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

We decided that the Plan does not have to pre-approve chiropractic services to be provided by an out-of-network provider.

You asked the Plan to pre-approve chiropractic services with an out-of-network provider. You say that you did not realize the requested provider is not participating with this Plan. The Plan denied your request. The Plan says chiropractic services are available in-network.

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 requested provider in this case is not a network provider with the Plan. 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 these items/services. Therefore, we decided that the Plan does not have to pre-approve chiropractic services to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a third level diagnostic medial branch block procedure.

You asked the Plan to pre-approve a third level diagnostic medial branch block procedure. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not describe unique circumstances justifying the medical necessity of adding a third level to this next diagnostic medical branch block procedure.

The Plan follows Medicare rules. Medicare rules say that under normal circumstances, the maximum number of levels for the medial branch block procedure is two. 

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 third level diagnostic medical branch block procedure. Our reviewer says that the requested third level diagnostic medical branch block procedure is not medically reasonable and necessary. Our physician reviewer found in this case, the LCD limits this procedure to just 2 levels per session under normal circumstances. There are no unique medical circumstances that would warrant an exception to this policy.

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 third level diagnostic medical branch block procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a third level diagnostic medial branch block procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient hospital facility visit provided on April 6, 2021.

You asked the Plan to waive the copayment for an outpatient hospital facility visit. You say that you did not receive chemotherapy and this was just a follow-up visit. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for outpatient hospital services. 

The medical records show that you had an outpatient hospital facility visit on April 6, 2021. Therefore, you are responsible to pay $23.72, which is less than the $250 copayment. 

You have been asked to pay $23.72 for an outpatient hospital facility visit. An outpatient hospital facility visit falls within the outpatient hospital 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 an outpatient hospital facility visit provided on April 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a PureWick female external catheter.
You asked the Plan to pre-approve a PureWick female external catheter. You say that you want a PureWick
system. The Plan denied your request. The Plan says a physician order has not been submitted and this would
be considered an item primarily hygienic.
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 PureWick external catheter. Our
reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our
physician reviewer found there are no peer-reviewed articles published in the medical literature specific to the
PureWick system, or external urinary collection system using a continuous low-pressure pump. Thus, there is
no evidence to show the PureWick system to be an effective alternative in managing urinary incontinence. The
records do not specify whether the incontinence is permanent or has been previously evaluated or treated.
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 PureWick external catheter have not been met. Therefore, we decided that the
Plan does not have to pre-approve a PureWick female external catheter
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for chemotherapy administration provided on
April 23, 2021.

You asked the Plan to waive the coinsurance for chemotherapy administration. You say that you do not think
you should pay the charge in question as you believe you have already met your maximum out-of-pocket
spending limit. The Plan denied your request. The Plan says the correct coinsurance was 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 20%
coinsurance for Medicare-covered Part B prescription drugs, including chemotherapy drugs.

The Plan has indicated that you met your maximum out-of-pocket spending limit on April 23, 2021, with the
charge in dispute. You have been asked to pay $87.82, or less than 20% of the Medicare-allowed charge of
$493.52, for chemotherapy administration. Chemotherapy administration falls within the "Medicare Part B
prescription drugs" benefit category. This means that you have been asked to pay less than or equal to the full
and 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 chemotherapy administration provided on April 23, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the audiology services provided on May 6, 2021.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says that the
services were not urgent, emergent, or approved in advance.

The Plan must follow Medicare rules. The contract with the Plan says that you receive your care from a
provider who is eligible to provide services under Original Medicare.

We looked at the file and Medicare rules. The enrollee's plan contract shows that services from both in-network
and out-of-network providers are allowed. The records do not indicate the provider is not eligible to
provide services under Original Medicare. Based on this information, we decided that Medicare rules for
coverage of the services provided have been met. Therefore, we decided that the Plan has to pay for the
audiology services provided on May 6, 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the trigger point injection procedure provided on January 29, 2021.

You asked the Plan to waive the copayment for the trigger point injection procedure. You say that you believe the Plan's copayment structure is unfair because it permits the Plan to not pay anything towards small procedures and minor surgeries. The Plan denied your request. The Plan says this copayment was charged correctly. The Plan says that because the allowed amount for this service ($286.16) is less than the copayment obligation, the enrollee is responsible for the full allowed 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $325 copayment for outpatient surgery.

The enrollee has been asked to pay a $325 copayment for the trigger point injection procedure. The trigger point injection procedure falls within the outpatient surgery benefit category. 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 trigger point injection procedure provided on January 29, 2021.
Appeal type: Imaging
Decision: Partially Favorable

We decided that the Plan has to waive the copayment for a bone density scan. We decided that the Plan does
not have to waive the copayment for an outpatient hospital facility visit.

You asked the Plan to waive the copayments for a bone density scan and an outpatient hospital facility visit.
You say that you disagree with the charges because this was a preventative bone density scan. The Plan says
that the claims were processed correctly, and you are being charged the correct amount.

We decided that the Plan has to waive the copayment for a bone density scan.

Your contract with the Plan says that there are no cost-sharing charges for bone density scans.

You received a bone density scan on March 18, 2021. The code provided for the bone density scan falls under
the preventative bone density benefit. The Plan did not provide any records indicating that the preventative
bone density benefit was exhausted prior to you receiving the services. The plan also did not provide medical
records indicating that diagnostic services took place. Therefore, you cannot be asked to pay a copayment for
the preventative bone density scan.

The Plan says that you must pay a $45 copayment, however, you cannot be asked to pay anything for a bone
density measurement. Therefore, we decided that the Plan has to waive the copayment for a bone density scan.

We also decided that the Plan does not have to waive the copayment for an outpatient hospital facility
visit.

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 $475
copayment for an outpatient hospital facility visit.

The record shows that you had an outpatient hospital facility visit on March 18, 2021. Therefore, you are
responsible to pay the allowed amount of $135.35, which is less than the $475 copayment. Therefore, we
decided that the Plan does not have to waive the copayment for an outpatient hospital facility visit.

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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the duplex scan of the extremity veins you had on April 27, 2021.

You asked the Plan to waive the copayment for the duplex scan. You say that this test was done to see results of leg vein surgery. You say that you would like the copayment covered. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for this service ($114.18) is less than your copayment obligation, you are responsible for the full allowed 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 $160 copayment for radiological diagnostic services.

You have been asked to pay a $160 copayment for the duplex scan. The duplex scan falls within the radiological diagnostic services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the duplex scan of the extremity veins you had on April 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that your wife is having knee surgery and there is nothing for her to hold on to in the shower. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a cardiac MRI provided on March 10, 2020.

You asked the Plan to waive the copayment for a cardiac MRI. You say that you cannot afford the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $0 copayment for mammograms and ultrasounds and a $250 copayment for all other diagnostic radiological services.

You have been asked to pay a $250 copayment for a cardiac MRI. A cardiac MRI falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a cardiac MRI provided on March 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation (D9310) provided on April 5, 2021.

You asked the Plan to pay for the consultation. You say that no provider you have found will treat you because of your heart condition. You also say that you cannot afford to pay this bill. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan.

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 the consultation (D9310) provided on April 5, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the abdomen and pelvis you had on March 2, 2021.

You asked the Plan to waive the copayment for the CT scan. You say that you have had to have several scans and the cost is excessive. 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 $300 copayment for advanced imaging services. 

You have been asked to pay a $300 copayment for the CT scan. The CT scan falls within the advanced imaging 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 computed tomography (CT) scan of the abdomen and pelvis you had on March 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve manual traction services (97012) to be provided by an out of network provider.
You asked the Plan to pre-approve the chiropractic services. You say that this service will help your sciatic nerve. Your neurosurgeon advised you to get this done as well. The Plan denied your request. The Plan says the plan only covers manual manipulation of the spine to correct subluxation. Enrollee's must receive their medical services from an in-network provider.
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 service at issue is not manual manipulation of the spine. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. Therefore, we decided that the Plan does not have to pre-approve manual traction services (97012) to be provided by an out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI provided on April 9, 2021.
You asked the Plan to waive the copayment for an MRI. You say that the physician refused to refer you to a free-standing facility because they render poor quality imaging. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 copayment for advanced imaging provided in an outpatient hospital facility. You have been asked to pay a $200 copayment for an MRI. An MRI falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an MRI provided on April 9, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgery to place a skin substitute (Kerecis Omega 3).
You asked the Plan to pre-approve these services. You say that this is an ongoing procedure to repair your skin after your initial surgery. The Plan denied your request. The Plan says that since the wound has already been treated fourteen times with the skin substitute, the request is considered not medically necessary.
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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. You have an open left face wound following a Moh's procedure. The skin substitute, Kerecis Omega 3, has been placed on the wound fourteen times without a measurable decrease in size since the tenth application, based on the provided reports. A request for an additional skin substitute application was made, which is not supported by the records. There appears to be minimal benefit from continued use of this skin substitute for this patient. Our physician reviewer found that your condition does not meet criteria for coverage of these services. 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 surgery to place a skin substitute (Kerecis Omega 3).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited bilateral noninvasive physiologic studies of upper or lower extremity arteries (93922) provided November 25, 2019.
You asked the Plan to pay for the diagnostic service. You say that the claim was initially billed on 11/30/2019. In spite of this hardship, you filed the claim in good faith and within the timely filing limit from when you were notified of this enrollee's service being rendered. The Plan denied your request. The Plan says the claim was received past the timely filing limitation.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the diagnostic service was not filed until March 30, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed.
Therefore, we decided that the Plan does not have to pay for the limited bilateral noninvasive physiologic studies of upper or lower extremity arteries (93922) provided November 25, 2019.