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

 We decided that the Plan does not have to waive the copayment for the ultrasound of one arm or leg veins (93971) provided on July 20, 2021.  You asked the Plan to waive the copayment for the ultrasound study. You say that you want to appeal this copayment. The Plan denied your request. The Plan says this claim was processed correctly, and your copayment was assessed in accordance with your contract.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance).  Your contract with the Plan clearly says that you must pay a $100 copayment for Medicare-covered radiological diagnostic services, not including x-rays.   You have been asked to pay a $100 copayment for the ultrasound study. An ultrasound study falls within the Medicare-covered radiological diagnostic services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ultrasound of one arm or leg veins (93971) provided on July 20, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy with specimen collection (45378) provided on September 14, 2021.  You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that you were frustrated with the whole colonoscopy process and were led to believe that you would have no copay for this procedure. The Plan denied your request. The Plan says the colonoscopy in question was diagnostic and not a screening. This claim was processed correctly, and your copayment was assessed in accordance with your contract.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $175 copayment for outpatient surgery services.   You have been asked to pay a $175 copayment for the diagnostic colonoscopy. The colonoscopy in this case was billed as a diagnostic colonoscopy and documentation shows that you have a history of colonic polyps. The diagnostic colonoscopy in this case is classified as outpatient surgery and was provided at an in-network facility. 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 diagnostic colonoscopy with specimen collection (45378) provided on September 14, 2021.
Appeal type: Imaging
Decision: Favorable

 We decided that the Plan has to pre-approve computed tomography (CT) scan, maxillofacial and head.  You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says that this request cannot be approved.  The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 the scan. Our reviewer says that the requested scan is medically reasonable and necessary. Our physician reviewer found the enrollee not only has a headache and sinus pressure, but has visible soft tissue swelling about the face. It is not clear whether you are diabetic from the notes. The fact that the symptoms recur and that soft tissue swelling is now present along with a headache provide positive criteria for CT scan of the sinuses without first trying a four week course of antibiotics.  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 scan have been met. Therefore, we decided that the Plan has to pre-approve computed tomography (CT) scan, maxillofacial and head.   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 pre-approve radiofrequency ablation (RFA).  You asked the Plan to pre-approve RFA. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.  The Plan follows Medicare rules. Medicare rules say that RFA is only covered for certain indications.  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 RFA. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has chronic axial neck pain. She had undergone 2 sessions of RFA, right and then left sided C3, C4, C5. The enrollee achieved 90% pain relief from these blocks. The enrollee is taking Gabapentin for pain. Since the enrollee has already received two sessions of RFA, the request exceeds the utilization guideline of the LCD. Therefore, the enrollee does not meet 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 RFA have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99214) and the laboratory service (80305) rendered by the out-of-network (OON) provider on April 26, 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 office visit (99214) and the laboratory service (80305) rendered by the out-of-network (OON) provider on April 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the continuous positive airway pressure (C-PAP) supplies you received on August 25, 2021.  You asked the Plan to waive the coinsurance for the C-PAP supplies. You say that you don't receive supplies from this vendor any more. The Plan denied your request. The Plan says they have provided a UPS tracking number showing that these supplies were delivered to you, so this coinsurance was charged correctly.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for durable medical equipment.   You have been asked to pay 20% coinsurance for the C-PAP supplies. The C-PAP supplies fall within the durable medical equipment benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the continuous positive airway pressure (C-PAP) supplies you received on August 25, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ultrasound services (76700) provided on August 5, 2021.  You asked the Plan to pay for code 76700. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  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, we have confirmed that code 76700 is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the ultrasound services (76700) provided on August 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the domiciliary or rest home visit (99335) rendered by the out-of-network (OON) provider on August 10, 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 domiciliary or rest home visit (99335) rendered by the out-of-network (OON) provider on August 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a second confirmatory diagnostic facet joint procedure.  You asked the Plan to pre-approve a second confirmatory diagnostic facet joint procedure. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.  The Plan follows Medicare rules. Medicare rules say that a second procedure is only covered when the enrollee had a positive response to the first one of at least 80% relief.  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 a second confirmatory diagnostic facet joint procedure. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has chronic neck pain due to cervical spondylosis, spinal stenosis, and cervical radiculitis.  She is s/p bilateral C4-C5-C6 medial branch block on 8/31/2021, with no significant improvement. According to the coverage criteria, a second confirmatory diagnostic facet joint procedure is considered medically reasonable and necessary when after the first diagnostic facet joint procedure, there must be a consistent positive response of at least 80% relief of primary (index) pain (with the duration of relief being consistent with the agent used). Review of the file shows that the enrollee did not have any significant pain relief from the first diagnostic procedure. Therefore, the enrollee does not meet 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 a second confirmatory diagnostic facet joint procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a second confirmatory diagnostic facet joint procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for an extra heavy-duty hospital bed (E0304).  You asked the Plan to pay for an extra heavy-duty hospital bed. You say that a lower weight class bed is not wide enough for you. The Plan denied your request. The Plan says you do not meet the weight requirement for the requested bed.  The Plan must follow Medicare rules. Medicare rules say that an extra heavy-duty hospital bed (E0302, E0304) is covered if the beneficiary meets one of the criteria for a hospital bed and the beneficiary's weight exceeds 600 pounds.  We looked at the file and Medicare rules. The submitted records do not show that your weight exceeds 600 pounds. Based on this information, we decided that Medicare rules for coverage of an extra heavy-duty hospital bed have not been met. Therefore, we decided that the Plan does not have to pay for an extra heavy-duty hospital bed (E0304).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a referral for diabetic shoes with an out-of-network provider.  You asked the Plan to pre-approve the diabetic shoes. You say that this is medically necessary. The Plan denied your request. The Plan says medically necessary care is available 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 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 a referral for diabetic shoes with an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the medication assisted treatment of Methadone (G2067) provided on August 29, 2020 by an out-of-network (OON) provider.  You asked the Plan to pay for the medication assisted treatment of Methadone. You say that the provider was not notified about the enrollee's insurance. You also say that it was too late when the provider tried to obtain the prior authorization, and it could not be backdated. The Plan denied your request. The Plan says this service was rendered by a non-participating provider. The Plan also says there is no referring provider, and prior authorization was not obtained.  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 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 medication assisted treatment of Methadone (G2067) provided on August 29, 2020 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a group 2 very heavy-duty power scooter (K0808).  You asked the Plan to pre-approve a group 2 very heavy-duty scooter (K0808). You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested item is not a covered benefit.  The Plan must follow Medicare rules. Medicare rules say that if a Group 2 POV is provided it will be denied as not reasonable and necessary.  The file shows that the requested scooter has added capabilities that are not needed for use in the home. Therefore, we decided that the Plan does not have to pre-approve a group 2 very heavy-duty power scooter (K0808).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an office consultation to be rendered by the out-of-network (OON) provider.  You asked the Plan to pre-approve this service. 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 render the requested service.  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 service at issue in this appeal.  We found no exception that would require the Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve an office consultation to be rendered by the out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the six extractions provided on March 30, 2021.  You asked the Plan to pay for the extractions. You say that you would like this denial to be reconsidered. The Plan denied your request. The Plan says you met your maximum benefit on March 30, 2021. The Plan also says that any portion that is in excess of the maximum will not be paid by the Plan and is your responsibility.  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 Plan offers a $1,000 allowance per year for all dental services combined. The record shows that you met the annual maximum benefit on March 30, 2021 and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the six extractions provided on March 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an out of network office visit with  You asked the Plan to pre-approve out of network providers. You say that you prefer to see the requested provider. The Plan denied your request. The Plan says it has been confirmed there is a provider who can treat you and is taking new patients.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must 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. Your office and staff are not network providers with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. Therefore, we decided that the Plan does not have to pre-approve an out of network office visit with the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for an elastic figure 8 leg strap.  You asked the Plan to pay for the item. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.  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 A9270 is "Non-covered item or service."  We find that the code A9270 is not supported in the medical record. Specifically, it is meant to represent a non-covered item. Based on this information, we decided that Medicare rules for coverage of the item have not been met. Therefore, we decided that the Plan does not have to pay for an elastic figure 8 leg strap.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve alginate dressings and saline wound wash for lymphedema.  You asked the Plan to pre-approve disposable supplies. You say that these items are medically necessary as your legs leak from lymphedema. The Plan denied your request. The Plan says these items are not covered by Medicare for lymphedema.  The Plan must follow Medicare rules. The rules say that these types of dressings are only covered for stage 3 or stage 4 open wounds. Your diagnosis is lymphedema. Although these items may be appropriate for your use, they are not covered by Medicare for your condition. Therefore, we decided that the Plan does not have to pre-approve alginate dressings and saline wound wash for lymphedema.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to pay for the emergency department visit (99285) with diagnosis codes R22.43 and R60.9 provided on August 29, 2021.  You asked the Plan to pay for the emergency department visit with diagnosis codes R22.43 and R60.9. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We looked at the file, the Plan's contract and Medicare rules. The file shows that you billed the emergency department visit with diagnosis codes R22.43 and R60.9. Per Medicare billing guidelines, these diagnosis codes cannot be reported together. Therefore, we decided that the Plan does not have to pay for the emergency department visit (99285) with diagnosis codes R22.43 and R60.9 provided on August 29, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the Skilled Nursing Facility (SNF) services provided on May 27, 2021, to June 19, 2021.  You asked the Plan to waive the coinsurance for skilled nursing facility services. You say that you are dissatisfied with the services provided at the SNF. The Plan denied your request. The Plan says the coinsurance applied correctly based on 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 a 5% coinsurance for Skilled nursing facility (SNF) care.     You have been asked to pay a 5% coinsurance for skilled nursing facility services provided from May 27, 2021, to May 31, 2021. (The total allowed amount for claim #21078412164 is $1,225, 5% of that is $61.25 and the total allowed amount for claim #21080400133 is $8,129, 5% of that is $406.49 for a total cost-sharing of $467.75). 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 Skilled Nursing Facility (SNF) services provided on May 27, 2021, to June 19, 2021.