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

 We decided that the Plan does not have to pre-approve Enbrel SureClick.  You asked the Plan to pre-approve the Enbrel SureClick. You say that the enrollee has active rheumatoid arthritis and has failed treatment with Xeljanz, Humira, Rinvoq, and Plaquenil for control of her symptoms. The Plan denied your request. The Plan says the requested drug is not covered under the enrollee's medical plan.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Enbrel SureClick.   Benefits for the Enbrel SureClick 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a cataract surgery provided on June 14, 2021.
You asked the Plan to waive the copayment for a cataract surgery. You say that you cannot afford the charges. 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 $260 copayment for outpatient surgery, including services provided at ambulatory surgical centers. You have been asked to pay a $260 copayment for a cataract surgery. A cataract surgery falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 a cataract surgery provided on June 14, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an osseous surgery provided by an out-of-network provider on August 17, 2021.
You asked the Plan to pay for an osseous surgery. You say that you would like the Plan to pay for this dental work. The Plan denied your request. The Plan says an osseous surgery 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 osseous surgery provided by an out-of-network provider on August 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the catheter placement in a coronary artery provided on July 22, 2021.
You asked the Plan to waive the copayment for the catheter placement in a coronary artery. You say that you were told that you would only owe a $100 copayment. 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 $195 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities. You received the catheter placement in a coronary artery at an outpatient hospital facility on July 22, 2021.
Because services were rendered in an outpatient hospital facility, you are responsible to pay the $195 copayment. You have been asked to pay a $195 copayment for the catheter placement in a coronary artery. The catheter placement in a coronary artery falls within the outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers 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 catheter placement in a coronary artery provided on July 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for therapeutic radiology services provided on June 28, 2021.  You asked the Plan to waive the coinsurance for therapeutic radiology services. You say that you disagree with the out-of-network charges. 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 20% coinsurance for therapeutic radiology services.  You received therapeutic radiology services on June 28, 2021. The total allowed amount is $443.73 and 20% of that is $88.75.    You have been asked to pay the total coinsurance amount of $88.75 for therapeutic radiology services. Therapeutic radiology services fall 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 coinsurance for therapeutic radiology services provided on June 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the cataract removal (66984) and astigmatism correcting function (V2787) provided on July 26, 2021 and August 2, 2021.

You asked the Plan to waive the copayment for the cataract surgery services. You say that you would like these claims to be re-processed, and you cannot afford these extra out-of-pocket expenses. The Plan denied your request. The Plan says outpatient surgery services require a $175 copayment. These claims were processed correctly, and your cost-sharing was assessed 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 $175 copayment for outpatient surgery provided in an ambulatory surgical center. 

You have been asked to pay a $175 copayment for each of the two days you received cataract surgery services. 

These surgeries were provided in an outpatient ambulatory surgical center setting. 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 cataract removal (66984) and astigmatism correcting function (V2787) provided on July 26, 2021 and August 2, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on May 10, 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 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, a pharmacogenetics panel, 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 rendered on May 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99214, 99204) routine electrocardiogram (93000) annual wellness visit (G0439) provided on October 8, 2020 to May 10, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the office visits. You say that date of service 10/08/2020 was paid $135-98 due to PX. Date of service 11/20/2020 was not received and dates of service 01/25/2021 and 05/10/2021 were denied due to no authorization. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 outpatient office visit (99214, 99204) routine electrocardiogram (93000) annual wellness visit (G0439) provided on October 8, 2020 to May 10, 2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Kerendia tablets.

You asked the Plan to pre-approve the Kerendia tablets. The Plan denied your request. The Plan says this drug is a non-covered benefit under the enrollee's plan.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Kerendia tablets.

Benefits for the Kerendia tablets may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) provided on August 13, 2021.

You asked the Plan to pay for the first intraoral periapical x-ray. You say that you changed insurance plans in April 2021 and were not aware that your dental benefits would revert back to January 2021 and deny your claim. The Plan denied your request. The Plan says this service is not a covered expense under your dental plan.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) provided on August 13, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) provided on July 31, 2021.   You asked the Plan to pay for the ambulance service. You say that previous charges for this type of service have always been covered. You say that there was no indication this would not be covered. You say that you were not made aware that it would not be covered by insurance. You also say that you would like for the plan to cover and pay for these charges. The Plan denied your request. The Plan says there was no transport provided on the date of service in this case. The Plan says that without transport, there is no payable service. The Plan also says that previous ambulance claims paid as transport to a facility was provided.  The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.   The ambulance company did not provide transport services on July 31, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) provided on July 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for deluxe frames (V2025), and progressive lenses (V2781) received on August 3, 2021.
You asked the Plan to pay for deluxe frames (V2025), and progressive lenses. You say that you want the Plan to pay for these items. The Plan denied your request. The Plan says the items were received from a non-participating provider and 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. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of deluxe frames (V2025), and progressive lenses have not been met. Specifically, the items were received from an out-of-network vendor and are not covered. Therefore, we decided that the Plan does not have to pay for deluxe frames (V2025), and progressive lenses (V2781) received on August 3, 2021
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the computed tomography (CT) scan of the thorax (71250) provided on June 16, 2021.  You asked the Plan to pay for the CT scan of the thorax. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says this claim was not billed with an appropriate modifier as required by Medicare rules.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 71250 is a column II code to column I code 71275. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the thorax (71250) provided on June 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement services (97598) provided on June 24, 2021.
You asked the Plan to pay for the debridement services. You say that these services should be covered based on the medical documentation provided. The Plan denied your request. The Plan says an appropriate modifier was not billed with this claim as required by Medicare rules.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 97598 is a column II code to column I code 11042. This claim has not been billed with an appropriate modifier to
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the debridement services (97598) provided on June 24, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for medication assisted treatment, methadone (G2067) alcohol and/or drug services (H0020) provided on February 15, 2021 to April 30, 2021 by an out-of-network (OON) provider.  

You asked the Plan to pay for the substance abuse services. You say that you have obtained an authorization starting from June 6th, however he had previous services between February 10, 2021 and June 6, 2021. You are looking for these services to be reconsidered for payment. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.  

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 medication assisted treatment, methadone (G2067) alcohol and/or drug services (H0020) provided on February 15, 2021 to April 30, 2021 by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; limited (76642) provided July 28, 2021.
You asked the Plan to waive the copayment for the breast ultrasound. You say that you feel this should be processed as a breast cancer screening with a $0 copayment. The Plan denied your request. The Plan says the diagnostic copayment has been 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 a $100 copayment for a Medicare-covered ultrasound. You have been asked to pay a $97.48 copayment for the breast ultrasound. The breast ultrasound falls within the Outpatient diagnostic tests and therapeutic services and supplies benefit category.
This means that you have been asked to pay less than or equal to 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, breast, unilateral, real time with image documentation, including axilla when performed; limited (76642) provided July 28, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the life alert.  

You asked the Plan to pre-approve the life alert. You say that the item is medically necessary. The Plan denied your request. The Plan says this item is not primarily medical in nature.  

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 the life alert.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for specialist services provided on August 25, 2021.  

You asked the Plan to waive the copayment for specialist services. You say that you were in hospital due to a surgical procedure and did not go to a doctors office to receive the specialist services. 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 $40 copayment for specialist services furnished in a hospital outpatient department.   

The record shows that you received specialist services during an outpatient hospital stay on August 25, 2021. Therefore, you are responsible to pay the $40 copayment.   

You have been asked to pay a $40 copayment for specialist services. Specialist services 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 copayment for specialist services provided on August 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the dental cleaning (D1110), bitewing x-rays (D0274) and periodic oral exam (D0120) provided on May 10, 2021.  

You asked the Plan to pay for the dental services. You say that you are entitled to two cleanings and two exams per year, so these services should be covered. The Plan denied your request. The Plan says the provider in this case is not part of the Plan's dental network. Out-of-network dental care 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. The Plan does not cover supplemental dental services obtained from vendors outside the Plan's dental vendor network.   

Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan does not cover out-of-network dental care. Documentation shows that the provider in this case is not part of the Plan's specified dental vendor network. Therefore, we decided that the Plan does not have to pay for the dental cleaning (D1110), bitewing x-rays (D0274) and periodic oral exam (D0120) provided on May 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Latera nasal implant (30468).
You asked the Plan to pre-approve Latera nasal implant. You say that this is medically necessary for the
enrollee's condition. The Plan denied your request. The Plan says the requested procedure is considered
experimental/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 Latera nasal implant. Our reviewer says
that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the record indicates that the enrollee has obstructive sleep apnea. The record
indicates that other causes of nasal obstruction are being treated. The record provided does not establish the
medical necessity and reasonableness, as defined by Medicare rules, of the requested service, at this time. The
elements of the coverage criteria are not satisfied. The requested service is not recommended.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Latera nasal implant have not been met.
Therefore, we decided that the Plan does not have to pre-approve Latera nasal implant (30468).