Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay an additional $35 from your coinsurance responsibility for a periodic oral evaluation. We also decided that the Plan does not have to waive the coinsurance for the remaining balance due for dental services.
You asked the Plan to waive the coinsurance for dental services. You say that you called the Plan and was told this provider was in network. You also say you do not understand why you are being charged for these services. The Plan says that you pay 30% of the total amount for services from an OON provider.
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 30% coinsurance for dental services received from an OON provider.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for waiving the coinsurance are partially met in this case. Specifically, the record shows that you are being charged $87.50 for a periodic oral evaluation. According to the Plan, this is based off an Allowed Amount of $175. 30% coinsurance from $175 is $52.50. This means that you are being overcharged $35 ($87.50 - $52.50 = $35). The documentation within the record does not explain why you are being charged $35 over the 30% coinsurance allowed for these services. Therefore, we decided that the Plan has to pay an additional $35 from your coinsurance responsibility (bringing your total coinsurance to $52.50 and the Plan's total share to $122.50) for a periodic oral evaluation (D0120).
The contract is clear however, that 30% coinsurance applies for the remaining dental services. This means that the Plan does not have to waive your entire coinsurance responsibility for these services. This is a contractual obligation that you agreed to pay when you enrolled with the Plan. Your contract with the Plan clearly says that you must pay a 30% coinsurance for dental services received from an OON provider. Therefore, we decided that the Plan does not have to waive the coinsurance for the remaining balance due for dental services.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a TempusHRD panel (81479) provided on March 3, 2021.
You asked the Plan to pay for a TempusHRD panel. You say that this was medically necessary. The Plan denied your request. The Plan says the requirements for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that molecular pathology procedures may be eligible for coverage when the testing assay(s) are Food and Drug Administration (FDA) approved/cleared or if LDT (lab developed test) or LDT protocol or FDA modified test(s) the laboratory documentation should support assay(s) of analytical validity and clinical utility. We looked at the file and Medicare rules. The records show that the testing at issue is not FDA approved and do not document that this is LDT protocol or FDA modified. Based on this information, we decided that Medicare rules for coverage of a TempusHRD panel have not been met. Therefore, we decided that the Plan does not have to pay for a TempusHRD panel (81479) provided on March 3, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for surgical services provided on
July 22, 2021, during a specialist physician office visit.
You asked the Plan to waive the copayment for surgical services. You say that the cost-share is incorrect. The Plan denied your request. The Plan says the correct copayment 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 $35 copayment for each Medicare-covered office visit for consultation, diagnosis, and treatment by a specialist.
You have been asked to pay a $35 copayment for surgical services. The surgical services rendered in this case
fall within the "Physician/Practitioner services, including doctor's office visits" benefit category. This means
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan
does not have to waive the copayment for surgical services provided on July 22, 2021, during a specialist
physician office visit
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to waive the coinsurance for the drug injections provided in 2020.
The rules say that Medicare plans must make reasonable and diligent efforts to gather and forward information to the Independent Review Entity (IRE).
We looked at your request, the file and Medicare rules. Based on this information we decided that Medicare criteria for coverage have been met. Specifically, the Plan has not forwarded the 2020 EOC. Without this contract information, we are unable to verify the cost share amounts applied to any services rendered in 2020. It is the burden of the Health Plan to substantiate their denial with evidence. In this case, the Plan's denial is not substantiated, so we must find in your favor. Therefore, we decided that the Plan has to waive the coinsurance for the drug injections provided in 2020.
We also decided that the Plan does not have to waive the coinsurance for the drug injections provided in 2021.
Service
Allowed Amount
20% Coinsurance
Leuprolide Injection - January 27, 2021
$673.35
$134.67
Leuprolide Injection - January 27, 2021
$686.79
$137.36
Leuprolide Injection - April 21, 2021
$612.21
$122.44
Chemotx Administration - April 21, 2021
$36.86
$35 (Copayment)
Total:
$429.47
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 each Part B drug, including chemotherapy. You have been asked to pay $429.47 for the injections received in 2021. This means that you have been asked to pay the correct amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the drug injections provided in 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hotel ASQ service package (A9270) provided on June 9, 2021 to June 24, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for hotel ASQ service package. You say that while traveling abroad in Thailand, you had to comply with Thai law to be quarantined in this facility and submit to COVID-19 testing until you were cleared. The quarantine should be covered. 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.
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 covers urgent care and
emergency services when traveling outside of the United States for less than six months. The documents provided that the quarantine took place in a hotel, not a hospital emergency room or urgent care facility. 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 hotel ASQ service package (A9270) provided on June 9, 2021 to June 24, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injection services.
You asked the Plan to pre-approve facet joint injection services. You say that the records provided support the
need for the requested injection services. The Plan denied your request. The Plan says there is no clinical
information documenting medical necessity.
The Plan follows Medicare rules. Medicare rules say that Facet Joint Interventions are covered when medically
reasonable and necessary. Medicare rules say that for Facet Joint Interventions are only considered medically
necessary when there is an absence of untreated radiculopathy or neurogenic claudication.
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 facet joint injection services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has bilateral low back pain with radiation down both legs. The pain is worse with standing, walking, and prolonged sitting. The enrollee feels like she has had some increased weakness in the left leg in the past year and occasionally feels unsteady on her feet. The enrollee endorses some bowel and bladder incontinence, but this is not a new finding for her. The enrollee has not responded well to physical therapy. The enrollee does not feel like anything truly alleviates the pain, other than medications but these take time to work. Imaging demonstrates progression of degenerative changes with disc space collapse, sclerosis and subchondral cyst formation with vacuum disc phenomenon and retrolisthesis. There is moderately severe foraminal encroachment right greater than left. The clinical documentation in the case file indicates that the enrollee has radiculopathy as well as non-facet pathology that could explain the source of the patient's pain. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of facet joint injection services have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injection services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pontic - porcelain fused to high noble metal (D6240) and retainer crowns - porcelain fused to high noble metal (D6750) for a dental bridge provided August 26, 2021.
You asked the Plan to pay for the dental bridge services. You say that this service was recommended, and you are too financially and emotionally stressed to afford the cost. The Plan denied your request. The Plan says these services are not covered under your benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the pontic
- porcelain fused to high noble metal (D6240) and retainer crowns - porcelain fused to high noble metal
(D6750) for a dental bridge provided August 26, 2021.
Your complaint about your dental policy not including bridges is not a valid appeal for medical coverage. This
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a
decision about these types of complaints.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the SNF admission. You say that it is felt that SNF care is needed. The Plan denied your request. The Plan says you do not require daily skilled care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital due to a hip fracture requiring surgical repair. The most recent therapy documentation indicates the member is able to ambulate up to 50 feet with a walker. She does not require hands on assistance for ambulation but does require contact guard assistance for transfers and toileting. The member has stabilized medically and is ready for discharge from the hospital. The member does not require skilled nursing and/or skilled therapy services on a daily basis. She is medically stable and can receive further rehab services at a lower level of care. Although further rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. 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 SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia (00402) rendered by the out-of-network (OON) provider on June 8, 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 anesthesia (00402) rendered by the out-of-network (OON) provider on June 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is no medical need for the multiple power options included with the wheelchair.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 wheelchair is not medically reasonable or necessary. Our physician reviewer found the E2300 Seat Elevator and K0108 Memory Seating are not medically necessary, as Medicare does not pay for any items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. The documentation does not reveal a musculoskeletal condition or the presence of a cast or brace which prevents 90 degree flexion at the knee; or significant edema of the lower extremities that requires a power elevating legrest. In terms of the power tilt and power recline, the enrollee is not at high risk for development of a pressure ulcer, does not use intermittent catheterization for
bladder management and does not need a power seating system to manage increased tone or spasticity per the physician documentation. The E2311, the E2377 Expandable Controller, E2313 Expandable Controller Harness are not medically necessary. The documentation does not reveal that the patient 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 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices), other electronic devices, or an attendant control. An attendant control cannot be covered if a user-operated control is requested. 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 a group 3 power wheelchair and accessories for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physician's services provided on
July 30, 2021, August 3, 2021, and on August 9, 2021.
You asked the Plan to waive the copayment for the physician's services. The Plan denied your request. The Plan says the correct cost share has been applied to the claims.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $10 copayment for each Medicare-covered visit from a primary care provider and a $45 copayment for each Medicare-covered specialist visit.
The enrollee has been asked to pay a $10 copayment for each Medicare-covered visit from a primary care provider and a $45 copayment for each Medicare-covered specialist visit. The physician's services falls within the Inpatient stay: Covered services received in a hospital or SNF during a non-covered inpatient stay benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for physician's services provided on
July 30, 2021, August 3, 2021, and on August 9, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical assistant services provided on February 17, 2021, billed with codes 25608-AS-RT and 25609-AS-RT.
You asked the Plan to pay for the surgical assistant services as billed. You say that this should be paid. The Plan denied your request. The Plan says the services 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. We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the surgical assistant services as billed. Our reviewer says that the billed codes are not supported. Our reviewer found the medical records provided does not include sufficient documentation to validate that an Open treatment of distal radial intra-articular fracture or epiphyseal separation; with internal fixation of 3 or more fragments was the procedure that was performed on February 17, 2021, therefore, this procedure cannot be verified. Code 25608 is a Column 2 code in relation to 25609. It was not billed with an appropriate modifier. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the surgical assistant services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the surgical assistant services provided on February 17, 2021, billed with codes 25608-AS-RT and 25609-AS-RT.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for eyeglasses provided on June 23, 2021.
You asked the Plan to reimburse you for the eyeglasses. The Plan denied your request. The Plan says you opted to use an out-of-network vision provider, which is not covered.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan
covers these services when provided by a doctor in the Plan's vision network. We looked at the file and the Plan's rules. The eyeglasses were not provided by a doctor in the Plan's vision network. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to reimburse you for eyeglasses provided on
June 23, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on June 14,
2021.
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request.
The Plan says genetic testing procedures submitted with code 81455 are unlikely to impact therapeutic
decision-making in the clinical management of the patient and will be denied automatically as 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 pay for the testing. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found genomic testing has not been show in high quality studies to lead to significantly improved outcomes or
changes in treatment for a significant number of patients in this clinical situation to help support the use of this
testing for this enrollee. Therefore, the genomic testing will be considered not medically necessary at this time.
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 testing have not been met. Therefore, we decided that the Plan does not have
to pay for laboratory services provided to the enrollee on June 14, 2021.