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

We decided that the Plan does not have to waive the copayment for the myelography via lumbar injection provided on May 4, 2021.

You asked the Plan to waive the copayment for myelography via the lumbar injection. You say that you were told there would be a $275 copayment. You say you are being billed $325 for 'surgery.' The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 copayment for each Medicare-covered in-network outpatient hospital facility visit.

You have been asked to pay a $325 copayment for myelography via the lumbar injection. The myelography via the lumbar injection falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows the myelography via lumbar injection is considered a separate surgical service. 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 myelography via lumbar injection provided on May 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on March 23, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that the referring provider is also out-of-network.

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 lab work provided on March 23, 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 drug testing (80307) rendered by the out-of-network (OON) provider on September 14, 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 drug testing (80307) rendered by the out-of-network (OON) provider on September 14, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the debridement provided on February 22, 2021.

You asked the Plan to reduce the copayment for the debridement. You say that you believe you should be charged a $25 copayment. You say you believed you were in a doctor's office for the service. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges.

You have been asked to pay a $295 copayment for the debridement. The debridement falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The record shows you were billed by an outpatient hospital. 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 reduce the copayment for the debridement provided on February 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xifaxan.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says self-administered drugs are not covered.

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 Xifaxan.

Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the step therapy requirement is not 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has osteopenia. She has not tried and failed the Plan's required drug, intravenous zoledronic acid. The records do not show that the required drug would be contraindicated or less effective; therefore, the Prolia is not reasonable or medically necessary. 

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 Prolia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the walker received on February 22, 2021.
You asked the Plan to pay for the walker. You say that you needed this walker due to pain as the result of a bad
fall. The Plan denied your request. The Plan says the item received is not a covered benefit when received by a
provider that does not accept Medicare payment.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items or services provided directly by a physician or practitioner who has opted out of the program except
in cases involving emergencies or urgently needed care.
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the walker
received on February 22, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve Blepharoplasty and Blepharoptosis surgery.

You asked the Plan to pre-approve Blepharoplasty and Blepharoptosis surgery. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 

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 Blepharoplasty and Blepharoptosis surgery. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the documentation shows that the enrollee has dermatochalasis. The enrollee complains of impaired vision secondary to the drooping eyelids. The record indicates that the enrollee has a margin reflex distance bilaterally of 0.5 mm. Visual field testing significantly improves with taping. The medical record supports the medical necessity and reasonableness, as defined by Medicare rules, of the requested service for the enrollee's clinical condition. Therefore, the enrollee meets criteria for the requested 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 Blepharoplasty and Blepharoptosis surgery have been met. Therefore, we decided that the Plan has to pre-approve Blepharoplasty and Blepharoptosis surgery.

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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan provided on May 11, 2021.

You asked the Plan to waive the copayment for the CT scan. You say that you have never had a copayment this high on any claim. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 copayment for diagnostic radiology (CT, MRI, PET scan, etc.).

You have been asked to pay a $100 copayment for the CT scan. The 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 CT scan provided on May 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for dermatology services provided on March 17, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for dermatology services. You say that you would like this claim reprocessed and paid due to medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that these services could have been provided in-network.

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 dermatology services provided on March 17, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on March 9, 2021.

You asked the Plan to waive the copayment for a specialist visit. You say that the provider did nothing to treat your condition and marked the wrong reason as to why you were there. 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 $40 copayment for each specialist visit. The medical records show that you received specialist services on March 9, 2021. Therefore, you are responsible to pay the $40 copayment. 

You have been asked to pay a $40 copayment for a specialist visit. A specialist visit falls 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 a specialist visit provided on March 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for therapy services (97110) provided January 21, 2021.

You asked the Plan to pay for the therapy 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 97110 is not supported in the medical record. Specifically, the services were provided in the home setting by a therapy assistant. There is a more appropriate CPT code for this service (G0157). Based on this information, we decided that Medicare rules for coverage of the therapy services have not been met. Therefore, we decided that the Plan does not have to pay for therapy services (97110) provided January 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit with an ophthalmologist (99204) to be
provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve an office visit. You say that the enrollee needs to have the prisms in her
eyes measured and there is no other ophthalmologist close in proximity that can perform the prism
measurement The Plan denied your request. The Plan says there are in-network providers available for these
services.
Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is
considered accessible to an enrollee if contract providers are available within reasonable distance and travel
time from the enrollee's home. The Plan says that enrollees must use contract providers.
The requested provider in this case is a non-contract provider. We were able to confirm that the Plan has
contract providers located within reasonable distance and travel time from the enrollee's home who can provide
an office visit. Under Medicare rules, this means that contract providers are accessible to the enrollee. 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 an office visit with an ophthalmologist (99204) to be provided by an outof-
network (OON) provider
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible and copayment for an office visit provided on
March 10, 2021.

You asked the Plan to waive the deductible and copayment for an office visit. You say that you disagree with
how high the charges are. 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 $150 deductible. Your contract with the Plan also clearly says that
after the $150 deductible has been met, enrollee's pay a $20 copayment for primary care provider visits.

You had an office visit on March 10, 2021. The record shows that you had only paid $100.28 toward the $150
deductible prior to receiving the services. Therefore, you are responsible to pay the remaining deductible
amount of $49.72. Now that the $150 deductible has been met, you are also responsible to pay the $20
copayment. The total amount you owe is: $69.72. 

The item or service you asked the Plan to waive the deductible and copayment for falls within the benefit category physician/practitioner services, including doctor's office visits. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $150 deductible and a $20 copayment for physician/practitioner services, including doctor's office visits. This cost sharing is a contractual obligation that had not been met at the time an office visit was received on March 10, 2021. Therefore, we decided that the Plan does not have to waive the deductible and copayment for an office visit provided on March 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve urology services to be provided by an out-of-network
(OON) provider.
You asked the Plan to pre-approve urology services. You say that you would like approval for these services.
The Plan denied your request. The Plan says there are in-network providers for these 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 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
urology services 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 waive the cost share for the office visit (99203) and the x-ray exam of the foot (73630) provided on February 8, 2021.

You asked the Plan to waive the cost share. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the cost share has been applied correctly to the services provided.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $35 per day, per provider, for Medicare-covered x-ray services. Additionally, you pay $45 for each Medicare-covered visit with a specialist.

You have been asked to pay $77.36 which includes a $45 copayment for the specialist office visit and a $32.36 copayment for the foot x-ray provided. The copayment applied for the foot x-ray is the Plan's allowed amount for this service which is less than the applicable copayment. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost share for the office visit (99203) and the x-ray exam of the foot (73630) provided on February 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing (80307, G0481) rendered by the out-of-network (OON) provider on April 27, 2021.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal.

The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay
for these services. Therefore, we decided that the Plan does not have to pay for the drug testing (80307, G0481)
rendered by the out-of-network (OON) provider on April 27, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve obstetrics services to be provided by an OON provider.
You asked the Plan to pre-approve obstetrics services to be provided by an OON provider. You say that you
would like the Plan to reconsider their denial. The Plan denied your request. The Plan says that the services are
not covered.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. In this case, the file shows that the enrollee's provider believes the enrollee is a
high-risk pregnancy due to her sickle cell disease, multiple external stressors, poor social support, and Bipolar
mixed type. The enrollee's provider says the enrollee would benefit from a "high-risk fetal medicine provider"
in the same location and system as her hematologist at the OON facility. The Plan failed to address these issues
and did not provide any information in regard to the enrollee's pregnancy, sickle cell disease and any other
conditions the enrollee may have that would put her at a higher pregnancy risk needing specialized care. We
sent a request for this additional information to the Plan with no response. Therefore, we decided that the Plan
has to pre-approve obstetrics services to be provided by an OON provider.
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.