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

We decided that the Plan does not have to waive the copayment for a cystourethroscopy provided on January 6, 2020.
You asked the Plan to waive the copayment for a cystourethroscopy. You say that you were not informed of 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 $325 copayment for surgery services provided in an outpatient hospital facility. You received a cystourethroscopy on January 6, 2020. A cystourethroscopy is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $325 copayment. You have been asked to pay a $325 copayment for a cystourethroscopy. A cystourethroscopy falls within the 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 a cystourethroscopy provided on January 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation provided on November 7, 2019.
You asked the Plan to pay for the comprehensive periodontal evaluation. You say that you believe this service should be paid because you saw a participating dentist. You also say that this provider did not tell you that the exam would not be covered. The Plan denied your request. The Plan says this service is not a covered benefit.
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 comprehensive periodontal evaluation provided on November 7, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided December 31, 2019 to
January 6, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary.
The Plan denied your request. The Plan says that rules for coverage were not met.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
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 acute inpatient hospital care. Our reviewer
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician
reviewer found the record showed that at the time of inpatient admission the admitting physician reasonably
expected that the patient's necessary hospital care (including earlier emergency and/or observation care) would
span two midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan
has to pay for the acute inpatient hospital care provided December 31, 2019 to January 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (HCPCS G0483) provided to the enrollee on February 6, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Healthcare Common Procedure Coding System (HCPCS) code G0483 (1 Unit) remains not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code G0483 is "Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed." 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 services. Our reviewer says that the services at issue in this case were not coded correctly. Our physician reviewer found the medical records provided does not include documentation in the patient's medical record that this test was being ordered. There is no lab requisition requesting HCPCS be performed on February 6, 2019, therefore this service cannot be verified. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing services (HCPCS G0483) provided to the enrollee on February 6, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copaymentthe ophthalmic ultrasound provided on February 11, 2020.You asked the Plan to waive the copaymentthe ophthalmic ultrasound. You say that you do not agree with the ultrasound copayment. You say this should be included in your office visit copayment. The Plan denied your request. The Plan says you have been charged the correctcost 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 $40 copaymentfor each basic imaging service (e.g., general x-rays or ultrasound). For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $40 copayment for the ophthalmic ultrasound.You have been asked to pay a $11.83 copayment for the ophthalmic ultrasound. The ophthalmic ultrasound 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 copaymentthe ophthalmic ultrasound provided on February 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on December 10, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are 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 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 has network providers available who can provide the services 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 these services.Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on December 10, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on January 29, 2020.
You asked the Plan to pay for drug 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 support a valid order for this testing.
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 valid 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 for drug testing provided on January 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular pathology services provided on March 13, 2020.You asked the Plan to pay for the molecular pathology services.The Plan denied your request. The Plan says services rendered by non-participating providers require prior authorization unless they are emergent or urgent.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 molecular pathology services provided on March 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient surgery provided on December
30, 2019.
You asked the Plan to waive the copayment for outpatient surgery. You say that this procedure was in a clinic
owned by the hospital but is a separate entity. The Plan denied your request. The Plan says the copayment
amount you are being charged is correct.
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 $250
copayment for outpatient surgery provided by an outpatient hospital. The rendering provided is considered to
be an outpatient hospital facility, therefore the outpatient hospital surgery copayment applies to this claim.
You have been asked to pay $250 copayment for outpatient surgery. Outpatient surgery falls within the
Outpatient Surgery, Including Services Provided at Hospital 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 outpatient surgery provided on December 30,
2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for hyperbaric oxygen therapy provided by a participating facility on January 27, 2020 to January 29, 2020.You asked the Plan to waive the coinsurance for hyperbaric oxygen therapy. You say that you have never been charged this much before.The Plan denied your request. The Plan says the correct coinsurance 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% coinsurance for outpatient diagnostic tests/in-network/therapeutic radiology services. You have been asked to pay a 20% coinsurance of the allowed amount for hyperbaric oxygen therapy. The total allowed amount is $1,533.88. The total amount you are being asked to pay is $306.78 ($1,533.88 x 20% = $306.78). Hyperbaric oxygen therapy falls within the outpatient diagnostic tests/in-network/therapeutic radiology 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 coinsurance for hyperbaric oxygen therapy provided by a participating facility on January 27, 2020 to January 29, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code G0249 provided from November 10, 2019 to
November 25, 2019.
You asked the Plan to pay for CPT code G0249. 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 and Medicare rules. We find that HCPCS code G0249 is not supported in the medical
record. Specifically, these services are being billed once per week on November 3, 2019, November 10, 2019,
November 17, 2019, and November 25, 2019. Each billing of HCPCS G0249 is for four tests. This means that
4 tests are being billed for each week, which exceeds the limits set by Medicare. The Plan paid for the
November 3, 2019 date of service. Therefore, we decided that the Plan does not have to pay for CPT code
G0249 provided from November 10, 2019 to November 25, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the subcutaneous tissue debridement services provided on
November 18, 2019.
You asked the Plan to pay for the debridement services. You say that the enrollee's hospice election period
ended on November 13, 2019. The Plan denied your request. The Plan says Original Medicare would be
responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal
condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for the subcutaneous tissue debridement services provided on
November 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac joint fusion.
You asked the Plan to pre-approve sacroiliac joint fusion. You say that the services are medically necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 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 sacroiliac joint fusion. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case there is no documentation of six months of conservative treatment and there is also evidence of arthritis of the hips that may be contributing to her back issues. There is no specific clinical rationale for the requested sacroiliac joint fusion. The requested sacroiliac joint fusion is not medically reasonable or 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 sacroiliac joint fusion have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroiliac joint fusion.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter.You asked the Plan to pre-approve a power scooter. The Plan denied your request. The Plan says that there is no evidence of you being unable to operate a manual wheelchair or have a caregiver operate it for you.The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a power scooter. Our reviewer says that a power scooter is not medically reasonable and necessary in this case. You have a personal mobility deficit but the documentation is not clear that it impairs participation in MRADLs in the home. The documentation is not clear that the mobility deficit is unable to be helped by the use of a walker, cane or manual wheelchair. There is no evidence of a home evaluation indicating you can safely operate a PMD. Our physician reviewer found that your condition does not meet Medicare criteria for a power scooter.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 power scooter have not been met.Therefore, we decided that the Plan does not have to pre-approve a power scooter.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 95937 provided on April 5, 2019. You asked the Plan to pay for CPT code 95937. 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, the CPT Code Manual definition of code 95937 is Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method. We find that CPT code 95937 is not supported in the medical record. Specifically, the record shows that train of four testing was performed and this is not the appropriate code for this service. Per Medicare guidelines, it is inappropriate to bill unlisted neurological or neuromuscular diagnostic CPT codes for train of four monitoring. There is no separate code for train of four monitoring. Therefore, we decided that the Plan does not have to pay for CPT code 95937 provided on April 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for mandibular partial denture -cast metal framework with resin denture bases (including any conventional clasps, restsand teeth) (D5214) provided on January 2, 2020.You asked the Plan to pay forthe dental services. You say that the dentist informed you that you would need an interim partial denture, and that the plan would only cover one (1) device every few years.The Plan denied your request. The Plan says the service is not a covered benefit under the 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. This service is not listed in your EOC as a covered benefit; therefore, it is not covered.Therefore, we decided that the Plan does not have to pay formandibular partial denture -cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) (D5214) provided on January 2, 2020
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the eye surgery provided on January 17, 2020.
You asked the Plan to waive the deductible for the eye surgery. You say that you cannot afford this bill. You say you should only pay a $45 copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $1,000 deductible that applies towards outpatient surgery. The eye surgery you asked the Plan to waive the deductible for falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,000 deductible that applies towards the outpatient eye surgery. This cost sharing is a contractual obligation that had not been met at the time the eye surgery was received on January 17, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the eye surgery provided on January 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the office visits provided from December 5, 2019 to January 9, 2020.You asked the Plan to waive the copayments for the office visits. You say that you were told this provider was in-network. The Plan denied your request. The Plan says you have been charged 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 $55 copayment for out-of-network primary care physician (PCP) services (including Medicare-covered telehealth and urgently needed services). You have been asked to pay a $55 copayment for each of the office visits. The office visits fall within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows the provider is out-of-network.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 office visits provided from December 5, 2019 to January 9, 2020.