Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the inpatient hospital services you received on May 26, 2021.

You asked the Plan to waive the coinsurance for the inpatient hospital services. You say that you entered the hospital at 10am and were discharged eleven hours later. You stated that because you were treated and released on the same day that this coinsurance should be waived. The Plan denied your request. The Plan says you were charged this coinsurance correctly. The Plan says that you were admitted to the hospital for the purpose of receiving inpatient care.

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 10% coinsurance for inpatient hospital care. 

You have been asked to pay 10% coinsurance for the inpatient hospital services. This coinsurance applies each time you are admitted to the hospital as an inpatient, regardless of how long your stay is. 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 inpatient hospital services you received on May 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the primary care telehealth visits you had from April 27, 2021, to May 18, 2021.

You asked the Plan to waive the copayments for the primary care telehealth visits. You say that you didn't ask for these services. The Plan denied your request. The Plan says you were charged these copayments 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 $20 copayment for primary care visit (including telehealth services). 

You have been asked to pay a $20 copayment for each of the primary care telehealth visits. The medical records explicitly state that you consented to participate in these telehealth visits. 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 the primary care telehealth visits you had from April 27, 2021, to May 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic injection provided on March 30, 2021, by an
OON provider.
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 were rendered by an out-of-network provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The 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 diagnostic injection provided on March 30,
2021, by an OON provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture provided on February 4, 2021.

You asked the Plan to pay for acupuncture. You say that this is a covered benefit and was medically necessary.
The Plan denied your request. The Plan says acupuncture and related services are not a covered benefit by
Medicare, except for chronic low back pain in this member's coverage document.

The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare.
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the
Plan's rules apply in this case.

We looked at the file, the Medicare rules, and the Plan's rules. Based on this information, we decided that the
rules for coverage of the acupuncture services have not been met. Specifically, the acupuncture was not
provided for chronic low back pain. Therefore, we decided that the Plan does not have to pay for acupuncture
provided on February 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the routine eyewear rendered to you on May 24, 2021.

You asked the Plan to pay more for these services. You say that you have not used the eyewear benefit since 2019. The Plan denied your request. The Plan says the claim was processed correctly.

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 covers up to $250 every year for routine eyewear. 

We looked at the file and the Plan's rules. The file shows that you purchased eyeglasses with lenses on May 24, 2021. The Plan applied the full $250 routine eyewear benefit for these services. Further payment is not covered by your supplemental routine vision benefit or Medicare. Based on this information, we decided that the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay more for the routine eyewear rendered to you on May 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a depression screening (G0444) provided April 28, 2021.
You asked the Plan to pay for the depression screening. You say that the service was medically necessary. The
Plan denied your request. The Plan says only one depression screening is covered per year.
The Plan follows Medicare rules. The plan provides covers for one depression screening per year. The record
shows a depression screening was previously billed on March 25, 2021. Therefore, we decided that the Plan
does not have to pay for a depression screening (G0444) provided April 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on April 20, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services billed are not payable.
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 testing at issue in this appeal was requested solely for screening purposes. The documentation does not
support complaints of urgency, hesitancy, burning on urination, or hematuria. Medicare does not cover this test
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory
services provided on April 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain rendered on March 18, 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 of the head/brain rendered on March 18, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (G0483 & 80307) provided March 31, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code G0483 & 80307 is not supported in the medical record. Specifically, the place of service on the claim (81, lab) does not match the place of service detailed in the records (11, office setting). Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (G0483 & 80307) provided March 31, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eye photography and the removal of an eyelid lesion to be rendered by the out-of-network (OON) provider.

You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to provide ophthalmology services for continued 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 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve eye photography and the removal of an eyelid lesion to be rendered by the out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lead lined underwear purchased on February 8, 2021.
You asked the Plan to pay for this purchase. You say that the Plan should pay for at least part of this purchase. The Plan denied your request. The Plan says these garments are not covered by Medicare.
The Plan must follow Medicare rules. Medicare does not cover precautionary or self-help items. The garments purchased do not serve a purpose that is primarily medical in nature. Their purpose is preventative, and their use is optional. Therefore, we decided that the Plan does not have to pay for lead lined underwear purchased on February 8, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Buprenorphine for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this is a self-administered drug.
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 Buprenorphine for the enrollee.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the clinical criteria for coverage have not been met.

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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the enrollee has metastatic breast cancer and is receiving chemotherapy. The record indicates that the plan has approved the preferred alternative agent. The provided records do not indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record does not indicate that the enrollee has a contraindication to, or would have an adverse effect from the plan's preferred step one alternative. The elements of the coverage criteria are not satisfied. 

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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Aranesp for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 87070 X 2, 87077, 87186, 87205 X 2) provided to the enrollee on May 3, 2021, by an out-of-network provider.
You asked the Plan to pay for the laboratory services. You say that the claim should be paid, and the services were referred by a network provider. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were 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 the laboratory services (CPT code(s): 87070 X 2, 87077, 87186, 87205 X 2) provided to the enrollee on May 3, 2021, by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a tissue expander placement for breast reconstruction provided from April 14, 2021, to April 17, 2021.
You asked the Plan to waive the coinsurance for a tissue expander placement for breast reconstruction. You say that you disagree with the outpatient charges because you were in the hospital for multiple nights. 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 outpatient surgery, including services provided at hospital outpatient facilities.
The medical records show that you received a tissue expander placement for breast reconstruction from April 14, 2021, to April 17, 2021. A tissue expander placement for breast reconstruction is considered an outpatient surgical procedure. Therefore, you are responsible to pay your share of the cost-sharing charges. The total allowed amount is $15,811.05 and 20% of that is $3,162.21. You have been asked to pay the total coinsurance amount of $3,162.21 for a tissue expander placement for breast reconstruction. A tissue expander placement for breast reconstruction 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 coinsurance for a tissue expander placement for breast reconstruction provided from April 14, 2021, to April 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an implant procedure (D6199).
You asked the Plan to pre-approve the implant procedure. The Plan denied your request. The Plan says this service is not covered under the enrollee's 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 pre-approve an implant procedure (D6199).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the OON physical therapy services. You say that there are no other providers who can supply outpatient therapy in the enrollee's home. You say that, without skilled intervention, the enrollee is at safety risk and is suspected to decline. The Plan denied your request. The Plan says they have confirmed that the enrollee is not in active treatment with the requested OON provider. The Plan says that they have confirmed that there are participating providers who can supply the services needed.
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 physical therapy to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for wound closure by adhesive (G0168) provided on October 16, 2020.
You asked the Plan to pay for wound closure by adhesive. You say that this was billed correctly. The Plan denied your request. The Plan says modifier -59 is not supported.
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service. The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural service. Specifically, the procedure note does not document this being performed on a different site or injury
from the simple repair billed with 12014, and code G0168 is bundled into this service. Based on this information, we decided that Medicare rules for coverage of services billed with a -59 modifier have not been met. Therefore, we decided that the Plan does not have to pay for wound closure by adhesive (G0168) provided on October 16, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex Superion device placement surgery for the enrollee.

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that unproven and not medically necessary procedures are not covered by Medicare due to insufficient evidence of efficacy.

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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The Vertiflex device is experimental. More research is needed to show safety and efficacy of the device. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services.

We looked at this physician's review, the file, and Medicare rules. 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 pre-approve Vertiflex Superion device placement surgery for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Osteogenesis stimulator (a bone growth stimulator).
You asked the Plan to pre-approve the bone growth stimulator. You say that the bone growth stimulator should be covered. The Plan denied your request. The Plan says the enrollee does not meet the Medicare coverage criteria.
The Plan follows Medicare rules. Medicare rules say that there must be evidence of failed fusion. Nonunion of long bone fractures is considered to exist only when serial radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the electrical osteogenic stimulator. Serial radiographs must include a minimum of 2 sets of radiographs, each including multiple views of the fracture site, separated by a minimum of 90 days.
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 bone growth stimulator. Our reviewer says that the enrollee does not meet the coverage criteria. Our physician reviewer found the records did not describe a previously failed spinal fusion surgery at the same site. Therefore, criteria for this device is not met, and the electric bone growth stimulator will be considered not medically necessary based on the provided documentation. 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 bone growth stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve an Osteogenesis stimulator (a bone growth stimulator).