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

We decided that the Plan does not have to waive the deductible for laser surgery performed on July 8, 2021.
You asked the Plan to waive the deductible for the laser surgery. You say that this was a cancer removal and should be covered. The Plan denied your request. The Plan says the correct amount was applied to your deductible.
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 $198 deductible which applies to covered services, including the laser surgery. The item or service you asked the Plan to waive the deductible for falls within the Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $198 deductible which applies to covered services, including laser surgery. This cost sharing is a contractual obligation that had not been met at the time the laser surgery was received on July 8, 2021. Therefore, we decided that the Plan does not have to waive the deductible for laser surgery performed on July 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided on June 15, 2021.
You asked the Plan to waive the copayment for a CT scan. You say that the CT scan was part of a follow-up exam so you should not be responsible for 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 $150 copayment for CT scans. You received a CT scan on June 15, 2021. CT scans are not included in follow-up visits and are subject to cost-sharing charges. Therefore, you are responsible to pay the $150 copayment. You have been asked to pay a $150 copayment for a CT scan. A CT scan falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a CT scan provided on June 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the lenses provided on September 17, 2021.
You asked the Plan to pay for the lenses. You say that you were not aware you could only go to the eye doctor every two years. You say that you only got new lenses and were told insurance would pay up to $300. The Plan denied your request. The Plan says these services have a limit of one every two plan years.
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 only covers these services once every two years. We looked at the file and the Plan's rules. Specifically, the Plan paid for the lenses provided on October 8, 2020, which exhausted your benefit. Based on this information, we decided that the Plan's rules for coverage of the lenses have not been met. Therefore, we decided that the Plan does not have to pay for the lenses provided on September 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the arthrocentesis rendered on June 22, 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 procedure codes J7328 and 20611 are 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 J7328 is hyaluronan or derivative, gelsyn-3, for intra-articular injection, 0.1 mg. The definition of code 20611 is arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting. We find that CPT codes J7328 and 20611 are not supported in the medical record. Specifically, there is no documentation of hyaluronan or derivative for intra-articular injection, .1 mg, to support code J7328. There is no documentation of arthrocentesis, aspiration and/or injection, to support code 20611.
Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the arthrocentesis rendered on June 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (87486, 87496, 87498, 87541, 87581, 87631, 87640, 87798) provided on August 25, 2020.
You asked the Plan to pay for laboratory services. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).
We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (87486, 87496, 87498, 87541, 87581, 87631, 87640, 87798) provided on August 25, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network outpatient mental health care provided on July 15, 2021.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says you did not have prior authorization for out of network care.
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 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 out of network outpatient mental health care provided on July 15, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services provided on April 6, 2021.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says no separate payment is made.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We find that CPT code 99100 and 99140 are bundled codes. When these services are covered, payment for them is subsumed by the payment for the services to which they are incident. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services provided on April 6, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a respiratory pathogen screening panel (87496, 87532, 87541, 87634, 97640, 97798) provided on June 8, 2021.
You asked the Plan to pay for a respiratory pathogen screening panel. You say that this should be covered. The Plan denied your request. The Plan says this was not medically necessary.
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 respiratory pathogen screening panel, was requested 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 a respiratory pathogen screening panel (87496, 87532, 87541, 87634, 97640, 97798) provided on June 8, 2021
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for a diagnostic mammogram provided on August 20, 2021.
You asked the Plan to waive the deductible for a diagnostic mammogram. You say that you disagree with the charges because you were diagnosed with breast cancer last year and never paid for a mammogram before. 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. Your contract with the Plan says that there is a $750 deductible for diagnostic procedures and tests. The medical records show that you received a diagnostic mammogram on August 20, 2021. The record shows that you had paid $0 toward the $750 deductible prior to receiving the services. Therefore, you are responsible to pay the allowed amount of $125.08. The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient
diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible for outpatient diagnostic tests and therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time a diagnostic mammogram was received on August 20, 2021. Therefore, we decided that the Plan does not have to waive the deductible for a diagnostic mammogram provided on August 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for Computed tomographic angiography, heart, coronary arteries and bypass grafts (when present), with contrast material, including 3d image postprocessing (75574) provided on April 20, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the diagnostic service. You say that please review the attached medical records to support the services and reprocess your claim 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 Computed tomographic angiography, heart, coronary arteries and bypass grafts (when present), with contrast material, including 3d image postprocessing (75574) provided on April 20, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the ConfirmMDx testing rendered on July 15, 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 criteria for coverage are not met.
The Plan must follow Medicare rules. The rules say that ConfirmMDx testing is covered for males with previous negative prostate biopsy who are being considered for repeat biopsy. We looked at the file and Medicare rules. There is no documentation of a prior prostate biopsy result for the enrollee. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the ConfirmMDx testing rendered on July 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care provided July 28, 2020 to August 2, 2020 by a non-participating provider.
You asked the Plan to pay for the hospital care. You say that the claim was denied for timely filing in error. The timeframe to submit health claims has been extended to 60 days after the announcement of the end of the current national emergency. The Plan denied your request. The Plan says the claim was filed past the timely filing limitation.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the hospital care was not filed until August 20, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care provided July 28, 2020 to August 2, 2020 by a non-participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0673, E0675) provided to the enrollee on June 28, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this was billed with an inappropriate place of service.
The Plan must follow Medicare rules. The Plan must follow Medicare rules. Medicare rules say that a pneumatic compression device (E0675) to treat peripheral artery disease is not eligible for reimbursement. The requested device (E0675) and accessory (E0673) are statutorily not covered by Medicare. 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 a pneumatic compression device (E0673, E0675) provided to the enrollee on June 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for out of network physician services provided on September 21, 2021.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says you did not have prior authorization for out of network care.
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 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 out of network physician services provided on September 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for out of network physician services provided on August 28, 2020.
You asked the Plan to pay for out of network services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says you did not have prior authorization for out of network care.
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 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 out of network physician services provided on August 28, 2020.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to waive the deductible for the nasal endoscopy and impacted cerumen removal you received from an otolaryngologist on August 4, 2021.
You asked the Plan to waive the deductible for the nasal endoscopy and impacted cerumen removal. You say that your insurance should cover these services. The Plan denied your request. The Plan says that you were charged this deductible 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 you have a $500 deductible that only applies to certain services. The deductible applies to the following: inpatient hospital care, inpatient mental health care, x-rays, radiological diagnostic services, ambulatory surgery center services, outpatient hospital services, and outpatient hospital observation services.
The services you received (i.e., the nasal endoscopy and the impacted cerumen removal) are considered surgical services. However, these services occurred in the otolaryngologist's office, not in an outpatient hospital or ambulatory surgery center setting. The contract does not say that the deductible applies to surgical services received in a doctor's office, so it is inappropriate for the Plan to assess a deductible for these services. Therefore, we decided that the Plan has to waive the deductible for the nasal endoscopy and impacted cerumen removal you received from an otolaryngologist on August 4, 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for three physical therapy visits rendered by a contracted provider from September 17, 2021, to September 22, 2021.
You asked the Plan to waive the copayment for physical therapy services. You say that the charges for physical therapy are adding up and becoming costly. You also say you might need to have surgery on your knee. The Plan denied your request. The Plan says the cost-sharing was applied correctly for Medicare-covered physical therapy services, as outlined in the Plan 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 $40 copayment for Outpatient Rehabilitation Services.
You have been asked to pay a sum of $120 in copayments for physical therapy services ($40  3 visits = $120). Physical therapy services fall within the Outpatient Rehabilitation 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 three physical therapy visits rendered by a contracted provider from September 17, 2021, to September 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on June 25, 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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem. We looked at the file and Medicare rules. The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on June 25, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan provided on June 3, 2020.
You asked the Plan to pay for the CT scan. You say that the enrollee had multiple exams on this date of service. The Plan denied your request. The Plan says the code is considered mutually exclusive.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. The file shows that CPT code 70450 was billed with code 70496. We find that CPT code 70450 may be eligible for payment when billed with this code pair. The claim information does not show that the code at issue was billed with a modifier suitable for payment. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan provided on June 3, 2020
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz FX injections (J7321).
You asked the Plan to pre-approve the injections. You say that Supartz FX injections are medically necessary. The Plan denied your request. The Plan says a trial of Orthovisc and Monovisc are required before alternatives can be considered.
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 the injections. Our reviewer says that the injections are not medically necessary. Our physician reviewer found the record shows no trial of the plan preferred drugs or any reason they would be unsafe or ineffective. 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 injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Supartz FX injections (J7321).