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

We decided that the Plan does not have to pay for the laboratory services provided on April 9, 2021.

You asked the Plan to pay for the laboratory services. 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. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on April 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for a mobile swallow study with barium contrast with an out-of-network provider.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says coverage is denied for an out-of-network provider.

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 a referral for a mobile swallow study with barium contrast with an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the eye exam, the computerized ophthalmic scan, and the visual field testing you received on October 6, 2021.
You asked the Plan to waive the cost sharing for the eye exam, the computerized ophthalmic scan, and the visual field testing. You say that you just went in for a specialist visit and had two tests. You do not understand why your liability is this high. The Plan denied your request. The Plan says you were charged this cost sharing correctly. The Plan says that because the allowed amounts for the computerized ophthalmic imaging ($32.62) and the visual field testing ($55.26) are less than your copayment obligations, so you are responsible for the full allowed amount for each of these services.
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 $150
copayment for diagnostic radiology, procedures and tests and a $25 copayment for eye exams.
You have been asked to pay a $25 copayment for the eye exam, and a $150 copayment (up to the allowed
amount) for the computerized ophthalmic scan and the visual field testing. the eye exam, The computerized
ophthalmic scan and the visual field testing fall within the diagnostic radiology, procedures and tests 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 cost sharing for the eye exam, the computerized ophthalmic
scan, and the visual field testing you received on October 6, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the rhythm electrocardiogram (ECG) (93042) provided on May 24, 2021.
You asked the Plan to pay for code 93042. 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 93042 is a column II code to column I code 99291. 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 rhythm electrocardiogram (ECG) (93042) provided on May 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the three resin-based composites of two surfaces (D2331 x3) and resin-based composite of three surfaces (D2332) provided on December 28, 2020.
You asked the Plan to pay for the resin-based composites. You say that you were not aware that these services would not be covered. You also say that you would like the $500 on the Mastercard to be used to pay for these procedures. The Plan denied your request. The Plan says your benefits for this service have been satisfied and the frequency limitation has been exceeded. The Plan also says that since you have already met the frequency limitation the $500 Mastercard could not be applied to this claim.
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, restorations are limited to two
procedures per calendar year. The record shows that you received two resin-based composites of two surfaces
(D2331 x2) on December 11, 2020 and your restorations benefit had been exhausted. Therefore, we decided
that the Plan does not have to pay for the three resin-based composites of two surfaces (D2331 x3) and resinbased
composite of three surfaces (D2332) provided on December 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a wound therapy pump provided from
January 28, 2021, to February 26, 2021.
You asked the Plan to waive the coinsurance for the wound therapy pump. You say that you should have help
with these bills. 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 medical device, including wound therapy pumps.
Item                                                                                      Allowed Amount                     20% Coinsurance
Wound Pump - January 28, 2021 to January 31, 2021                   $348.00                                   $69.60
Wound Pump - February 1, 2021 to February 26, 2021                 $2375.10                                 $475.02
Total:                                                                                                                                      $544.62

You have been asked to pay $544.62, which is 20% of the allowed amount for the wound therapy pump. Wound therapy pumps fall within the Durable Medical Equipment (DME) and Related 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 coinsurance for a wound therapy pump provided from January 28, 2021, to February 26, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that the facility advised you it was already approved
before they moved you. You say that your provider can provide the necessary information to support the need
for SNF care. The Plan denied your request. The Plan says the enrollee has not had a change in function
warranting daily skilled therapy. The Plan says that there are no daily skilled nursing needs. The Plan says that
the enrollee's needs can be met at a lower level of care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled
nursing services. While the enrollee does require skilled therapy services, they are not required on a daily basis.
Based on the medical records provided this enrollee does not require the services on an inpatient basis, only in
a skilled nursing facility setting. Services in a long-term care facility on a part time basis appear appropriate in
this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (63047) provided May 6, 2021.

You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The Plan denied your request. The Plan says the billed code is inclusive to another code 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. 

We find that CPT code 63047 is not supported in the medical record. Specifically, 63047 is inclusive to 22633 and is not separately payable. Based on this information, we decided that Medicare rules for coverage of the surgical services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (63047) provided May 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the telehealth visit you had with a gastroenterologist on April 26, 2021.
You asked the Plan to waive the copayment for the gastroenterology telehealth visit. You say that this was only for a prescription refill. You said that they didn't speak to you about your health. The Plan denied your request. The Plan says you were charged this copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 copayment for telehealth visits with a specialist. You have been asked to pay a $15 copayment for the gastroenterology telehealth visit. This copayment applies regardless of the reason for the telehealth visit.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the telehealth visit you had with a gastroenterologist on April 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit you had with your primary care provider (PCP) on July 22, 2021.
You asked the Plan to waive the copayment for the PCP visit. You say that this was an office visit with your PCP, so there should be no copayment. 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 $10 copayment for office visits with a primary care provider. You have been asked to pay a $10 copayment for the PCP visit. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the office visit you had with your primary care provider (PCP) on July 22, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. You say that you are not safe at home. You say that you could get strong enough to return home with robust physical therapy. The Plan denied your request. The Plan says the enrollee does not meet the guidelines for coverage of SNF care. The Plan says that the clinical information indicates that the enrollee's needs can be safely met in an alternate level of care.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing services. The enrollee does not require skilled therapy services. Based on the medical records provided this enrollee does not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in a long-term care facility on a part time basis (as needed) appear appropriate in this case. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft (D7953) and guided tissue regeneration (D4267) provided on February 27, 2021.

You asked the Plan to pay for the dental services. You say that the services should be covered. The Plan denied your request. The Plan says the bone replacement graft is not listed as a covered service. The Plan says that guided tissue regeneration is not listed as a covered service either.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the bone replacement graft and guided tissue regeneration are not among those covered under this benefit. Additionally, the record shows that you signed a financial agreement acknowledging financial responsibility for the services in this case. Therefore, we decided that the Plan does not have to pay for the bone replacement graft (D7953) and guided tissue regeneration (D4267) provided on February 27, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the ultrasound, retroperitoneal (eg, renal,
aorta, nodes), real time with image documentation; complete (76770) provided August 20, 2019.
You asked the Plan to reduce the copayment for the ultrasound. You say that you feel you should be charged a
$20 copayment for your ultrasounds. The Plan denied your request. The Plan says the copayment was applied
correctly based on your 2019 benefits.
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 each Medicare-covered radiological diagnostic service, not including x-rays, performed in a
physician's office or a free-standing facility.
You have been asked to pay a $75 copayment for the ultrasound. The ultrasound 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 reduce the
copayment for the ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation;
complete (76770) provided August 20, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the insulin injection (J1815) provided on July 20, 2021.
You asked the Plan to pay for the insulin. You say that the insulin was needed during the surgery procedure, and you feel it should be included in the payment from the Plan. The Plan denied your request. The Plan says insulin is a self-administered drug and is not covered under your plan.
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 pay for the insulin injection (J1815) provided on July 20, 2021.
Benefits for the insulin 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the maxillary implant/abutment supported removable denture for edentulous arch (D6110) provided on August 23, 2021.

You asked the Plan to pay for the maxillary implant/abutment supported removable denture for edentulous arch. You say that the implant helps you eat. You also say that you lost a lot of weight and the implants were necessary. 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 maxillary implant/abutment supported removable denture for edentulous arch (D6110) provided on August 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on October 8, 2021.
You asked the Plan to pay for the limited oral evaluation (D0140). You say that the provider needed to examine the tooth to see what was wrong. You say that after the exam, the provider advised it was infected and prescribed antibiotics. The Plan denied your request. The Plan says this is only covered once per plan year.
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 one limited oral evaluation per plan year. The Plan paid for the limited oral evaluation provided on January 20, 2021, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on October 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug test (G0481) rendered by the out-of-network (OON) provider on August 2, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the drug test (G0481) rendered by the out-of-network (OON) provider on August 2, 2021.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Udenyca.

You asked the Plan to pre-approve Udenyca. You say that this is medically necessary. The Plan denied your request. The Plan says that that Udenyca is not supported for you.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Udenyca. Our reviewer says that Udenyca is medically reasonable and necessary. Udenyca is FDA-approved for your diagnosis. The documentation supports that Udenyca is safe and effective and otherwise reasonable and necessary for you. Our physician reviewer found that your condition meets criteria for coverage of Udenyca. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Udenyca have been met. Therefore, we decided that the Plan has to pre-approve Udenyca.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99204) provided June 24, 2021.
You asked the Plan to pay for the chiropractic services. You say that on this visit no service was rendered other than the doctor explaining his reason for not doing an adjustment. 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 service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99204) provided June 24, 2021.