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

We decided that the Plan does not have to pre-approve Actemra for the enrollee.

You asked the Plan to pre-approve this drug. You say that the enrollee is doing well on this medication. The Plan denied your request. The Plan says that this is not covered under Part B.

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 pre-approve Actemra for the enrollee.

Benefits for this drug 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost for the hyaluronan injection and arthrocentesis provided on June 4, 2021.
You asked the Plan to waive the cost for the hyaluronan injection and arthrocentesis. You say that everything is going up in cost, but your Social Security check stays the same. You say that you are on a fixed income and are appealing this amount. The Plan denied your request. The Plan says the cost share applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for chemotherapy and other drugs covered by Medicare Part B and a $40 copayment for each covered specialist office visit. You have been asked to pay a total of $283.80 for the hyaluronan injection and arthrocentesis.
Service
Allowed Amount
Standard Cost
Member Liability
Hyaluronan Injection
$1,219
20%
$243.80
Arthrocentesis
$96.67
$40
$40
TOTAL:
$283.80
The hyaluronan injection falls within the "Medicare Part B prescription drugs" benefit category. The arthrocentesis 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 cost for the hyaluronan injection and arthrocentesis provided on June 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital outpatient clinic visit provided on January 28,
2021, by an OON provider.
You asked the Plan to pay for the hospital outpatient clinic visit (G0463). You say that you went to this
provider because your daughter works there. The Plan denied your request. The Plan says you did not receive
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 requested 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 the service. Therefore, we decided that
the Plan does not have to pay for the hospital outpatient clinic visit provided on January 28, 2021, by an OON
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on May 20, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for physician services. You say that these services were medically necessary. You say that you would like this reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by a participating 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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for physician services provided on May 20, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound services provided on May 3, 2021.

You asked the Plan to pay for the services provided. You say that the enrollee had multiple exams on this date
of service. The Plan denied your request. The Plan says an appropriate modifier was not 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, the CPT Code Manual definition of code 76705 is ultrasound, abdominal, real time with image
documentation; limited (eg, single organ, quadrant, follow-up). We looked at the file and the rules. We find
that CPT code 76705 was billed with code 93976, which was paid by the plan. Code 76705 is separately
payable when billed with an appropriate modifier. The provided claim does not show that the code at issue was
billed with a modifier to indicate a separate payment is valid. Based on this information, we decided that
Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan
does not have to pay for the ultrasound services provided on May 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the electrocardiogram (ECG) you had on March 3, 2021.

You asked the Plan to waive the copayment for the ECG. You say that you have never had to pay for this in the past, and your Explanation of Benefits says "you should not be billed for this charge." You also stated that this charge is a financial hardship. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for the ECG ($21.48) is less than your copayment obligation, you are responsible for the full allowed amount. The Plan also says that the statement 'you should not be billed for this charge' that appears on your April Explanation of Benefits refers to procedure code 99072 (additional supplies), and is not applicable to the ECG charge.

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 non-radiological diagnostic services. The contract also says that your annual wellness visit does not include any diagnostic testing and you are responsible for separate cost sharing for those services.

You have been asked to pay a $30 copayment for the ECG. The ECG falls within the non-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 electrocardiogram (ECG) you had on March 3, 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 gynecologist on May 7, 2021.
You asked the Plan to waive the copayment for the telehealth visit. You say that you should not have to pay the copayment because you did not receive an in-house visit. You said that you were denied an in-person visit because you could not wear a mask. 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 $40 copayment for telehealth visits with a specialist. You have been asked to pay a $40 copayment 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 gynecologist on May 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on April 8, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for out of network physician services provided to the enrollee on April 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services and wound care provided on July 21, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for skilled nursing services and wound care. You say that you would like this claim reprocessed and paid. You say that these services were medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained for these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for skilled nursing services and wound care provided on July 21, 2020 by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services provided on February 2, 2021, by an
OON provider.
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 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the testing services provided on February 2, 2021,
by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the rest home visit provided on February 22, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the rest home visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the rest home visit provided on February 22, 2021 by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network outpatient mental health services provided from May 4, 2021, to May 18, 2021.

You asked the Plan to pay for out of network services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says the provider is not a Medicare eligible mental health provider.

Medicare requires enrollees to get care form eligible providers. The contract with the Plan states enrollees must get outpatient mental healthcare in network and from Medicare eligible providers. The licensed clinical social worker who provided this service is not a Medicare eligible provider. The Plan had network providers who could render this treatment. Therefore, we decided that the Plan does not have to pay for out of network outpatient mental health services provided from May 4, 2021, to May 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on May 26, 2021.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for out of network physician services provided to the enrollee on May 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray rendered on April 1, 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 procedure code 71046 is not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically
appropriate NCCI modifier is used to report the reason it should be paid as well.
The provider submitted a claim for procedure codes 70496 (chest x-ray, two views) and 32555 (thoracentesis,
needle or catheter, aspiration of pleural space with imaging guidance). Code 71046 is a column II code with a
modifier indicator of 1 when billed with column I code 32555. Code 71046 was not billed with an appropriate
modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the chest
x-ray rendered on April 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (80053, 82607, 83540, 85025) provided
on May 25, 2021, by an OON provider.

You asked the Plan to pay for OON laboratory services. You say that this should be covered. The Plan denied
your request. The Plan says this was not authorized.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for laboratory services (80053, 82607, 83540, 85025)
provided on May 25, 2021, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on May 11, 2021.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that the dental facility used codes that are not covered under your plan. The Plan denied your request. The Plan says this service is not covered.
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 problem focused limited oral evaluation (D0140) provided on May 11, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy to be provided by the requested out-of-network provider.

You asked the Plan to pre-approve physical therapy. The Plan denied your request. The Plan says members are entitled to receive services from out-of-network providers for emergency or out-of-area urgently needed services.

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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physical therapy to be provided by the requested out-of-network provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health services (90832) provided on March 19, 2021.
You asked the Plan to pay for outpatient mental health services. You say that this was medically necessary. The Plan denied your request. The Plan says the provider of this service cannot be paid.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for outpatient mental health services (90832) provided on March 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro2 orthotic device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says the use of this brace is considered experimental and investigational.
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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is insufficient literature in the peer reviewed publications to assess efficacy, long term outcomes or patient management associated with the use of the MyoPro Orthosis for upper extremity paralysis/paresis from conditions such as the patient's spinal paraplegia, cervical disc disorder and neuropathy or other neuromuscular/neurological disease or injury. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the MyoPro2 orthotic device for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the myelography via lumbar injection (procedure code 62305) you had at an outpatient hospital facility on April 30, 2021.
You asked the Plan to waive the copayment for the myelography via lumbar injection. You say that you believe this procedure should be considered advanced radiology and not surgery. 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 $400 copayment for outpatient surgery at an outpatient hospital facility. You have been asked to pay a $400 copayment for the myelography via lumbar injection. Medicare's physician fee schedule lookup tool (payment policy indicator field) confirms that procedure code 62305 is considered a surgical code, not advanced radiology. That is why the myelography via lumbar injection falls within the outpatient surgery 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 myelography via lumbar injection (procedure code 62305) you had at an outpatient hospital facility on April 30, 2021.