Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an unspecified preventive procedure (D1999) provided on May 4, 2021.
You asked the Plan to pay for an unspecified preventive procedure. You say that the provider's office submitted prior authorization to the Plan before the services were completed and the Plan approved the services. The Plan denied your request. The Plan says a separate fee for infection control is not covered under the member's plan. The charge for infection control is included in the fee for the services being performed.
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 unspecified preventative procedure is not a covered benefit of Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for an unspecified preventive procedure (D1999) provided on May 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the endoscopy-cystoscopy procedure you had at an ambulatory surgery center on June 16, 2021.
You asked the Plan to waive the copayment for the endoscopy-cystoscopy procedure. You say that this copayment is more than you can afford. 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 $245 copayment for outpatient surgery and services at an ambulatory surgery center. You have been asked to pay a $245 copayment for the endoscopy-cystoscopy procedure. The endoscopy-cystoscopy procedure falls within the outpatient surgery and services at an ambulatory surgery center 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 endoscopy-cystoscopy procedure you had at an ambulatory surgery center on June 16, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the culture services coded 87150 provided on October 14, 2020.
You asked the Plan to pay for the culture services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 87150 is culture, typing; identification by nucleic acid (DNA or RNA) probe, amplified probe technique, per culture or isolate, each organism probed.
We find that CPT code 87150 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage of the culture services have not been met. Therefore, we decided that the Plan does not have to pay for the culture services coded 87150 provided on October 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Freestyle Libre 2 sensors for the enrollee.
You asked the Plan to pre-approve the sensors. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that the enrollee does not meet criteria for coverage.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this
information, we decided that Medicare rules for coverage of the sensors have not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle Libre 2 sensors for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel-One (J7326).
You asked the Plan to pre-approve Gel-One. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says the enrollee has not tried and failed the required drugs, Monovisc and Orthovisc.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Gel-One. Our reviewer says that Gel-One is not medically necessary. Our physician reviewer found the provided documentation does not indicate that the enrollee has trialed viscosupplemental treatments such as Orthovisc and Monovisc. The documentation does not outline contraindications or reasons these medications were not considered or that the Plan's additional required drug would likely be less effective and/or likely have adverse effects for the enrollee. Without the support of the documentation, Gel-One is not approved, as step criteria have not been met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gel-One have not been met. Specifically, the file shows that the enrollee has not tried and failed the required drugs. Therefore, we decided that the Plan does not have to pre-approve Gel-One (J7326).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion services (99601, 99602) provided February 19, 2021 to February 20, 2021.
You asked the Plan to pay for the home infusion services. You say that the services were medically necessary. The Plan denied your request. The Plan says the billed codes are not eligible for Medicare payment.
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 codes 99601, & 99602 are not supported in the medical record. Specifically, per the National Physician Fee Schedule, the code billed has a status of "I" and is not eligible for Medicare payment. Based on this information, we decided that Medicare rules for coverage of the home infusion services have not been met. Therefore, we decided that the Plan does not have to pay for home infusion services (99601, 99602) provided February 19, 2021 to February 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre 2 Sensor for use with a continuous glucose monitor (CGM).
You asked the Plan to pre-approve the Freestyle Libre 2 Sensor for use with a CGM. You say that you are adjusting the enrollee's insulin dose. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not require frequent self-adjustment of insulin dosage based on the blood glucose testing results. The documentation indicates that the enrollee is on a fixed dose of insulin that the practitioner adjusts. Based on this information, we decided that Medicare rules for coverage of the Freestyle Libre 2 Sensor for use with a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 2 Sensor for use with a continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the triamcinolone acetonide injection (J3301), arthrocentesis, aspiration and/or injection of a major joint or bursa (20610), and the office visit (99203) rendered by the out-of-network (OON) provider on June 24, 2020.
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 triamcinolone acetonide injection (J3301), arthrocentesis, aspiration and/or injection of a major joint or bursa (20610), and the office visit (99203) rendered by the out-of-network (OON) provider on June 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on June 1, 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.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on June 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for progressive lenses (V2781) and anti-reflective coating 
(V2750) provided on March 23, 2021. 
 
You asked the Plan to pay for progressive lenses and anti-reflective coating. You say that you were denied 
these charges twice. You also say you were informed that you would need glasses to bring your eyes up to 
standard. You paid your part of the cost and would appreciate the Plan covering the remainder due. The Plan 
denied your request. The Plan says eyeglasses are a covered benefit after cataract surgery; however, upgrades 
are not covered. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan contract says that covered eyeglasses after cataract surgery includes standard frames and 
lenses as defined by Medicare. Upgrades are not covered including deluxe frames, tinting, progressive lenses, 
or anti-reflective coating. 
 
We looked at the file and the Plan's rules. The records show that the Plan paid the allowed amount for your 
eyeglasses. The progressive lenses and anti-reflective coating which you purchased are not covered benefits of 
Medicare or the Plan. Based on this information, we decided that the Plan's rules for coverage of progressive 
lenses and anti-reflective coating have not been met. Therefore, we decided that the Plan does not have to pay 
for progressive lenses (V2781) and anti-reflective coating (V2750) provided on March 23, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for telephone evaluation and management services (99442) 
provided on February 4, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the telehealth visit. You say that please review the attached medical 
documentation to show the medical necessity of the services. The Plan denied your request. The Plan says 
enrollee's must receive their telehealth services from an in-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 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 telephone evaluation and management services 
(99442) provided on February 4, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan has to waive the copayment for wound debridement billed by the physician on 
February 12, 2021. 
 
You asked the Plan to waive the copayment for wound debridement. You say that this visit was approved, and 
you do not owe the bill. You say that you do not have the finances to pay and the bill should be taken off your 
account. The Plan denied your request. The Plan says that the copayment applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees pay $0 per visit for all covered physician services. 
 
The Plan says you must pay a $150 copayment for a facility fee for the wound debridement. Based on the Plan 
contract, however, you cannot be asked to pay more than $0 for the wound debridement. A physician cannot 
bill an outpatient hospital facility fee. The wound debridement billed by the doctor would be considered a 
physician service that applies the $0 copayment. Therefore, we decided that the Plan has to waive the 
copayment for wound debridement billed by the physician on February 12, 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce the copayments for four separate emergency 
ambulance transports (A0425, A0427) provided from March 1, 2021, to March 10, 2021. 
 
You asked the Plan to waive or reduce the copayments for the ambulance services. You say that you needed to 
go to the hospital several times before you were able to get the care you needed. The bills for your 
transportation are high and you are struggling to pay them; you would appreciate assistance. The Plan denied 
your request. The Plan says these claims were processed correctly and in accordance with your contract. 
 
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 $300 
copayment for each Medicare-covered one-way ambulance transport.  

You have been asked to pay a $300 copayment for each ambulance trip. 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 or 
reduce the copayments for four separate emergency ambulance transports (A0425, A0427) provided from 
March 1, 2021, to March 10, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered by the out-of-network (OON) provider on June 16, 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 laboratory services rendered by the out-of-network (OON) provider on
June 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the ski passes purchased on July 21, 2021.
You asked the Plan to reimburse you for the ski passes. You say that a plan representative advised that the season ski pass would be eligible for coverage under the Benefit Bank fitness membership. You say that skiing helps with your depression and anxiety. You also say that this benefit was the only reason you signed up for this plan. The Plan denied your request. The Plan says ski passes are not an approvable Fitness Membership.
Medicare generally does not cover fitness memberships. However, the Plan offers a supplemental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the ski passes have not been met. Specifically, the file shows that you were advised that the code that the Ski Lodge uses does not match the approved codes for fitness memberships. Therefore, we decided that the Plan does not have to reimburse you for the ski passes purchased on July 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an implant maintenance procedure (D6080) provided by a 
participating provider on July 1, 2021. 
 
You asked the Plan to pay for an implant maintenance procedure. You say that you think that the Plan should 
pay 50% of this. The Plan denied your request. The Plan says this is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, 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 an 
implant maintenance procedure (D6080) provided by a participating provider on July 1, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on May 7, 2021.
You asked the Plan to pay for physical therapy services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 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 physical therapy services provided on May 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that you need these supplies to clean your mother from incontinent issues. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies..
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapy services (97110) provided July 9, 2020.
You asked the Plan to pay for the therapy services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the procedure 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 97110 is not supported in the medical record. Specifically, the procedure was performed in the home by a therapy assistant. There is a more appropriate CPT code to describe this service (G0158). Based on this information, we decided that Medicare rules for coverage of the therapy services have not been met. Therefore, we decided that the Plan does not have to pay for therapy services (97110) provided July 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you cannot walk without orthotics. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.