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

 We decided that the Plan does not have to waive the cost sharing for the alteplase recombinant injection and the drug administration services you received at an outpatient hospital facility on July 12, 2021.  You asked the Plan to waive the cost sharing for the alteplase recombinant injection and drug administration services. You say that because the nurse was unable to draw blood from your port for lab services, the nurse ordered this drug for you.  You stated that this should be covered in full because it was medically necessary. The Plan denied your request. The Plan says these services were not denied, but you were charged this cost sharing correctly.  The Plan says that for the administration services, because the allowed amount for this service ($192.32) is less than your outpatient hospital copayment obligation, you are responsible for the full allowed amount for this service.  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 Part B drugs and a $295 copayment for services in an outpatient hospital facility.   You have been asked to pay 20% coinsurance for the alteplase recombinant injection and a $295 copayment for the drug administration services. The alteplase recombinant injection falls within the Medicare Part B drugs benefit category. In addition, your contract explicitly states that for the administration of that drug, you will pay the cost-sharing that applies to outpatient hospital services.  That copayment is $295. 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 alteplase recombinant injection and the drug administration services you received at an outpatient hospital facility on July 12, 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. The Plan denied your request. The Plan says you do not require daily skilled nursing or therapy services on an inpatient basis.  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 physician reviewer found that from a nursing perspective, you received oral medications and had stable vital signs. There are no identifiable skilled nursing service needs. Regarding rehabilitation services, you were at a supervision assist level for functional mobility. You required varying assist with activities of daily living. Although there are identifiable skilled therapy service needs, you do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting.  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 iliac revascularization (37720) provided on April 27, 2020.  You asked the Plan to pay for the iliac revascularization. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says code 37220 has a status indicator of "1" which does not allow for assistant surgeon payment.  The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current Procedural Terminology (CPT) code 37220. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the iliac revascularization have not been met. Therefore, we decided that the Plan does not have to pay for iliac revascularization (37720) provided on April 27, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound you had on May 29, 2021.
You asked the Plan to waive the copayment for the ultrasound. You say that you thought diagnostic work didn't have a copayment. 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 ($101.22) 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 ultrasound. The ultrasound 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 ultrasound you had on May 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the dermatology visit and the skin biopsy you had on July 16, 2021.
You asked the Plan to waive the deductible for the dermatology visit and the skin biopsy. You say that you do not understand why the Plan didn't pay anything for these services. The Plan denied your request. The Plan says you had not yet met your deductible at the time of these services.
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 there is a $500 deductible which applies to specialist services and outpatient procedures. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible which applies to specialist services and outpatient procedures. This cost sharing is a contractual obligation that had not been met at the time the dermatology visit and the skin biopsy was received on July 16, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the dermatology visit and the skin biopsy you had on July 16, 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 a primary care doctor on June 28, 2021.  You asked the Plan to waive the copayment for the primary care visit. You say that this was your annual wellness visit, so there should not be a copayment. The Plan denied your request. The Plan says you were charged this copayment correctly.  The Plan says that they originally charged you a $40 copayment for a specialist visit, but that has been adjusted down to $10.  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 primary care office visits.   You have been asked to pay a $10 copayment for the primary care visit. We looked at the medical records to see what type of visit you had with this doctor on this date of service.  The records do not show that this was an annual wellness visit.  Rather, the records show that you went to this visit to be evaluated for a rash. Your Evidence of Coverage explicitly states that if you receive services that address a medical condition, the office visit copayment applies. 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 a primary care doctor on June 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve endodontic therapy (D3320).  You asked the Plan to pre-approve endodontic therapy. You say that you wear partials on the bottom of your mouth and tooth 21 is cracked and broke off. This is the tooth the partial hooks to, the nerve is exposed, you are in pain and you cannot wear your partial. You also say the provider put filling on it but says you need a root canal. The Plan denied your request. The Plan says endodontic therapy is not a covered service with your 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 pre-approve endodontic therapy (D3320).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound provided on June 4, 2021.
You asked the Plan to waive the copayment for the ultrasound. You say that the ultrasound was requested by your doctor. 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 $110 copayment for radiological diagnostic services, including ultrasounds. You have been asked to pay $104.84, which is less than the $110 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 waive the copayment for the ultrasound provided on June 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a face-down positioning table.  You asked the Plan to pre-approve face-down positioning table. You say that you need to lie face down after your procedure so this item is necessary, but you are on a fixed income. The Plan denied your request. The Plan says the denial of authorization for this item is correct, because this is a precautionary item and can be used for non-medical purposes.  The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.    The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a face-down positioning table.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for wound care and negative pressure wound therapy you received at an outpatient hospital facility from August 2, 2021, to August 30, 2021.
You asked the Plan to waive the copayments for the wound care and negative pressure wound therapy services. You say that these copayments are exorbitant to you and you don't think you should have to pay this much for services that were not really 'surgical.' The Plan denied your request. The Plan says you were charged these copayments 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 $150 copayment per visit for outpatient hospital surgery services. You have been asked to pay a $150 copayment per visit for the wound care and negative pressure wound
therapy services. Medicare considers wound care therapy to be surgical in nature. That is why the wound care
and negative pressure wound therapy services falls within the outpatient hospital surgery 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 copayments for wound care and negative pressure wound
therapy you received at an outpatient hospital facility from August 2, 2021, to August 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the visual field examination, unilateral or bilateral, with interpretation and report (92083), the scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral (92134 x 2), the ophthalmological medical examination and evaluation (92004), the anterior segment imaging with interpretation and report (92286 x 2), the fundus photography with interpretation and report (92250), the ophthalmic ultrasound, diagnostic (76514), and the Gonioscopies (92020 x 2) rendered by the out-of-network (OON) provider on June 29, 2021.  You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the visual field examination, unilateral or bilateral, with interpretation and report (92083), the scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral (92134 x 2), the ophthalmological medical examination and evaluation (92004), the anterior segment imaging with interpretation and report (92286 x 2), the fundus photography with interpretation and report (92250), the ophthalmic ultrasound, diagnostic (76514), and the Gonioscopies  (92020 x 2) rendered by the out-of-network (OON) provider on June 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99203) and the laboratory service (87426) rendered by the out-of-network (OON) provider on April 14, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. The Plan did not pre-approve the services at issue.
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the office visit (99203) and the laboratory service (87426) rendered by the out-of-network (OON) provider on April 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a VivAer procedure.  You asked the Plan to pre-approve the requested procedure. You say that the enrollee has an inability to sustain a long-term benefit from pharmacologic therapies. The Plan denied your request. The Plan says the procedure is not medically necessary in the management of nasal obstruction and deviation.  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 the requested procedure. Our physician reviewer found that you have clinical signs and symptoms of nasal airway obstruction, such as internal nasal valve (INV) narrowing, nasal septal deviation, and boggy, congested intranasal mucosa. The clinical note indicated that septoplasty may be necessary in the future. The VivAer system facilitates radiofrequency ablation (RFA) of the INV. Clinical documentation indicated that you had just begun medical therapy (azelastine and fluticasone) at the initial visit. It did not clearly indicate why you would not derive long-term benefit from medications. Moreover, there is no substantive evidence that immediate RFA-assisted reduction of intranasal soft tissue is superior to the various other procedural techniques currently available.  It is reasonable to conclude that the plan was to conservatively reduce intranasal soft tissue swelling first, with more invasive treatments reserved for later use if necessary. The requested VivAer device does not meet criteria for being medically reasonable and necessary to manage your nasal airway obstruction.  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 requested procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a VivAer procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve dialysis services to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve OON services. The Plan denied your request. The Plan says OON services are not medically necessary.  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 dialysis services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve dialysis services to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for outpatient mental health visits you had from April 28, 2021, to August 18, 2021.  You asked the Plan to waive the copayments for the outpatient mental health visits. You say that you are disabled and cannot afford these copayments. The Plan denied your request. The Plan says you were charged these copayments 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 $40 copayment per visit for outpatient mental health care.   You have been asked to pay a $40 copayment per visit for the outpatient mental health visits. 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 outpatient mental health visits you had from April 28, 2021, to August 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the arthrocentesis procedure and related services you received at an outpatient hospital facility on July 13, 2021.  You asked the Plan to waive the copayment for the arthrocentesis procedure. You say that you wish to appeal this cost sharing. 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 ($261.91) 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 $275 copayment for outpatient surgery and services at an outpatient hospital facility.   You have been asked to pay a $275 copayment for the arthrocentesis procedure. The arthrocentesis procedure falls within the outpatient surgery and services at an outpatient hospital facility 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 arthrocentesis procedure and related services you received at an outpatient hospital facility on July 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on July 13, 2021.
You asked the Plan to waive the copayment for an office visit. You say that all the nurse did was take your blood pressure and referred you to a specialist. 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 $10 copayment for primary care provider visits. You have been asked to pay a $10 copayment for an office visit. An office visit falls within the physician/practitioner services, including doctor's office visits 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 office visit provided on July 13, 2021.