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

We decided that the Plan does not have to pay for the FoundationOne Heme (81455) provided on July 27,
2021.
You asked the Plan to pay for the FoundationOne Heme. You say that you would like reconsideration because
this testing was medically necessary. The Plan denied your request. The Plan says genetic testing procedures
submitted with code 81455 are unlikely to impact therapeutic decision-making in the clinical management of
the patient and will be denied automatically as 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 pay for the FoundationOne Heme. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found there was no specific clinical rationale for the test given the enrollee's diagnosis of
autoimmune hemplytic anemia.
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 FoundationOne Heme have not been met. Therefore, we decided that the
Plan does not have to pay for the FoundationOne Heme (81455) provided on July 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a left total knee arthroplasty for the enrollee.  

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there is no specific documentation of participation in supervised physical therapy for the enrollee's knee and there is no documentation of using non-steroidal medications for a prolonged period.  

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. There are limited large-scale, long-term references showing the safety and efficacy of the requested surgery in this clinical setting. The studies support exhaustion of conservative care measures prior to undergoing the requested total knee arthroplasty. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a left total knee arthroplasty for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the coronavirus testing provided on September 1, 2021.
You asked the Plan to pay for the testing services. You say that you could not get on a plane unless you had a
test. The Plan denied your request. The Plan says this is not a covered benefit.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and
pre-approved care.
We looked at the file, and Medicare rules. The records show that the testing was provided for traveling
purposes. The records do not indicate the testing was related to signs, symptoms, or illness related to the
coronavirus.
Based on this information, we decided that Medicare rules for coverage of the testing services have not been
met. Therefore, we decided that the Plan does not have to pay for the coronavirus testing provided on
September 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Humira pen injection.
You asked the Plan to pre-approve Humira. You say that this is medically necessary. The Plan denied your
request. The Plan says the requested drug is considered self-administered. The Plan says self-administered
drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not
covered under Medicare 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 Humira pen injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) and endodontic therapy, molar tooth (excluding final restoration) (D3330) provided November 4, 2021.

You asked the Plan to pay for the limited oral exam and root canal. You say that this is a necessary tooth, and it doesn't make sense that the Plan doesn't provide any coverage to save the tooth. The Plan denied your request. The Plan says these services are not covered under your benefits.

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 limited oral evaluation - problem focused (D0140) and endodontic therapy, molar tooth (excluding final restoration) (D3330) provided November 4, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional home health visits.  You asked the Plan to pre-approve home health care. You say that you need assistance and do not have anyone to help you. The Plan denied your request. The Plan says the denial of authorization for additional home health visits is correct, because you do not meet criteria.  The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.  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 home health care. Our reviewer says that you do not meet Medicare criteria for additional home health visits beyond what the Plan already approved. Our physician reviewer found you do not have documented skilled nursing needs, so home health skilled nursing visits are not medically necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health care have not been met. Therefore, we decided that the Plan does not have to pre-approve additional home health visits.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90853) provided on March 3, 2021.

You asked the Plan to pay for psychotherapy services. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.

The Plan must follow Medicare rules. Medicare rules say that the CP will attempt to consult with the enrollee's attending or primary care physician.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of psychotherapy services have not been met. Specifically, the provided records do not document an attempt to consult with, nor a referral from, the enrollee's attending or primary care physician. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90853) provided on March 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for specialist office visits provided by a
network physician from July 8, 2021, to July 28, 2021.
You asked the Plan to waive the copayments for the specialist office visits. You say that you received nothing
on any of your visits except a look and comments on the progress of your operation. The Plan denied your
request. The Plan says you have been asked to pay 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 $35
copayment for services obtained from a specialist, or under certain circumstances, treatment by a nurse
practitioner or physician's assistant or other non-physician health care professionals in a specialist's office.
You have been asked to pay a $35 copayment for each of the specialist office visits. ($35 x 3 visits = $105).
The specialist office visits fall 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 copayments for specialist office visits provided
by a network physician from July 8, 2021, to July 28, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound provided by an in-network provider on September 27, 2021.

You asked the Plan to waive the copayment for the ultrasound. You say that the benefits say there is a $0 cost-share for diagnostic mammograms. You say you should not be responsible for the copayment. The Plan denied your request. The Plan says you have been asked to pay 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 an $80 copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in an in-network physician's office or at an in-network free-standing facility (such as a radiology center or medical clinic).

You have been asked to pay an $80 copayment for the ultrasound. The ultrasound falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The record shows you were charged for the ultrasound which was done in addition to the diagnostic mammogram. 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 by an in-network provider on September 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an urgent care visit provided on October 8, 2021.  

You asked the Plan to waive the copayment for the urgent care visit. You say that the services should be covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.  

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 $65 copayment for Urgently needed services.       

You have been asked to pay a $65 copayment for the urgent care 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 an urgent care visit provided on October 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the arthrocentesis, aspiration and/or injection, of a major joint or bursa (20610) provided on September 29, 2021.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.

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 $375 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges.

You have been asked to pay $242.59 for the Medicare-covered surgery provided at an outpatient hospital. This is the Plan's allowed amount for this service, which is less than the applicable copayment. 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, aspiration and/or injection, of a major joint or bursa (20610) provided on September 29, 2021.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency transport (A0428), and ground mileage (A0425) provided on January 6, 2021.  You asked the Plan to pay for the transportation services. You say that the services were provided to the enrollee prior to the start of their hospice election. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.   The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency transport (A0428), and ground mileage (A0425) provided on January 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the radiologic examination, hip, unilateral (73502) provided September 15, 2021.

You asked the Plan to waive the copayment for the diagnostic services. You say that please pay for the hip x-rays. They are preventative care tools to help you know how to hopefully prevent hip replacement surgery. The Plan denied your request. The Plan says the claim was processed with the correct cost share applied per the Evidence of Coverage.

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 50% coinsurance for basic radiological services in a freestanding radiological facility.

You have been asked to pay $25 for the diagnostic services. The diagnostic service 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 radiologic examination, hip, unilateral (73502) provided September 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee.
You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically
necessary. The Plan denied your request. The Plan says that there is no documentation provided to support the
expectation the enrollee will require a greater than 2 midnight stay.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
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 inpatient hospital services. Our
reviewer says that inpatient hospital services are not medically reasonable and necessary.
The patient was recently evaluated and shown to not have obstruction or infection or medical history that might
require inpatient hospital care that would likely cross 2 midnights. The procedure could be safely performed at
a lower level of care based on the provided documentation. Our physician reviewer found that the enrollee's
condition does not meet criteria for coverage for inpatient hospital 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 inpatient hospital services have not been met. Therefore, we decided that the
Plan does not have to pre-approve inpatient hospital services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for an automatic external defibrillator (AED) vest provided on October 9, 2021.  You asked the Plan to waive the coinsurance for the AED vest. You say that you were only able to wear the vest for one month and you should not have to pay for it to sit on your dresser. 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 durable medical equipment (DME) and supplies.     Item Allowed Amount 20% Coinsurance AED - July 26, 2021 $2,931.45 $586.29 AED - August 26, 2021 $2,931.45 $586.29 AED - September 26, 2021 $2,931.45 $586.29 Total:  $1,758.87  You have been asked to pay $1,758.87, which is 20% of the allowed amount for the AED vest. The AED vest falls 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 an automatic external defibrillator (AED) vest provided on October 9, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to waive the cost share for the office visit (99214) provided on April 5, 2021.  

You asked the Plan to waive the cost share. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the cost share has been applied correctly to the service provided.  

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 $0 copayment for physician services rendered at a primary care physician's office or at a specialist's office.   

The Plan says you must pay a $25.30 cost share for the office visit provided. Based on the Plan contract, however, you cannot be asked to pay more than a $0 copayment for physician services rendered by a primary care physician or specialist. Therefore, we decided that the Plan has to waive the cost share for the office visit (99214) provided on April 5, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services provided on January 20, 2021, to June 17, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for dental services. You say that you were unaware that the Plan provided dental coverage until you spoke with a Plan representative. Due to the nature of the procedure needed, you chose to go to a specialist. You also say that you were not aware that you would need a prior authorization to go to the provider until you began receiving bills. The Plan denied your request. The Plan says you must use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed services when the network is not available, out of area dialysis services and cases in which the Plan authorizes use of OON providers.

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. The records provided for review do not show that the services at issue were urgent or emergent. 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 dental services provided on January 20, 2021, to June 17, 2021, by an out-of-network (OON) provider.