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

We decided that the Plan does not have to waive the copayments for the application of a cast.

You asked the Plan to waive the copayments for the application of a cast. You say that you disagree with the charges and you feel that you should only owe one $200 copayment. 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 $200 copayment for outpatient surgery, including services provided at hospital outpatient facilities.

You received the application of a cast at an outpatient hospital facility for a total of 3 services. The application of a cast is considered an outpatient surgical procedure. Therefore, you are responsible to pay a $200 copayment per each service. The total amount you owe is: $600.

You have been asked to pay the total copayment amount of $600 for the application of a cast. The application of a cast 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 copayments for the application of a cast.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the follow-up visit provided on November 8, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the follow-up visit. You say that the services were medically necessary. The Plan denied your request. The Plan says no prior authorization was 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 follow-up visit provided on November 8, 2019 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the EGD provided on November 19, 2020.
You asked the Plan to waive the copayment for the EGD. You say that this service processed incorrectly because everything was in-network. 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 $365 copayment for surgery services at an in-network and out-of-network outpatient hospital. You have been asked to pay a $365 copayment for the EGD. The EGD falls within the "Outpatient hospital 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 EGD provided on November 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the podiatry visit provided on July 13, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the podiatry visit. You say that you have been seeing this doctor for years and the provider did not tell you that they do not accept your insurance. The Plan denied your request. The Plan says no prior authorization was 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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the podiatry visit provided on July 13, 2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided by a participating provider on October 9, 2020.
You asked the Plan to waive the copayment for ambulance services. You say that this copayment is way too high. You say that you think the Plan should pay for this. 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 $240 copayment for ambulance services/emergency ambulance. You have been asked to pay a $240 copayment for ambulance services. The correct copayment has been applied to the ambulance services that were provided. Ambulance services fall within the ambulance services/emergency ambulance 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 ambulance services provided by a participating provider on October 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that transfer to an LTACH is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the current acute care hospital can provide for all of the enrollee's present inpatient care needs and the enrollee is receiving an appropriate level of care in the present setting. Medicare coverage criteria for transfer to an LTACH are not met. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on September 25, 2020.
You asked the Plan to pay for the ambulance services. You say that you were following the Covid executive order for treatment in place. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on September 25, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on September 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of benign odontogenic cyst or tumor (D7451).

You asked the Plan to pay for the removal of benign odontogenic cyst or tumor. You say that you cannot pay for this service in full. The Plan denied your request. The Plan says this service is not covered under your plan.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the removal of benign odontogenic cyst or tumor (D7451).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Bupivacaine hydrochloride injection services.

You asked the Plan to pay for the Bupivacaine hydrochloride injection services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.

The Plan 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 S0020 is injection, Bupivacaine hydrochloride, 30 ml. 

We find that CPT code S0020 is not supported in the medical record. Specifically, this code has a status code of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the Bupivacaine hydrochloride injection services have not been met. Therefore, we decided that the Plan does not have to pay for the Bupivacaine hydrochloride injection services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis.

You asked the Plan to pay for the lumbar-sacral orthosis (L0650). You say that the orthosis was medically
necessary. The Plan denied your request. The Plan says the enrollee denies a video or telephonic physician
visit.

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 lumbar-sacral orthosis (L0650). Our
reviewer says that the orthosis is not medically necessary. Our physician reviewer found the available
documentation in the case file does not support that the requested lumbar-sacral orthosis was medically
reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the
LCD.

An appropriate history and a physical examination of the back would reasonably be required to adequately
assess whether the coverage criteria for a lumbar sacral orthosis have been met. The documentation does not
support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as
there is insufficient documentation of an adequate evaluation and a credible physical examination of the back.

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 lumbar-sacral orthosis (L0650) have not been met. Therefore, we decided
that the Plan does not have to pay for the lumbar-sacral orthosis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for bilateral knee orthoses (L1833x2) provided on October 13, 2020.
You asked the Plan to pay for knee orthoses. You say that the requested items are medically necessary for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met because there is no evidence of an established relationship between the enrollee and the ordering physician.
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 knee orthoses. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation in the case file does not support that the requested knee orthoses were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by Medicare. There is no documentation of recent injury to, or recent surgical procedure on, either of the enrollee's knees, and there is insufficient credible objective documentation of joint laxity. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of knee orthoses have not been met. Therefore, we decided that the Plan does not have to pay for bilateral knee orthoses (L1833x2) provided on October 13, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy.

You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that you were not aware that having a polyp removed during your colonoscopy would result in a charge. The Plan denied your request. The Plan says you were charged this copayment 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 $250 copayment for outpatient surgery in an outpatient hospital facility.

You have been asked to pay a $250 copayment for the diagnostic colonoscopy. Records from this colonoscopy show that it was ordered as a diagnostic colonoscopy as part of a work-up for colon Diverticulosis and polyps. There is no evidence in your medical records that this colonoscopy was ordered as a screening. That is why the diagnostic colonoscopy falls within the outpatient surgery in 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 for the diagnostic colonoscopy.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services.

You asked the Plan to pay for the laboratory services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the laboratory services. 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 laboratory services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services that you provided on October 12, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the Plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 physician's services. 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 physician's services that you provided on October 12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for COVID-19 testing.

You asked the Plan to pay for the COVID-19 testing. You say that you would like reconsideration because this testing was ordered by your physician and should be a covered benefit. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.

The test at issue in this appeal, the COVID-19 testing, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Additionally, the record does not indicate that this exam was performed due to a relationship to treatment or diagnosis for a specific illness. Therefore, we decided that the Plan does not have to pay for COVID-19 testing.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on
October 20, 2020.
You asked the Plan to pay for the domiciliary or rest home visit. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider such as an urgent or an emergent situation that has been documented.
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 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 a domiciliary or rest home visit provided on October 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar brace provided on September 14, 2020.
You asked the Plan to pay for the services provided. You say that the provider has properly billed for all services. The Plan denied your request. The Plan says the claim processed correctly.
The Plan must follow Medicare rules. Medicare rules say that the information submitted must corroborate the documentation in the beneficiary's medical documentation.
We looked at the file and the rules. In this case, the records only include a telephone conversation with the enrollee. There are insufficient records to show a brace is needed to restrict mobility, or following an injury or surgical procedure. There are no medical records showing the enrollee has tried and failed conservative measures. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar brace provided on September 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the microslide consultation (88321) provided on September 23, 2020.
You asked the Plan to pay for the microslide consultation. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says procedure code 88321 does not meet MUE criteria.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. In this case, the MUE for CPT code 88321 is 1. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the microslide consultation have not been met. Therefore, we decided that the Plan does not have to pay for the microslide consultation (88321) provided on September 23, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray provided on October 12, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the x-ray. You say that the diagnostic radiology procedures you are billing for does not require authorization. The Plan denied your request. The Plan says no prior authorization was 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 x-ray provided on October 12, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee brace provided on May 22, 2020.
You asked the Plan to pay for the knee brace. The Plan denied your request. The Plan says there is no
documentation of injury or surgery to the knees.
The Plan follows Medicare rules. Medicare rules say that knee orthoses are only covered under certain medical
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 pay for the knee brace. Our physician reviewer
found that the enrollee has a history of primary osteoarthritis and chronic pain in the left knee. There is no
documentation of a recent injury or surgical procedure on the knee. The knee was stable to varus and valgus
stress. The documentation in the case file does not support that the provided knee orthosis was medically
reasonable and necessary for the enrollee in this case.
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 knee brace have not been met. Therefore, we decided that the Plan does not
have to pay for the knee brace provided on May 22, 2020.