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

 We decided that the Plan does not have to pre-approve Intracept procedure.  You asked the Plan to pre-approve Intracept procedure. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are 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 Intracept procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has longstanding back pain. The Intracept procedure is experimental. More research is needed to show safety and efficacy. Therefore, the enrollee does not meet criteria for the requested 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 Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve Intracept procedure.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Keytruda for the enrollee.  You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this therapy is not appropriate for the enrollee's treatment.  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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found this regimen is not supported by any of the compendia. The requested drug requires microsatellite instability (MSI) or tumor mutational burden (TMB) of 10. There are no PDL1 levels in the records.  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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ConfirmMDx testing rendered on June 25, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.  The Plan must follow Medicare rules. The rules say that ConfirmMDx testing is covered for males with previous negative prostate biopsy who are being considered for repeat biopsy.  We looked at the file and Medicare rules. The records show that the enrollee was not being considered for a repeat biopsy. 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 pay for the ConfirmMDx testing rendered on June 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home infusion and related services provided June 15, 2021.  You asked the Plan to pay for the home infusion and related services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were submitted with invalid or incorrect dates of service.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  We find that the home infusion and related services are not supported in the medical record. Specifically, the documentation submitted to the Plan did not include medical records for this date of service. Based on this information, we decided that Medicare rules for coverage of the home infusion and related services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion and related services provided June 15, 2021.
Appeal type: Imaging
Decision: Favorable

 We decided that the Plan has to waive one of the copayments for the x-ray of the chest and the x-ray of the ribs you had on June 17, 2021.  You asked the Plan to waive one of the copayments for the two x-rays. You say that you should only be charged one copayment for these two x-rays. The Plan denied your request. The Plan says that you were charged these copayments correctly.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay a $20 copayment for x-rays.   The Plan says you must pay a $20 copayment for each of the two x-rays. The Explanation of Benefits that the Plan provided in the case file shows that you were charged a separate $20 copayment for each of the two x-rays you received on this date.  Your contract explicitly states that if you receive the same service type more than once in the same session, only one copayment will be applied.  Both of the x-rays were done in the same session, and they are the same service type (i.e., x-rays).  Based on the Plan contract, you cannot be asked to pay more than one $20 copayment for the two x-rays. Therefore, we decided that the Plan has to waive one of the copayments for the x-ray of the chest and the x-ray of the ribs you had on June 17, 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: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an emergency department visit provided on July 24, 2021.  You asked the Plan to waive the copayment for the emergency department visit. You say that you were advised to go to the emergency room if the nosebleeds continued. You say that the provider told you there would be no copayment. 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 $90 copayment for each emergency room visit.   You have been asked to pay a $90 copayment for the emergency department visit. The copayment will only be waived if you are admitted to the hospital within 24 hours for the same condition. The records show you were not admitted. Emergency department visits fall within the Emergency Care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an emergency department visit provided on July 24, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the physical therapy evaluation billed by a nurse practitioner on May 28, 2021.  You asked the Plan to pay for the physical therapy evaluation. You say that plans are required to pay non-contracted providers at the preferred provider rate when services are not available from preferred providers in the service area. You say that the in-network benefits should be honored, and the claim processed for payment. The Plan denied your request. The Plan says the code is not appropriate for the service billed.  The Plan must follow Medicare rules. Medicare rules say that coverage of services incident to the professional services of a physician or non-physician practitioner (NPP) is limited to situations in which there is direct supervision of auxiliary personnel.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the physical therapy evaluation have not been met. Specifically, the billing provider is a nurse practitioner. As such, physical therapy services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for the physical therapy evaluation billed by a nurse practitioner on May 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99214) provided on July 6, 2021.  You asked the Plan to pay for the office visit. You say that you would like reconsideration because this was for a separate service and was billed with the appropriate modifier. The Plan denied your request. The Plan says an edit exists between 99483 and 99214.  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 99214 is a column II code to column I code 99483. This edit does not allow for a modifier and these services are not separately payable. 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 office visit (99214) provided on July 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hearing aids provided on May 25, 2021.  You asked the Plan to pay for the hearing aids. You say that you went to a network provider and you were not told when their contract was void with the Plan. You say that you were told you would be reimbursed $500. The Plan denied your request. The Plan says you must use network providers.  Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays up to $500 for hearing aids only when they are received from a network provider.   We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Specifically, the hearing aids were not received from a network provider. Therefore, we decided that the Plan does not have to pay for the hearing aids provided on May 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Cxbladder testing coded 0013M provided on May 22, 2021.  You asked the Plan to pay for the Cxbladder testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not a covered benefit.  The Plan must follow Medicare rules. Medicare rules say that Cxbladder testing is non-covered.  We looked at the file and Medicare rules. Review of the file shows that the enrollee had Cxbladder testing. Cxbladder testing is non-covered. Based on this information, we decided that Medicare rules for coverage of the Cxbladder testing have not been met. Therefore, we decided that the Plan does not have to pay for the Cxbladder testing coded 0013M provided on May 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the periodic oral evaluation (D0120) provided on August 18, 2021.  You asked the Plan to pay for dental codes D0150 and D0120. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says your dental provider is a non-contracting dentist with the Plan. Furthermore, a comprehensive oral exam is only covered once every 36 months. You received this service on March 4, 2020, which is less than 36 months ago.  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, dental services provided by a non-participating dental provider are not among those covered under this benefit. Furthermore, the Plan contract clearly says that comprehensive oral exams are only covered once every 36 months. The file shows that you received this service on March 4, 2020, which is less than 36 months ago. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the periodic oral evaluation (D0120) provided on August 18, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for emergency care provided on April 26, 2021.  You asked the Plan to waive the copayment for emergency care. You say that you were told to go to the emergency room because of irregular labs. 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 $90 copayment for emergency care.   You have been asked to pay a $90 copayment for emergency care. Emergency care falls within the emergency care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for emergency care provided on April 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the periapical x-ray's (D0220 and D0230) provided on July 20, 2021.  You asked the Plan to pay for dental codes D0220 and D0230. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says dental codes D0220 and D0230 are not covered under the Plan's supplemental dental 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, dental codes D0220 and D0230 are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periapical x-ray's (D0220 and D0230) provided on July 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for wound care supplies you received from August 13, 2020, to September 3, 2020.  You asked the Plan to waive the coinsurance for the wound care supplies. You say that you did not need these supplies and you were unable to return them. You stated that you are on a fixed income and were told that you had a $0 balance for these items. The Plan denied your request. The Plan says you were charged this coinsurance 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). The enrollee's contract with the Plan clearly says that enrollees must pay 20% coinsurance for durable medical equipment and supplies.   The enrollee has been asked to pay 20% coinsurance for the wound care supplies. The wound care supplies fall within the durable medical equipment and supplies 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 coinsurance for wound care supplies you received from August 13, 2020, to September 3, 2020.   Your complaint about the supplier's return policy 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the diagnostic casts provided on July 14, 2021 and the pontics, retainer crowns and resin-based composite provided on July 26, 2021.  You asked the Plan to pay for the diagnostic casts, pontics, retainer crowns and resin-based composite. You say that you did not realize it was going to cost so much and you really need help with this bill. The Plan denied your request. The Plan says the diagnostic casts, pontics and retainer crowns are not covered benefits. The Plan also says that reimbursement has already been issued for two fillings.  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, you also have a maximum benefit of two fillings per calendar year. The Plan paid for two resin-based composites provided on May 27, 2021, which exhausted your benefit. The diagnostic casts, pontics and retainer crown remain denied as non-covered benefits. Therefore, we decided that the Plan does not have to pay for the diagnostic casts provided on July 14, 2021 and the pontics, retainer crowns and resin-based composite provided on July 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve endoskeletal system, below knee, alignable system (CPT code L5910), for the enrollee.  You asked the Plan to pre-approve the item. You say that the item is medically necessary. The Plan denied your request. The Plan says the prepatory prosthesis is a non-alignable system.  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 item. Our physician reviewer found the preparatory prosthesis is a non-alignable system, therefore, the medical necessity for the requested item is not met. In addition, the physician progress note does not provide medical justification for the alignable system. The review has determined that the medical records provided do not meet the requirements listed in the LCD for Medicare coverage.  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 item have not been met. Therefore, we decided that the Plan does not have to pre-approve endoskeletal system, below knee, alignable system (CPT code L5910), for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Durolane.  You asked the Plan to pre-approve Durolane. 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 Durolane. Our reviewer says that the documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer found you have osteoarthritis of the knee. The documentation indicates that you have tried and failed Orthovisc but no primary source documentation is submitted to support this claim. The provided records do not indicate that you have tried and failed the plan's preferred step one alternative, Monovisc. The record does not indicate that you have a contraindication to or would have an adverse effect from the plan's preferred step one alternative, Monovisc.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Durolane have not been met. Therefore, we decided that the Plan does not have to pre-approve Durolane.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for eye surgery performed on September 1, 2021.  You asked the Plan to waive the copayment for the eye surgery. You say that you were informed that you would only be responsible for the $560 copayment. 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 a 20% coinsurance for each surgery in an ambulatory surgical center.   Procedure Allowed Amount 20% Coinsurance Dilation to improve eye fluid flow $1129.21 $225.84 Cataract removal and lens insert $326.19 $65.24 Total:  $291.08   You have been asked to pay $291.08, which is 20% of the allowed amount for eye surgery. Eye surgery 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 copayment for eye surgery performed on September 1, 2021.   Your complaint about the Plan customer service representatives misinforming you of your total cost sharing 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: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for the remote device interrogation services you received from July 22, 2021, to August 26, 2021.  You asked the Plan to waive the copayments for the remote device interrogation services. You say that you did not give approval for these services and you did not know there would be a monthly charge. 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 $27.03) 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 $30 copayment for diagnostic procedures and tests.   You have been asked to pay a $30 copayment for the remote device interrogation services. The remote device interrogation services fall within the diagnostic procedures and tests benefit category. These copayments apply regardless of the reason for these services. 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 the remote device interrogation services you received from July 22, 2021, to August 26, 2021.