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

We decided that the Plan does not have to waive the copayment for an office visit (99214) rendered on October
26, 2021.
You asked the Plan to waive the copayment for an office visit. The Plan denied your request. The Plan says you
were 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 $5
copayment for each Medicare-covered visit with a primary care physician (PCP).
You have been asked to pay a $5 copayment for an office visit. 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 an office visit (99214) rendered on October 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve right shoulder arthroscopic surgery (29826) for the enrollee.  You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says subacromial decompression was associated with a small risk of clinically significant harm.  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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of any recent physical therapy for shoulder pain. A six week trial is needed.  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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve right shoulder arthroscopic surgery (29826) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for pain management services (procedure code 62320) provided to the enrollee on July 26, 2021.

You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your request. The Plan says this provider has not submitted any clinical records to support the medical necessity of the service.

The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 

We looked at the file and Medicare rules. Specifically, the case file did not contain medical records for the billed services. Without the medical records, the billed services cannot be verified. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of pain management services (procedure code 62320) provided to the enrollee on July 26, 2021 have been met. Therefore, we decided that the Plan does not have to pay for pain management services (procedure code 62320) provided to the enrollee on July 26, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services you received on
August 1, 2021.
You asked the Plan to waive the copayment for the ambulance services. You say that you should not have to
pay this copayment because you were forced into the ambulance without your consent. You said that you were
not permitted to decline. 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 ambulance services.
You have been asked to pay a $250 copayment for the ambulance services. This copayment applies regardless
of the reason for the transport and regardless of whether you approved the transport. 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 you received on August 1, 2021.
Your complaint about being forced to take an ambulance against your will 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) (K0554) and
supplies (K0553).

You asked the Plan to pre-approve a CGM and supplies. You say that the item is medically necessary. The Plan
denied your request. The Plan says the member is not on insulin with at least three daily injections and does not
self-adjust dosage based on blood glucose results.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations,
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment
plan.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin
with at least three daily injections and require frequent self-adjustment of insulin dosage based on the blood
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM and
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous
glucose monitor (CGM) (K0554) and supplies (K0553).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the reline of complete lower denture (D5751) and sales tax
(D9985) provided on July 15, 2021.
You asked the Plan to pay for the dental services. You say that the provider is listed as in network. You say that
you do not understand why the services are not covered. You also say that you purposely signed up for
additional coverage to help alleviate the cost. The Plan denied your request. The Plan says denture reline is not
listed as a covered service. The Plan also says that sales tax is not listed as a covered service either.
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 denture reline and sales tax are not
among those covered under this benefit. Additionally, the record shows that you were not enrolled in the
optional supplemental dental rider on the date of service in this case. Therefore, we decided that the Plan does
not have to pay for the reline of complete lower denture (D5751) and sales tax (D9985) provided on July 15,
2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Reblozyl.
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 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found Reblozyl is Food and Drug Administration (FDA)-approved for the treatment of anemia failing an erythropoiesis-stimulating agent and requiring two or more red blood cell units over eight weeks in adults with very low- to intermediate-risk myelodysplastic syndromes with ring sideroblasts (MDS-RS) or with myelodysplastic/myeloproliferative neoplasm with ring sideroblasts and thrombocytosis (MDS/MPN-RS-T). This enrollee has high risk myelodysplastic syndrome (MDS) and thrombocytopenia. Off-label use or support from the medical literature is not found for high risk MDS. The service 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 Reblozyl.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam with photos (92250) and
office visit (99204) or pay for the eye refraction (92015) provided on October 20, 2021.
You asked the Plan to waive the copayment for the vision services. You say that you do not have problems with your eyes, and this was a routine eye exam. The Plan denied your request. The Plan says they contacted the provider and found that you showed signs of cataracts during this visit, therefore, the services provided are medical in nature and are covered by Medicare. There is a $45 copayment for Medicare-covered vision services provided in a specialist's office. The Plan also states that they are reviewing your concerns as a separate grievance case.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $45 copayment for Medicare-covered vision services provided in a specialist's office.
The enrollee has been asked to pay a $45 copayment for the vision services. The vision services were billed with medical diagnoses, and it is indicated that bilateral cataracts were discovered during this exam. Therefore, the vision care in question is considered medical rather than routine, and these services are covered by Medicare. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.
Therefore, we decided that the Plan does not have to waive the copayment for the eye exam with photos (92250) and office visit (99204) provided on October 20, 2021.
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. The Plan covers eye refractions when they are provided during a routine eye exam performed by a provider in the Plan's specified routine vision vendor network.
We looked at the file and the Plan's rules. The eye exam provided in this case was a medical eye exam, and the provider in this case is not listed as being part of the Plan's routine vision vendor network. Based on this information, we decided that the Plan's rules for coverage of the eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction (92015) provided on October 20, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for laboratory services provided from August 13, 2020, to January 22, 2021. We also decided that the Plan does not have to waive the copayment for a diagnostic mammogram provided on September 20, 2021.

You asked the Plan to waive the copayments for the laboratory services and mammogram. You say that these claims were submitted incorrectly. 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 $10 copayment for laboratory services at an outpatient hospital facility. 

Your contract with the Plan clearly says that you must pay a $200 copayment for other diagnostic radiological services.

You have been asked to pay a $10 copayment for each of the laboratory services. You have also been asked to pay $84.80, which is less than the $200 copayment for the mammogram. The laboratory services and mammogram fall 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 copayments for laboratory services provided from August 13, 2020, to January 22, 2021. We also decided that the Plan does not have to waive the copayment for a diagnostic mammogram provided on September 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visit services to be provided by an OON provider.
You asked the Plan to pre-approve office visit services. You say that the enrollee requires a tertiary level of care. The Plan denied your request. The Plan says the requested tertiary level of care is not medically necessary for the enrollee's condition.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.
The provider at issue in this case is not a network provider with the Plan. 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 office visit services. Our reviewer says that the requested services to be rendered by OON providers is not medically reasonable and necessary. Our physician reviewer found that the reviewed documentation indicates that the member is a 67-year-old male, diagnosed with malignant neoplasm of head, face and neck being seen by an in-network Otolaryngologist Surgeon due to his Laryngeal Mass. The member had undergone direct laryngoscopy with biopsy frozen section on February 15, 2022, and was seen again for a post-operative evaluation on February 23, 2022. The member was previously seen by an in-network Oncologist, and he does not wish to go back since he had a bad experience with the provider. There is no
clinical rationale for the requested OON/tertiary level of care provider. The Plan has additional in-network providers who can provide care for the enrollee's condition.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of office visit services have not been met.
The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve office visit services. Therefore, we decided that the Plan does not have to pre-approve office visit services to be provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the primary care office visit you had on
May 25, 2021.
You asked the Plan to waive the copayment for the primary care visit. You say that this was your annual exam
so it should be covered in full. 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 $15
copayment for primary care visits.
You have been asked to pay a $15 copayment for the primary care visit. Only annual wellness visits and annual
physicals have no copayment. The Plan contract says that an annual physical exam includes a detailed
medical/family history and the performance of a detailed head to toe assessment with hands-on exam of all
body systems as well as a full examination to assess your overall general health and detect an abnormalities or
signs that could indicate a disease process that should be addressed. An annual wellness visit is to develop or
update a personalized prevention plan based on your current health and risk factors.
We looked at the medical records for this visit to determine if the visit was an annual wellness visit, an annual
physical, or a regular primary care visit. The records show that in addition to the services that are part of an
annual exam or physical, you were also evaluated for postmenopausal atrophic vaginitis and counseled on
weight loss. Because these services are beyond the scope of an annual physical or wellness visit, the regular
primary care visit cost sharing applies. 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 primary
care office visit you had on May 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (procedure code 00811) provided to the enrollee on April 14, 2021.
You asked the Plan to pay for the services. You say that The Plan denied your request. The Plan says the documentation submitted did not include documentation of 70 units.
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 00811 is "anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; not otherwise specified." 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found the anesthesiology record documented that the anesthesiology start time was 12:39; anesthesia end time recorded at 12:49; surgical start at 12:44 and surgical end time at 12:49. The enrollee received monitored anesthesia care with a total of 240mg of IV Propofol during the procedure; supplemental oxygen (4L), blood pressure, heart rate, and oxygen saturation were monitored. The documentation submitted did not include documentation of 70 units billed for the anesthesia services provided. Therefore, the billed service cannot be verified.
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 services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia services (procedure code 00811) provided to the enrollee on April 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) head or brain (70450)
provided October 5, 2021.
You asked the Plan to pay for the CT scan. You say that the enrollee had multiple exams on this date of
service. Attached reports to support level of service. Please reconsider for processing. The Plan denied your
request. The Plan says these are unbundled services.
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, we have confirmed that code 70450
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we
decided that the Plan does not have to pay for the computed tomography (CT) head or brain (70450) provided
October 5, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to waive the copayment for a specialist office visit rendered on October 25, 2021.
You asked the Plan to waive the copayment for a specialist office visit. You say that you should not have to
pay a $40 copayment for office surgery since the surgery was not done in the office. You also say that you did
not appeal claim number E18813494200, and you paid that bill. You also say that you appealed claim number
E18735784500, because this surgery was done in a hospital and not in their office. The Plan denied your
request. The Plan says that you were charged the correct copayment amount.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The enrollee appealed claim number E18735784500 for a copayment of $40, for
a specialist office visit. The Plan also failed to submit a remittance advice or any documentation for claim
number E18735784500 for a specialist office visit rendered on October 25, 2021. Instead, the Plan reviewed
and sent in documentation for claim number E18813494200 for inpatient surgical services rendered from
October 25, 2021, to October 26, 2021. Therefore, we decided that the Plan has to waive the copayment for a
specialist office visit rendered on October 25, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.