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

We decided that the Plan does not have to waive the copayment for the emergency department visit (99284) provided on June 26, 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 service 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 $110 copayment for each covered emergency room visit. You have been asked to pay a $110 copayment for the emergency room visit provided. 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 (99284) provided on June 26, 2021.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to waive the copayment for an emergency room visit (99283) provided April 5, 2021.

You asked the Plan to waive the copayment for the emergency room visit. You say that the copayment should be waived. The Plan denied your request. The Plan says that the correct copayment was applied.

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. In this case, the plan was not able to produce any medical records to the IRE for review. Without medical records to review, it cannot be established if the correct copayment was assessed. Therefore, we decided that the Plan has to waive the copayment for an emergency room visit (99283) provided April 5, 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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health treatment.

You asked the Plan to pre-approve inpatient mental health treatment. 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 must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve inpatient mental health treatment. Our reviewer says that the services are not medically necessary. Our physician reviewer found based upon review the records provided, the enrollee does not meet the criteria for continued acute inpatient mental health treatment for the dates in question of October 19, 2021 forward as this enrollee was not shown to be a danger to herself or others. She was not showing any auditory or visual hallucinations and was cooperative/compliant with treatment. This enrollee was not showing any aggressive behaviors, or any treatment required for acute threats of safety.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient mental health treatment.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for Prosthetic eye, plastic, custom (V2623) provided June 8, 2021.
You asked the Plan to pay for Prosthetic eye. You say that you received medical reimbursement for less than what you paid for ocular prosthesis surgery. The Plan denied your request. The Plan says reimbursement was approved and paid in the amount of $738.53 according to the Medicare Fee Schedule. The plan will not cover the difference between the Medicare allowable rate and the amount paid by you.
The Plan must follow Medicare rules. 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 Plan is only responsible for paying the Medicare Allowed amount and that if the provider is not enrolled in Medicare, they are not required to accept the Medicare amount as payment in full. In this case the Plan is only responsible for paying the Medicare Allowed amount. If the provider is not enrolled in Medicare, they are not required to accept the Medicare amount as payment in full. Based on this information, we decided that Medicare rules for coverage of Prosthetic eye have not been met. Therefore, we decided that the Plan does not have to pay for Prosthetic eye, plastic, custom (V2623) provided June 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmological services provided on February 18, 2021.

You asked the Plan to pay for ophthalmological services. The Plan denied your request. The Plan says out-of-network benefits are not offered under the Plan.

Medicare generally does not cover routine vision services. However, the Plan offers a routine vision benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when you use a provider in the Plan's vision care network. 

We looked at the file and the Plan's rules. The file shows that the ophthalmological services were not provided by a provider in the Plan's vision care network. Based on this information, we decided that the Plan's rules for coverage of ophthalmological services have not been met. Therefore, we decided that the Plan does not have to pay for ophthalmological services provided on February 18, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eylea.

You asked the Plan to pre-approve Eylea. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug does not meet step therapy 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 Eylea. Our reviewer says that the requested drug does not meet step therapy criteria. Our physician reviewer found the enrollee has exudative age-related macular degeneration, right eye, with active choroidal neovascularization. The documentation does not support that the enrollee has tried and failed bevacizumab. The documentation does not support an indication that the plan's required drug 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 Eylea have not been met. Therefore, we decided that the Plan does not have to pre-approve Eylea.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided June 24, 2021.
You asked the Plan to pay for the limited oral evaluation. You say that the services were medically necessary.
The Plan denied your request. The Plan says this dental service is not covered under your benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a limited
oral evaluation (D0140) provided June 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis (L1851) and suspension sleeve (L2397) provided on September 9, 2019.

You asked the Plan to pay for a knee orthosis and suspension sleeve. You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the requested items have not been met.

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 pay for a knee orthosis and suspension sleeve. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no documentation of recent injury to, or recent surgical procedure on, either of the enrollee's knees, and there is insufficient credible objective documentation of joint laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered. 

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 knee orthosis and suspension sleeve have not been met. Therefore, we decided that the Plan does not have to pay for a knee orthosis (L1851) and suspension sleeve (L2397) provided on September 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the contacts rendered on June 1, 2021.

You asked the Plan to pay for these services. You say that you were not given prior notification regarding the allowable amount. The Plan denied your request. The Plan says the claim was processed correctly.

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 up to $300 per calendar year towards the purchase and fitting of a pair of contact lenses from a network optical provider. 

We looked at the file and the Plan's rules. The file shows that the Plan applied the full $300 benefit towards the routine eyewear. Further payment is not covered by your supplemental benefit or Medicare. Based on this information, we decided that the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the contacts rendered on June 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81405, 81404, 81401, 81403) provided
December 24, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan
denied your request. The Plan says the tests were performed for screening and 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 test at issue in this appeal, genetic testing, was requested solely for screening purposes. Medicare does not
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for lab
services (81405, 81404, 81401, 81403) provided December 24, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the transthoracic echocardiography (TTE) you received at an outpatient hospital facility on May 25, 2021.
You asked the Plan to waive the copayment for the TTE. You say that you were told there would not be any copayment for this service. 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 $75 copayment for diagnostic radiology services in an outpatient hospital. You have been asked to pay a $75 copayment for the TTE. The TTE falls within the diagnostic radiology services in an outpatient hospital 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 transthoracic echocardiography (TTE) you received at an outpatient hospital facility on May 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visits (99215, 99204) provided on
March 11, 2021 to April 15, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit. You say that this doctor has been your doctor since January 2021
and you do not want to change doctors. This doctor has proven himself to be a caring and competent physician.
The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network
provider with the exception being urgent or emergent services. Non-emergent services with non-contracted
providers require prior authorization before services being rendered.
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 the outpatient office visits (99215, 99204)
provided on March 11, 2021 to April 15, 2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Enbrel Srclk Inj 50mg/Ml.
You asked the Plan to pre-approve Enbrel Srclk Inj 50mg/Ml. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.
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 Enbrel Srclk Inj 50mg/Ml.
Benefits for Enbrel Srclk Inj 50mg/Ml 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray represented by code 72170 provided on April 8, 2021.

You asked the Plan to pay for code 72170. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 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, we have confirmed that code 72170 has a bundled relationship with code 73502 and cannot be paid as billed. This code cannot be paid as a separate line item. 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 x-ray represented by code 72170 provided on April 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D6245) provided December 10, 2020.

You asked the Plan to pre-approve the dental services. You say that the services were medically necessary and
should be covered. The Plan denied your request. The Plan says the dental benefit was exhausted, and the
services are non-covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the record shows the enrollee's $2,500
benefit was exhausted at the time this service was rendered. Therefore, we decided that the Plan does not have
to pre-approve dental services (D6245) provided December 10, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided on
January 25, 2021.
You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says this service is considered Custodial Care, which is not covered under the Plan.
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided on January 25, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional supplies represented by code 99072 provided 
from April 7, 2021 to April 14, 2021. 
 
You asked the Plan to pay for code 99072. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed. 

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. Code 99072 has a status code of "B" under the Medicare Physicians 
Fee Schedule Database (MPFSDB) and no separate payment is made for this code under the fee schedule as 
payment is bundled into the payment for the services to which this code is incident to. Therefore, we decided 
that the Plan does not have to pay for the additional supplies represented by code 99072 provided from April 7, 
2021 to April 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wheelchair accessories and features (E2311, E2377, E2313, K0108).

You asked the Plan to pre-approve the wheelchair features. You say that the features should be covered. The Plan denied your request. The Plan says the enrollee does not meet coverage criteria for the enhanced features.

The Plan must follow Medicare rules. Medicare rules say that other accessories for the power wheelchair, such as the transit options (K0108) is categorically uncovered. The electrical connection between the wheelchair controller and two or more motors (E2311), expandable controller (E2377) and harness (E2313) cannot be covered. Although there are three approved power options on this wheelchair (tilt, recline and elevating leg rests), there is not a demonstrated need to control these power options through the joystick. The enhanced features are therefore not necessary. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the wheelchair features have not been met. Therefore, we decided that the Plan does not have to pre-approve wheelchair accessories and features (E2311, E2377, E2313, K0108).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric services. 
 
You asked the Plan to pre-approve inpatient psychiatric services. 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 must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve inpatient psychiatric services. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found based upon review 
of the records provided, the enrollee does not meet the criteria for continued acute inpatient mental health 
treatment for the dates in question of October 18, 2021 forward as this enrollee was not shown to be a danger to 
herself or others. She was not showing any auditory or visual hallucinations. This enrollee was not showing any 
aggressive behaviors, or any treatment required for acute threats of safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient psychiatric services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the declotting by thrombolytic agent of an implanted vascular access device or catheter (36593) provided on May 19, 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 service 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 $200 copayment for each Medicare-covered visit to an ambulatory surgical center or outpatient hospital facility.
You have been asked to pay a $200 copayment for the Medicare-covered surgery provided at an outpatient hospital facility. 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 declotting by thrombolytic agent of an implanted vascular access device or catheter (36593) provided on May 19, 2021.