Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for specialists office visits (99203), and an x-ray examination of the wrist (73110). We also decided that the Plan does not have to waive the coinsurance for cast supplies, long arm cast, and a wrist hand orthosis (L3908, Q4006) rendered from December 31, 2020, to February 15, 2021.  You asked the Plan to waive the copayment for specialist office visits and an x-ray examination of the wrist. You also asked the Plan to waive the coinsurance for cast supplies, long arm cast, and a wrist hand orthosis. You say that you have Medicaid, and the member was advised that the provider did not accept Medicaid but was not informed of any copayments whatsoever until the final visit. You also say that you cannot pay this amount in any way. The Plan denied your request. The Plan says you were charged the correct cost sharing amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that enrollees must pay a $35 copayment for each visit to a specialty physician office. The Plan contract also says that enrollees must pay a $35 copayment for each outpatient x-ray, diagnostic procedure and test. The Plan contract also says that enrollees must pay 20% coinsurance of the Medicare-allowable amount for each Medicare covered item for durable medical equipment.   You have been asked to pay a $35 copayment for each specialist office visit. A specialist office visit falls under the physician/practitioner services, including doctor's office visits benefit category. You have also been asked to pay a $35 copayment for an x-ray examination of the wrist. X-ray examinations of the wrist fall under the  outpatient diagnostic tests and therapeutic services and supplies (PA) benefit category.   You have also been asked to pay $6.07 coinsurance, which is 20% of the allowed amount for cast supplies, long arm cast provided on December 31, 2020 ($30.33 allowed amount x 20% coinsurance = $6.07).  You have also been asked to pay $7.69 coinsurance, which is 20% of the allowed amount for a wrist hand orthosis provided on January 22, 2021 ($38.44 allowed amount x 20% coinsurance = $7.69). Cast supplies, long arm cast, and a wrist hand orthosis fall within the durable medical equipment (DME) and related supplies (PA) 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 specialists office visits (99203), and an x-ray examination of the wrist (73110). We also decided that the Plan does not have to waive the coinsurance for cast supplies, long arm cast, and a wrist hand orthosis (L3908, Q4006) rendered from December 31, 2020, to February 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the breast biopsy provided on March 18, 2021.  You asked the Plan to pay for the biopsy. The Plan denied your request. The Plan says this is not a covered screening test.  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 breast biopsy provided on March 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing services (G0482) provided on August 10, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service is not supported.  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 G0482 is "Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed".  We find that CPT code G0482 is not supported in the medical record. Specifically, the records do not show that 15-21 drug classes were tested on the date of service in question. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services (G0482) provided on August 10, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services provided on May 7, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed incorrectly.  The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. The two exceptions are for enrollees who are registered hospital inpatients or outpatients, in which case, the inpatient or outpatient hospital POS code would be reported regardless of where the face-to-face service takes place.   We looked at the file and Medicare rules. The records show that the enrollee in this case was an inpatient when the services in question were provided. This means that it is inappropriate to bill POS 11 for these services. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services provided on May 7, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an emergency room visit (99281) provided on November 19, 2021.  You asked the Plan to waive the copayment for the emergency room 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 $90 copayment for Emergency care.   You have been asked to pay a $56.76 copayment for an emergency room visit, which is less than the $90 stated in the Plan's contract. Emergency room visits fall within the Emergency care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an emergency room visit (99281) provided on November 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional sclerotherapy sessions (36471).  You asked the Plan to pre-approve additional sclerotherapy sessions. You say that the requested services are a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the requested services have not been met.  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 additional sclerotherapy sessions. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that for further sclerotherapy to be approved there has to be demonstration of successful elimination of truncal reflux. According to the case record, the Plan has approved endovenous ablation and a single session of sclerotherapy performed at the time of the ablation. As these procedures have not yet been performed, there has not been an opportunity to reassess the enrollee and determine if more procedures are reasonable or warranted.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional sclerotherapy sessions have not been met. Therefore, we decided that the Plan does not have to pre-approve additional sclerotherapy sessions (36471).
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ambulance service, basic life support, non-emergency transport (A0428) and ground mileage (A0425) provided October 29, 2021.  You asked the Plan to waive the copayment for the non-emergency ambulance service. You say that the transport was arranged by the hospital. The Plan denied your request. The Plan says the copayment was 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 $290 copayment per date of service regardless of the number of trips by ground ambulance.  You have been asked to pay $252.90 for the non-emergency ambulance service. The non-emergency ambulance service falls within the Ambulance services 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 ambulance service, basic life support, non-emergency transport (A0428) and ground mileage (A0425) provided October 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) provided September 9, 2021, and the endodontic therapy, molar tooth (excluding final restoration) (D3330), retreatment of previous root canal therapy - premolar (D3347), treatment of root canal obstruction; non-surgical access (D3331), and post removal (D2955) provided September 16, 2021.  You asked the Plan to pay for the limited oral exam, the root canal, retreatment of previous root canal, treatment of root canal obstruction and post removal. You say that you were not aware the provider was not in the network. The Plan denied your request. The Plan says these services are not covered when provided OON.  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 covers the limited oral exam, the root canal, retreatment of previous root canal, treatment of root canal obstruction and post removal when the services are rendered by a Participating Provider. We looked at the file and Medicare rules. 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 to be performed by this provider. We found no exception that would require the Plan to pay for these items/services. Based on this information, we decided that the Plan's rules for coverage of the limited oral exam, the root canal, retreatment of previous root canal, treatment of root canal obstruction and post removal have not been met. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) provided September 9, 2021, and the endodontic therapy, molar tooth (excluding final restoration) (D3330), retreatment of previous root canal therapy - premolar (D3347), treatment of root canal obstruction; non-surgical access (D3331), and post removal (D2955) provided September 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.  You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your request. The Plan says medical studies haven't proven that the device(s) is helpful for treatment of the enrollee's health problem.  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 service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed. 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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the below-knee alignable system component (L5910) for an approved below the knee preparatory prosthesis (L5530).  You asked the Plan to pre-approve the L5910 prosthetic component. You say that the L5910 component is crucial in order to provide maximum stability with use of the prosthetic. The Plan denied your request. The Plan says the L5910 component is not shown to be reasonable and 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 pre-approve the L5910 prosthetic component. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested component of the prosthesis exceeds the medical need as it cannot be used with the approved prosthesis coded L5530.  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 L5910 prosthetic component have not been met. Therefore, we decided that the Plan does not have to pre-approve the below-knee alignable system component (L5910) for an approved below the knee preparatory prosthesis (L5530).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve excision of excessive skin (15830, 15847).  You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is 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 pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that in this case, the record indicates that the enrollee has undergone bariatric surgery. The provided record does indicate the presence of intertrigo refractory to standard conservative treatment or evidence of impaired function.  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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve excision of excessive skin (15830, 15847).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the cost sharing for the three duplex scans you had on November 9, 2020, November 16, 2020, and November 23, 2020.  You asked the Plan to waive the cost sharing for the duplex scans. You say that these were follow-ups from surgery you had, so there should be no charge.  You also say that you were not asked for a copayment at the time of these services. The Plan denied your request. The Plan says you were charged this cost sharing correctly.  The Plan says that for the first two duplex scans you had, the allowed amount ($115.92) is less than your copayment obligation, so you are responsible for the full allowed amount for those services.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 copayment for each radiological diagnostic service. The rules also say that when a surgery is performed, certain services performed in the post-surgery period are included in the price of the surgery itself.  This is called the global surgical package. However, diagnostic tests and procedures (including diagnostic radiological procedures) are not included in the global surgical package and are separately payable.  You have been asked to pay a $150 copayment for each of the duplex scans. The duplex scans fall within the radiological diagnostic service benefit category. As noted above, radiological diagnostic services, even if done in the post-surgical period, can have separate cost sharing applied. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost sharing for the three duplex scans you had on November 9, 2020, November 16, 2020, and November 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for radiation treatment services provided on September 23, 2021.  You asked the Plan to waive the coinsurance for the radiation treatment services. You say that the provider informed you that they would waive the member responsibility for the charges. 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 therapeutic services, such as radiation treatment.  You have been asked to pay $53.02, which is 20% of the allowed amount for the radiation treatment services ($265.08 allowed amount x 20% coinsurance = $53.02). The radiation treatment 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 radiation treatment services provided on September 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Freestyle Libre 2 reader.  You asked the Plan to pre-approve a Freestyle Libre 2 reader. You say that this is medically necessary. 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 use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre 2 reader have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 2 reader.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for a wrist hand orthosis (27096) provided on July 13, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for a wrist hand orthosis. You say that the enrollee was unaware that prior authorization was required for services to be rendered by the out-of-network provider and you request that the Plan authorize a one-time exception retro-authorization of these services to ensure that the enrollee does not incur an undue financial burden. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.  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 a wrist hand orthosis (27096) provided on July 13, 2021, by an out-of-network (OON) provider.