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

We decided that the Plan does not have to waive the copayment for the radiologic examination, wrist (73110) application of short arm splint (forearm to hand) (29125) provided May 6, 2021.
You asked the Plan to waive the copayment for the diagnostic outpatient services. You say that this should be covered because the services were necessary because you broke your arm. The Plan denied your request. The Plan says the claim was processed with the correct copayment 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 $50 copayment for each standard x-ray and ultrasound and $550 copay for each outpatient hospital observation visit. You have been asked to pay $283.30 ($50 x-ray copay + $233 outpatient observation copayment) for the outpatient services. Since the amount is less than the copayment amount, you are responsible for the lesser amount. The diagnostic outpatient services fall within the Outpatient diagnostic tests and therapeutic services and supplies and Outpatient Hospital Observation 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, wrist (73110) application of short arm splint (forearm to hand) (29125) provided May 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213) rendered by the out-of-network (OON) provider on February 3, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99213) rendered by the out-of-network (OON) provider on February 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral - complete series of radiographic images (D0210), provided April 2, 2021, and extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140), extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210), immediate maxillary partial denture - resin base (including retentive/clasping materials, rests and teeth) (D5221), and immediate mandibular partial denture - resin base (including retentive/clasping materials, rests and teeth) (D5222) provided April 21, 2021.
You asked the Plan to pay for the intraoral x-rays, tooth extractions, immediate upper partial denture and immediate lower partial denture. You say that you thought the Plan would cover the services. The Plan denied your request. The Plan says these services are not covered under your benefits. You signed up for optional
supplemental dental benefits effective June 1, 2021. These supplemental benefits were not active at the time of the services at issue.
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 were not among those covered under this benefit at the time of service. Therefore, we decided that the Plan does not have to pay for the intraoral - complete series of radiographic images (D0210), provided April 2, 2021, and extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140), extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210), immediate maxillary partial denture - resin base (including retentive/clasping materials, rests and teeth) (D5221), and immediate mandibular partial denture - resin base (including retentive/clasping materials, rests and teeth) (D5222) provided April 21, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the outpatient physical therapy services
rendered from December 1, 2020, to December 31, 2020.

You asked the Plan to waive the cost sharing for these services. You say that you were told you didn't have to
stay within a specific network. The Plan denied your request. The Plan says the deductible was 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 there is $500 yearly deductible which applies to your covered medical services
and a 30% coinsurance for out-of-network physical therapy services.

Review of the file shows that you received physical therapy services from an out-of-network provider from
December 1, 2020, to December 31, 2020. The Plan has followed Medicare rules by clearly disclosing in the
contract that there is $500 yearly deductible which applies to your covered medical services. This cost sharing
is a contractual obligation that had not been met at the time these services were received on December 1, 2020,
to December 31, 2020. After applying the deductible charges for these services, your $500 deductible had been
met.

Given that the deductible charges did not cover the entire cost of the services, you have also been asked to pay
a 30% coinsurance on the remaining Medicare allowed amount for these services. This cost sharing is a
contractual obligation that 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 outpatient physical therapy
services rendered from December 1, 2020, to December 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377) for the enrollee.
You asked the Plan to pre-approve the additional accessories. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee has adequate upper extremity strength and is noted to be independent with eating.
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 additional accessories. Our reviewer says that the requested accessories are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal that the enrollee requires other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control,
etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.). The enrollee does not need to operate three or more powered seating actuators through the drive control, a separate display (i.e. for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The enrollee's strength and function in the bilateral upper extremities indicates that the enrollee can control any power options through their own individual switches. 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 additional accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient services provided on May 10, 2021, and the inpatient admission and services provided from May 14, 2021, to May 19, 2021.

You asked the Plan to waive the copayment for the outpatient and inpatient care. You say that there is an issue with your plan enrollment during these dates. The Plan denied your request. The Plan says that the copayments for these services were 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 $360 copayment for each of the first five days of an inpatient hospital stay, and a $360 copayment for surgical services provided in an outpatient hospital setting.

You have been asked to pay a $360 copayment for the outpatient procedure and a $1,800 for the five day hospital admission ($360 x 5 = $1,800). 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 outpatient services provided on May 10, 2021, and the inpatient admission and services provided from May 14, 2021, to May 19, 2021.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an auricular peripheral nerve stimulator.
You asked the Plan to pre-approve an auricular peripheral nerve stimulator. You say that the requested device is medically necessary for treatment of the enrollee's lower back and bilateral lower extremity pain. The Plan denied your request. The Plan says the requested service is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare rules say that auricular peripheral nerve stimulation will be denied as non-covered. This service is not a covered Medicare benefit because acupuncture for auricular stimulation does not meet the definition of reasonable and necessary Therefore, we decided that the Plan does not have to pre-approve an auricular peripheral nerve stimulator.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on April 21, 2021.
You asked the Plan to waive the copayment for lab services. You say that you have not been charged this copayment before. The Plan denied your request. The Plan says your copayment is correct.
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 lab services only when provided in an outpatient hospital facility.
You have been asked to pay a $35 copayment for lab services. Lab 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 copayment for laboratory services provided on April 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 panel rendered on May 16, 2019.

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 testing is not covered.

The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. 

We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479.

Therefore, we decided that the Plan does not have to pay for the Guardant360 panel rendered on May 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the infusion pump rendered on June 4, 2021.
You asked the Plan to waive the coinsurance for these services. You say that you should not be held liable. The Plan denied your request. The Plan says the coinsurance 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 20% of the plan allowed amount for Medicare-covered durable medical equipment.
Review of the file shows that you received an infusion pump on June 4, 2021. You have been asked to pay 20% of the plan allowed amount for these services, for a total of $72.99. These services fall within the Medicare-covered durable medical equipment 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 the infusion pump rendered on June 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy (90832) rendered by the out-of-network (OON) provider on September 4, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the psychotherapy (90832) rendered by the out-of-network (OON) provider on September 4, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance service, basic life support, emergency transport (A0429) provided April 25, 2021.
You asked the Plan to waive the copayment for the emergency ambulance transport. You say that if you were taken to the hospital you believe the copayment would be waived. 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 $240 copayment for each one-way Medicare-covered ground ambulance trip. You have been asked to pay a $240 copayment for the emergency ambulance transport. The emergency ambulance transport falls within the Ambulance services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance service, basic life support, emergency transport (A0429) provided April 25, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan rendered on April 13,
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 separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically
appropriate NCCI modifier is used to report the reason it should be paid as well.
The provider submitted a claim for procedure codes 70450 (CT head/brain) and 70496 (computed tomography
angiography of the head). Code 70450 is a column II code with a modifier indicator of 1 when billed with
column I code 70496. Code 70450 was not billed with an appropriate modifier to allow for separate payment.
Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan rendered on
April 13, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa bilateral knee injections.

You asked the Plan to pre-approve Hyaluronan or derivative, euflexxa, for intra-articular injection, per dose (J7323). You say that you would like to treat the enrollee with this drug. The Plan denied your request. The Plan says the enrollee has not first tried and failed Durolane, Gelsyn-3 and Synvisc/Synvisc-One.

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 Hyaluronan or derivative, euflexxa, for intra-articular injection, per dose (J7323). Our reviewer says that the drug is not medically reasonable or necessary. Our physician reviewer found there is no documentation provided indicating that the Plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Hyaluronan or derivative, euflexxa, for intra-articular injection, per dose (J7323) have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa bilateral knee injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for cardiology office visits provided on January 26, 2021 and January 27, 2021.
You asked the Plan to waive the copayments for specialist visits. You say that you feel these should have been covered under your hospital visit. The Plan denied your request. The Plan says the copayment amounts you are being charged are correct.
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 $40 copayment for each specialist visit in a hospital outpatient department. This hospital stay was for outpatient observation; therefore, the specialist copayment applies to each of these visits. There were 2 visits, resulting in a total copayment amount of $80. You have been asked to pay $40 copayment for each specialist visit. Specialist 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 cardiology office visits provided on January 26, 2021 and January 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve twenty (20) chiropractor services to be provided by an out-of-network provider.

You asked the Plan to pre-approve the out-of-network chiropractor services. You say that the services are necessary. The Plan denied your request. The Plan says the services can be provided by 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve twenty (20) chiropractor services to be provided by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the respiratory viral panel of 3-5 targets (87631) and the individual genetic viral pathogen testing for 11 other microbes (87496, 87498, 87532, 87541, 87640, and 87798 x6) provided on January 4, 2021.
You asked the Plan to pay for the respiratory pathogen testing. You say that this testing was ordered and is medically necessary. The Plan denied your request. The Plan says this is not billed correctly, and testing for more than six viral pathogens is not covered.
The Plan must follow Medicare rules. Medicare rules say that coverage for viral respiratory pathogen testing is limited to panels for 3-5 targets, when ordered in a facility that cares for critically ill patients or ordered by an infectious disease specialist. In this case, the code 87631 is coverable as it describes testing for 3-5 targets; however, this was ordered for a
patient in an assisted living facility by a doctor of Internal Medicine. This is not a setting where critically ill
patients can be treated and was not ordered by an infectious disease specialist. The remaining 11 individual
testing targets clearly exceed the 5-target maximum allowed by Medicare rules. As such, this testing is not
covered. Therefore, we decided that the Plan does not have to pay for the respiratory viral panel of 3-5 targets
(87631) and the individual genetic viral pathogen testing for 11 other microbes (87496, 87498, 87532, 87541,
87640, and 87798 x6) provided on January 4, 2021.