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

We decided that the Plan does not have to waive the coinsurance foran open treatment of distal radial fracture provided on September 16, 2019.You asked the Plan to waive the coinsurance foran open treatment of distal radial fracture. You say that you were told that you would only owe a $120 copayment and were not informed that you would owe more for switching facilities.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 surgery performed in an outpatient hospital facility. You received an open treatment of a distal radial fracture at an outpatient hospital facility on September 16, 2019. Therefore, you are responsible to pay your share of the cost-sharing charges. The allowed amount is $5,331.93 and 20% of that is $1,066.39. You have been asked to pay the total coinsurance amount of $1,066.39 for an open treatment of distal radial fracture. An open treatment of distal radial fracture 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 foran open treatment of distal radial fracture provided on September 16, 2019.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to hold you harmless for transluminal dilation (66174) provided on March 13, 2019 and March 20, 2019.You asked the Plan to hold you harmless for transluminal dilation. You say that this should be covered.The Plan denied your request. The Plan says that this service is not covered with cataract surgery or other major glaucoma surgeries.Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan  follows these rules. The transluminal dilation at issue was provided by the provider. The provider is a contract provider. The file does not show that the plan provided notice that transluminal dilation would not be covered. Under Medicare rules, this means transluminal dilation is considered approved by the plan.Therefore, we decided that the Plan has to hold you harmless fortransluminal dilation (66174) provided on March 13, 2019 and March 20, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient lab tests provided on October 8, 2019.
You asked the Plan to waive the copayment for an outpatient lab test. You say that you made sure that this test
would be covered. The Plan denied your request. The Plan says the correct copayment has been 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 $20
copayment for outpatient diagnostic tests/laboratory tests.
You have been asked to pay $4.23 which is less than your copayment amount of $20 for an outpatient lab test.
An outpatient lab test falls within the outpatient diagnostic tests/laboratory tests 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 an outpatient lab tests provided on October 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (00731) provided on March 15, 2018.You asked the Plan to pay for the anesthesia services. You say that the bill was passed the time for filing due to a coordination of benefit with other insurance issues. The Plan denied your request. The Plan says non-par providers are required to submit claims within 365 calendar days from the date of service.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service.The record shows that a claim for the anesthesia services was not filed until October 31, 2018. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for anesthesia services (00731) provided on March 15, 2018.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to the enrollee on March 25, 2019.
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 claim was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for an independent laboratory; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered to the enrollee on March 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray provided on October 23, 2019.You asked the Plan to pay forthe problem focused limited oral evaluationand first intraoral periapical x-ray. You say that you had reviewed your contract information with the provider's office of what was covered and what was not covered.The Plan denied your request. The Plan says these services are not covered 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 forthe problem focused limited oral evaluation and first intraoral periapical x-ray provided on October 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an injection and physician services to be provided by an out of network (OON) provider.You asked the Plan to pre-approve an injection and physician services. You say that this is a tertiary facility. You say that the member needs to have thislevel of specialized care.The Plan denied your request. The Plan says there is an in-network provider available 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-approvean injection and physician services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay forthe belt, strap, sleeve, garment,or covering, any type provided on May 14, 2019.You asked the Plan to pay forthe abdominal binder (A4467). You say that your doctor prescribed this binder after surgery.The Plan denied your request. The Plan says that this item is not covered by Medicare.Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules.You were referred for the Velcro abdominal binder (A4467) by a contract provider. The file does not show that the plan provided notice that the abdominal binder (A4467) would not be covered. Under Medicare rules, this means the abdominal binder (A4467) is considered approved by the plan.Therefore, we decided that the Plan has to pay for the belt, strap, sleeve, garment, or covering, any type provided on May 14, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed.
You asked the Plan to pre-approve a total electric hospital bed. You say that the enrollee is bedridden and it is difficult and time consuming to manually adjust the height of the bed. The Plan denied your request. The Plan says total electric hospital beds are not covered by Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an urgent care visit provided on October 14, 2019.
You asked the Plan to waive the copayment for an urgent care visit. You say that your doctor's office called and told you that you needed a computerized axial tomography (a CAT) scan. When you got there, the person came into the room and apologized to you. She said they couldn't help you because they didn't have a CAT scan. You were told to go to the emergency department for your scan. The Plan denied your request. The Plan says urgently needed services have a $65 copayment per visit.
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 $65 copayment for urgently needed services. You have been asked to pay a $65 copayment for an urgent care visit. This service falls within the urgently needed services benefit category. The record shows that you received services at the urgent care location, including a physical examination. 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 an urgent care visit provided on October 14, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe transthoracic echocardiogram (TTE) rendered to you on September 27, 2019.You asked the Plan to waive the copayment forthese services. You say that you shouldn't be liable.The Plan denied your request. The Plan says the copayment was applied 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 $100 copayment for each in-network Medicare-covered diagnostic procedure and testat an outpatient hospital facility. Review of the file shows that you received a TTE at an outpatient hospital facility on September 27, 2019. You have been asked to pay a $100 copayment for these services. These services fall within the in-network Medicare-covered diagnostic procedure and test at an outpatient hospital facility 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 forthe transthoracic echocardiogram (TTE) rendered to you on September 27, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for assistant at surgery services during the removal of a breast lesion provided on August 15, 2019.
You asked the Plan to pay for the assistant at surgery services. You say that the services were medically necessary and the procedure needed an assistant surgeon. You say that the assistant was chosen by the operating surgeon and had no choice. The Plan denied your request. The Plan says the services of an assistant surgeon, co-surgeon, or surgical team are not covered for this procedure.
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT code 19120. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the assistant at surgery services have not been met. Therefore, we decided that the Plan does not have to pay for assistant at surgery services during the removal of a breast lesion provided on August 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foam dressing wound covers.You asked the Plan to pre-approve foam dressing wound covers (A6213, A6209). You say that the enrollee needs the wound care supplies to treat and prevent sores.The Plan denied your request. The Plan says documentation does not show stage III or IV ulcers.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The enrollee does not have a qualifying wound. Based on this information, we decided that Medicare rules for coverage of foam dressing wound covers (A6213, A6209) have not been met.Therefore, we decided that the Plan does not have to pre-approvefoam dressing wound covers.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an ultrasound guidance (76937) provided on February 27, 2019.
You asked the Plan to pay for the ultrasound guidance. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says 76937 is an add-on code and was not billed with an appropriate primary code.
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 76937 is ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent real time ultrasound visualization of vascular needle entry, with permanent recording and reporting (List separately in addition to code for primary procedure). We find that CPT code 76937 is not supported in the record. Specifically, 76937 is a Type II add-on code. Per Medicare, claims processing contractors are encouraged to develop their own lists of primary procedure codes for this type of add-on code. The record indicates that the primary procedure code billed with 76937, is not included on the list of appropriate primary procedure codes. Based on this information, we decided that Medicare rules for coverage of the ultrasound guidance have not been met. Therefore, we decided that the Plan does not have to pay for an ultrasound guidance (76937) provided on February 27, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for cryosurgery provided on October 10, 2019.
You asked the Plan to waive the copayment for cryosurgery. You say that you did not receive a surgical procedure and disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly, and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $400 copayment for outpatient hospital surgery services. You received cryosurgery on October 10, 2019. Cryosurgery is considered an outpatient surgical procedure. Therefore, you are responsible to pay the allowed amount of $187.79, which is less than the $400 copayment. You have been asked to pay $187.79 for cryosurgery. Cryosurgery 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 copayment for cryosurgery provided on October 10, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of a Vertiflex device (22869, C1821).You asked the Plan to pre-approveinsertion of a Vertiflex device. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.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 insertion of a Vertiflex device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no clear documentation why you would not be a candidate for formal laminectomy that would require a newer procedure (interspinous process decompression with stand-alone spacer), which is the standard treatment for lumbar spinal stenosis.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of insertion of a Vertiflex device have not been met.Therefore, we decided that the Plan does not have to pre-approveinsertion of a Vertiflex device (22869, C1821).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on September
22, 2019 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that the services were provided to the enrollee in
good faith. The Plan denied your request. The Plan says authorization was not obtained before the services
were provided to the enrollee. The Plan also says that the services were not urgent or emergent.
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 subsequent nursing facility care provided on
September 22, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay fordrug testing provided on March 15, 2019.You asked the Plan to pay fordrug tests. You say that you have submitted a valid physician laboratory requisition form.The Plan denied your request. The Plan says the denial of payment for these services is correct, because the documentation submitted does not include a valid physician order, lab requisition, or medical records stating exactly which tests were to be performed.The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a physician order or clear intent to order the specific lab services billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug tests have not been met.Therefore, we decided that the Plan does not have to pay fordrug testing provided on March 15, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz FX injections for the enrollee.You asked the Planto pre-approve Supartz FX. The Plan denied your request. The Plan says that they did not receive documentation supporting the medical necessity for a step therapy exception.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 Supartz FX. Our reviewer says that Supartz FX is not medically reasonable and necessary for the enrollee in this case. Supartz FX is being requested for the treatment of osteoarthritis in bilateral knees. The enrollee has not trialed viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the plan, requires these be trialed first. The documentation does not outline contraindications or reasons these medications were not considered. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Supartz FX.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Supartz FX have not been met.Therefore, we decided that the Plan does not have to pre-approveSupartz FX injections for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary visit provided on October 14, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe physician services. You say that the services were provided to the enrollee in good faith.The Plan denied your request. The Plan says authorization was not obtained before the services were provided to theenrollee. The Plan also says that the services were not urgent or emergent.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 has network providers available who can provide 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 forthe domiciliary visit provided on October 14, 2019 by an out of network (OON) provider.