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

 We decided that the Plan does not have to pay for immunization administration (CPT code 904710), Zoster (shingles) vaccine (CPT code 90736) and Zoster (shingles) vaccine (CPT code 90750 provided from September 2, 2020, through December 2, 2020.  You asked the Plan to pay for the medication. You say that the claim should be paid. The Plan denied your request. The Plan says the Medicare guidelines say the following procedure codes represent immunizations that are considered routine preventative immunizations, or they are not a disease entity endemic in the United States and therefore, are not covered by Medicare.  In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the medication. The Plan follows the same rules.   Records do not show that you have been injured or directly exposed to any illness related to the medication. Therefore, we decided that the Plan does not have to pay for immunization administration (CPT code 904710), Zoster (shingles) vaccine (CPT code 90736) and Zoster (shingles) vaccine (CPT code 90750 provided from September 2, 2020, through December 2, 2020.   Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a specialist office visit provided on September 28, 2021.  You asked the Plan to waive the copayment for the specialist office visit. You say that the services should be covered at a higher rate as you did not see a specialist, only a nurse practitioner. The Plan denied your request. The Plan says the cost-sharing applied correctly based on 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 $50 copayment for Physician/Practitioner services, including doctor's office visits.        You have been asked to pay a $50 copayment for a specialist office visit. The record indicates that the nurse practitioner who rendered the services is also a cardiology specialist. 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 specialist office visit provided on September 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Prolia.  You asked the Plan to pre-approve Prolia. You say that Prolia is medically necessary. The Plan denied your request. The Plan says the enrollee has not tried and failed an oral bisphosphonate and zoledronic acid.   Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Prolia. Our physician reviewer found that in this case, the record indicates the enrollee has age related osteoporosis without osteoporotic fracture.  The requested medication is a new start. The Plan requires a trial of an oral bisphosphonate and zoledronic acid before they will approve the requested drug. The provided records do not indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record does not indicate the enrollee has a contraindication to or would have an adverse effect from the plan's preferred step one alternative. The elements of the coverage criteria are not satisfied.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating provider on August 19, 2021.  You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you do not agree with paying for this. You say that this was a terrible for you. 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 $350 copayment per day for days 1-5. There is a $0 copayment for additional days for inpatient hospital care/in-network.   You have been asked to pay a $350 copayment per day for days 1-5. The total amount you are being asked to pay is $1,750 ($350 x 5 days = $1,750). The correct copayment has been applied to the services that were provided. An inpatient hospital stay falls within the inpatient hospital care/in-network 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 an inpatient hospital stay provided by a participating provider on August 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the complex wound repair provided on September 24, 2021.  You asked the Plan to waive the copayment for the complex wound repair. You say that you were told there would be no charge because it was Moh's surgery due to skin cancer. You say that this is a huge sum of money for a senior citizen on a limited income. The Plan denied your request. The Plan says the copayment 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 $325 copayment for a surgical visit at an in-network hospital.    You have been asked to pay a $325 copayment for the complex wound repair. The complex wound repair falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The complex wound repair is considered a surgical service that was provided by the 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 complex wound repair provided on September 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (CPT code 99204) provided to the enrollee on July 2, 2021, by an out-of-network provider.  You asked the Plan to pay for the out-of-network services. You say that the enrollee's daughter was unaware of the type of insurance the enrollee had. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they approved in advance.  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 office visit (CPT code 99204) provided to the enrollee on July 2, 2021, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the annual wellness exam (99397) provided on October 18, 2021.  

You asked the Plan to pay for the annual wellness exam. You say that you would like the Plan to cover this claim. The Plan denied your request. The Plan says although this is a covered benefit, you have exceeded the limit set in the subscriber agreement.  

The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once every 12 months.   

Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. Therefore, we decided that the Plan does not have to pay for the annual wellness exam (99397) provided on October 18, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the observation care services provided from August 6, 2021, through August 7, 2021.  You asked the Plan to pay for the observation care services. You say that this claim has been billed correctly. The Plan denied your request. The Plan says this claim has not been billed in accordance with Medicare coding regulations.  The Plan must follow Medicare rules. Medicare rules say that if a period of observation spans more than 1 calendar day, all of the hours for the entire period of observation must be included on a single line.  We looked at the file and Medicare rules. In this case, you have billed observation care on more than one line of the claim contrary to Medicare coding regulations. Based on this information, we decided that Medicare rules for coverage of the observation care services have not been met. Therefore, we decided that the Plan does not have to pay for the observation care services provided from August 6, 2021, through August 7, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 We decided that the Plan has to pay for the acute inpatient hospital care provided from June 21, 2021, to June 23, 2021.  

You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary. The Plan denied your request. The Plan says that the services were not medically necessary.  

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.  

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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the provided documentation indicates that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier Emergency Department and/or observation care) would span two midnights.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from June 21, 2021, to June 23, 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to reimburse you for a swimming pool membership provided on March 20, 2021.  You asked the Plan to reimburse you for a swimming pool membership. You say that swimming in the pool is your primary source of exercise, and this is not a pool only facility. You say this is a high school pool where members can use other equipment available in the gym, such as stationary bikes and weights. The Plan denied your request. The Plan says the high school pool program is not a Plan qualified health club or fitness facility.  The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.    The Plan's rules for coverage of gym benefits have not been met because the high school pool program is not a Plan qualified health club or fitness facility. Therefore, we decided that the Plan does not have to reimburse you for a swimming pool membership provided on March 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the molecular genetic screening testing (CPT code 81479) provided to the enrollee on May 3, 2021.  You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request.  The Plan says SelectMDx in males with previous negative prostate biopsy who are being considered for repeat biopsy is promising with evidence of some clinical utility to reduce unnecessary repeat prostate biopsies. The Plan states there was no documented result of prior prostate biopsy and there was no documented significant interval increase in PSA level.  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.  There was no documented result of prior prostate biopsy. There was no documented significant interval increase in PSA level. The test at issue in this appeal, the laboratory services, 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 the molecular genetic screening testing (CPT code 81479) provided to the enrollee on May 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the CT scan, head or brain; without contrast material (CPT code 70450) provided to the enrollee on May 22, 2021.  You asked the Plan to pay for the CT scan. You say that the claim should be paid. The Plan denied your request. The Plan says the service is 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 70496 is a column II code to column I code 70450. 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 CT scan, head or brain; without contrast material (CPT code 70450) provided to the enrollee on May 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Prolia injections (J0897).  You asked the Plan to pre-approve Prolia injections. You say that the enrollee cannot take oral medications because they have gastroesophageal reflux disease (GERD). The Plan denied your request. The Plan says the criteria for coverage have not been met and it has not been demonstrated that it is medically necessary to make an exception for the enrollee.  Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Prolia injections. Our reviewer says that the elements of the coverage criteria are not satisfied. Our physician reviewer found the provided records do not indicate that the enrollee has tried and failed the Plan's preferred step one alternative, Zoledronic acid. Our reviewer also found that the record does not indicate that the enrollee has a contraindication to, or would have an adverse effect from the Plan's preferred step one alternative, Zoledronic acid.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia injections (J0897).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the mechanical traction therapy (97012) and electrical stimulation (G0283) provided on July 28, 2021.  You asked the Plan to pay for the mechanical traction therapy and electrical stimulation. You say that you have an advance beneficiary notice (ABN) in place, so the claim processed incorrectly. The Plan denied your request. The Plan says these services are not covered when rendered by a chiropractor.    The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.   The records show that the services at issue are not manual manipulation of the spine. Of note, Medicare prohibits the use of an ABN with Medicare Advantage Plans. Therefore, we decided that the Plan does not have to pay for the mechanical traction therapy (97012) and electrical stimulation (G0283) provided on July 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the prophylaxis (D1110) or pay more for the bitewing x-rays (D0274) provided on June 8, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the prophylaxis and to pay more for the bitewing x-rays. You say that your dentist does not accept insurance and you would like to be reimbursed the difference. The Plan denied your request. The Plan says your prophylaxis benefit has been satisfied and the frequency limitation has been exceeded. The Plan also says that these services were performed by a non-participating provider, and you are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for the service.  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, prophylaxis (D1110) is limited to one procedure code per calendar year. The record shows that you received a prophylaxis (D1110) on January 27, 2021 and your prophylaxis (D1110) benefit has been exhausted. The Plan contract says that you are responsible for a 50% coinsurance for bitewing x-rays (D0274), plus the difference between the billed amount and allowed amount because the service was received OON. Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110) or pay more for the bitewing x-rays (D0274) provided on June 8, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for outpatient surgical services rendered from December 17, 2020, to December 23, 2020.  You asked the Plan to waive the coinsurance for outpatient surgical services. You say that you went in for pre-operation appointment and they gave you a form that was all filled out with the provider's name and the procedure that would be done. You also say that it stated you would be admitted as inpatient, and no one told you it would be changed to outpatient. 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 20% coinsurance for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.   You have been asked to pay $2,777.35 coinsurance, which is 20% of the allowed amount for outpatient surgical services ($13,886.75 x 20% = $2,777.35). Outpatient surgical services falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 outpatient surgical services rendered from December 17, 2020, to December 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve placement of an auricular peripheral nerve stimulation device.  You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the requested service is not covered by Medicare or the health plan.  The Plan must follow Medicare rules. Medicare rules say that auricular peripheral nerve stimulators are electro-acupuncture devices which are not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve placement of an auricular peripheral nerve stimulation device.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing (CPT code G0482) provided on February 4, 2021.  You asked the Plan to pay for the drug testing. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not supported by the records.  The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. CPT code G0482 (1 Units) remains not supported. The place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11. Also, the laboratory results submitted indicate the specimen was collected on February 4, 2021, and received by the lab on February 22, 2021. It is noted multiple attempts were made to obtain additional information from the provider. Therefore, we decided that the Plan does not have to pay for the drug testing (CPT code G0482) provided on February 4, 2021.