroablation) (22899, C9752).

You asked the Plan to pre-approve an Intracept procedure. You say that this is medically necessary. The Plan denied your request. The Plan says this is experimental.

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 an Intracept procedure. Our reviewer says that the requested Intracept procedure is not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is considered experimental at this time. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure (Intraosseous Neuroablation) (22899, C9752).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xolair.

You asked the Plan to pre-approve Xolair. You say that this is medically necessary. The Plan denied your request. The Plan says no records have been submitted to support this is necessary.

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. The rules also say for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. 

We looked at the file and Medicare rules. No medical records have been submitted. Without this information, the medical necessity of the requested medication cannot be determined. Based on this information, we decided that Medicare rules for coverage of Xolair have not been met. Therefore, we decided that the Plan does not have to pre-approve Xolair.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport provided on January 11, 2021.

You asked the Plan to pay for ambulance response and treatment, no transport. You say that you tested positive for Coronavirus (COVID-9) and your primary care physician informed you to call emergency medical services. The Plan denied your request. The Plan says the ambulance benefit is a transport benefit and if no transport of a Medicare beneficiary occurs, then there is no Medicare-covered service.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on January 11, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport provided on January 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repair of eyebrow ptosis (eyelid surgery) (99499) to be provided by an out-of-network (OON) provider with in-network benefits.

You asked the Plan to pre-approve the eyelid surgery. You say that you need the surgery done as you cannot set properly. The Plan denied your request. The Plan says if you use an out of network provider, your share of the costs for your covered services may be higher. This service is available with an in-network provider.

The Plan must follow Medicare rules. Medicare rules say that this PPO plan will generally cover your medical care as long as the care you receive is considered medically necessary and you receive your care from a provider who is eligible to provide services under Original Medicare 

The requested provider in this case is not a network provider with the Plan. The health Plan contract specifically says if you use an out of network provider, your share of the costs for your covered services may be higher. The Plan has network providers available who can provide the items/services at issue in this appeal. The plan approved the repair of brow ptosis (eyelid surgery) with an out of network provider. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan not have to pre-approve repair of eyebrow ptosis (eyelid surgery) (99499) to be provided by an out-of-network (OON) provider with in-network benefits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office services provided on June 30, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for office services. You say that you believe this was medically necessary. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and authorization was not 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 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 office services provided on June 30, 2020 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for eyeglasses provided on March 21, 2021.

You asked the Plan to reimburse you for eyeglasses. The Plan denied your request. The Plan says your Plan has a point of service option available but requires a pre-authorization request for vision services provided out-of-network.

Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services out-of-network with authorization when provided out-of-network.

We looked at the file and the Plan's rules. The file shows that the eyeglasses were purchased from an out-of-network provider without authorization from the Plan. Based on this information, we decided that the Plan's rules for coverage of eyeglasses have not been met. Therefore, we decided that the Plan does not have to reimburse you for eyeglasses provided on March 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids provided on April 12, 2021.

You asked the Plan to pay for hearing aids. You say that you called the Plan on April 27, 2021 and you were told that you were eligible for hearing aids. The Plan denied your request. The Plan says it is important to know which providers are part of our network because, with limited exceptions, while you are a member of our Plan you must use network providers to get your medical care and service. The only exceptions are emergencies, urgently needed services when the network is not available (generally, when you are out of the area), out of area dialysis services, and cases in which the Plan authorizes the use of out of network provider.

The Plan must follow Medicare rules. The rules say that Medicare does not cover hearing aids or related services. 

Though hearing aids may be appropriate in this case, neither Medicare nor the Plan covers or pays for these types of items and services. Therefore, we decided that the Plan does not have to pay for hearing aids provided on April 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the diagnostic mammogram and ultrasound rendered on April 19, 2021.

You asked the Plan to waive the copayments for these services. You say that you should not be responsible for the charges. The Plan denied your request. The Plan says the copayments were 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 $50 copayment for all other Medicare-covered outpatient diagnostic tests and a $110 copayment for Medicare-covered diagnostic radiology services.

Review of the file shows that you received a diagnostic mammogram on April 19, 2021. You have been asked to pay a $50 copayment for these services. These services fall within the all other Medicare-covered outpatient diagnostic tests benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.

The file shows that you received an ultrasound on April 19, 2021. Per the contract with the Plan there is a $110 copayment for Medicare-covered diagnostic radiology services. However, the Medicare allowed amount for these services was $105.84. Given that the allowed amount was less than the $110 copayment, you have been asked to pay $105.84 for these services.

The total amount you have been asked to pay for these services is $155.84. 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 the diagnostic mammogram and ultrasound rendered on April 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on March 5, 2020.

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 testing is not covered.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. 

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on March 5, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Hydrocodone-Acetaminophen 5-325 mg tablet.
You asked the Plan to pre-approve Hydrocodone-Acetaminophen tablet. You say that the requested drug is the only thing that gives you comfort. The Plan denied your request. The Plan says rules for self-administered drugs have not been met.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Hydrocodone-Acetaminophen 5-325 mg tablet.
Benefits for Hydrocodone-Acetaminophen tablet 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 reimburse you for the weight loss program provided on March 28, 2021.

You asked the Plan to reimburse you for the weight loss program. You say that this should be covered because you were given portion containers and a food plan. You say that you have a tracking system through a website and post weight each week and have a coach on a weekly basis. You say that you only get recommendations, not food with this program. The Plan denied your request. The Plan says the weight loss program is not a covered benefit under the Weight Management Program benefit.

The Plan contract covers a Weight Management Program benefit. The Plan will cover program fees for weight loss programs or a hospital-based weight loss program.

We looked at the file and the Plan's rules. The file shows that the Plan's Weight Management Program benefit does not cover the weight loss program. Therefore, we decided that the Plan does not have to reimburse you for the weight loss program provided on March 28, 2021.