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

We decided that the Plan does not have to waive the copayment for the Electrocardiogram (ECG) (93010)
provided on September 24, 2020.
You asked the Plan to waive the copayment for the ECG. You say that the copay waiver should have been
applied for these services. The Plan denied your request. The Plan says the copay waiver has been applied to
the office visit; however, the ECG is a separate service that has a separate copayment.
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 laboratory tests, non-radiological diagnostic tests, flat film x-rays, and ultrasounds.
You have been asked to pay a $20 copayment for the ECG. An ECG falls within the laboratory tests, nonradiological
diagnostic tests, flat film x-rays, and ultrasounds benefit category. Cost sharing for services in this
category will apply even if they are provided during an office visit with your provider. 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 Electrocardiogram (ECG) (93010) provided on September 24,
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for frames (V2020) and lenses (V2781, V2799, V2761) purchased form an out-of-network provider on September 29, 2020.

You asked the Plan to pay for frames and lenses. You say that these items should be covered. The Plan denied your request. The Plan says eyewear is only covered when purchased in-network.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when provided by in-network providers. 

We looked at the file and the Plan's rules. The Plan's benefit does not include out-of-network coverage. Based on this information, we decided that the Plan's rules for coverage of frames and lenses have not been met. Therefore, we decided that the Plan does not have to pay for frames (V2020) and lenses (V2781, V2799, V2761) purchased form an out-of-network provider on September 29, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for physician's services provided on September 30, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that authorization was absent for this service.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has not provided the name and network status of the referring provider. Therefore, we decided that the Plan has to pay for the physician's services provided on September 30, 2020.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the occlusal guard (D9944) provided on December 21, 2020.
You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says this item is not a covered benefit under your dental policy.
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 item provided is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the occlusal guard (D9944) provided on December 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for post stabilization.

You asked the Plan to pay for the inpatient services. You say that the inpatient services were medically
reasonable and necessary. The Plan denied your request. The Plan says the emergency stabilization and care are paid but the hospital failed to request pre-approval for post stabilization.

The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider,
approval is required.

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 inpatient services. Our reviewer says that
the post stabilization services were not medically necessary. Our physician reviewer found that the enrollee was stable for ambulance transport with monitoring to a Plan facility because the issues were resolved. Post-stabilization care services were not medically necessary or reasonable. The treating physician did not document (in the physician notes, on a form, or in an order) that the patient was not stable for transfer on any dates of service.

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 inpatient services have not been met. Therefore, we decided that the Plan
does not have to pay for inpatient services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room (ER) and laboratory services rendered on September 22, 2020.
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 billed incorrectly.
The Plan must follow Medicare rules. The rules say that all charges, except for therapies, telehealth originating site facility fee, PPV, influenza virus vaccine, hepatitis B vaccine and hospital-based ambulance services are combined and reported under revenue code 0510 (clinic visit) on TOB 13X (hospital outpatient). We looked at the file and Medicare rules. The file shows that the outpatient services were not billed with the required TOB 13x. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the emergency room (ER) and laboratory services rendered on September 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0676).

You asked the Plan to pay for a pneumatic compression device. You say that this service was medically necessary. The Plan denied your request. The Plan says this service is not covered by Medicare.

The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. 

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0676).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (82542, 83090, 83497, 83789, 83918, 83921, 84207 and 84585) provided on August 24, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration because this testing helps members with pain management. The Plan denied your request. The Plan says this service was not medically necessary.
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 the laboratory services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found no data are provided to support the contention that functional biomarker testing or correcting functional biomarker findings aid in the treatment of chronic illness and pain. 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 laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services (82542, 83090, 83497, 83789, 83918, 83921, 84207 and 84585) provided on August 24, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for air ambulance services provided on August 17, 2019.
You asked the Plan to pay for the air ambulance services. You say that the Plan should pay the claim. The Plan denied your request. The Plan says transport back to the United States is not covered.
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate. We looked at the file and Medicare rules. You were not transported to the nearest appropriate facility and transport back to the United States is not covered by Medicare or the Plan. Based on this information, we decided that Medicare rules for coverage of the air ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for air ambulance services provided on August 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on June 19, 2020.
You asked the Plan to pay for the physician's services. 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 emergency situation, 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 physician's services provided on June 19, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the clinical information provided supports the need for IRF care. The Plan denied your request. The Plan says IRF care is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the blood bank physician services (86077) provided on August 29, 2020.
You asked the Plan to pay for the blood bank physician services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says code 86077 supports 1 (one) unit for date of service and Provider billed 2 units of 86077.
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 86077 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 blood bank physician services have not been met. Therefore, we decided that the Plan does not have to pay for the blood bank physician services (86077) provided on August 29, 2020.
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 September 17, 2020.
You asked the Plan to waive the copayment for the urgent care visit. You say that you should not be responsible for the 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $65 copayment per visit for Medicare-covered urgently needed services. You have been asked to pay a $65 copayment for the urgent care visit. The urgent care visit falls within the "Urgently needed services" benefit category. The medical record shows a physical exam was done in addition to the Covid-19 test. 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 urgent care visit provided on September 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the EKG.

You asked the Plan to waive the copayment for the EKG. You say that you did not know there would be a
copayment and you think the service was unnecessary. The Plan denied your request. The Plan says you are
required to pay $10 per day for Medicare-covered tests.

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 $10
copayment for outpatient diagnostic tests and therapeutic services and supplies.

You have been asked to pay a $10 copayment for the EKG. The EKG falls within the outpatient diagnostic
tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment
for the (EKG).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic urea breath test (78267, 78268) provided on August 7, 2020.
You asked the Plan to waive the copayment for the breath test. You say that the cost is too high, and this service was provided by a primary care provider, not a specialist. The Plan denied your request. The Plan says this type of diagnostic procedure has a $150 copayment, regardless of where the service is 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 $150 copayment for all other diagnostic and nuclear medicine radiological services. You have been asked to pay a $116.02 copayment for the breath test. A urea breath test is classified as a diagnostic nuclear medicine procedure and falls within the other diagnostic and nuclear medicine radiological 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 diagnostic urea breath test (78267, 78268) provided on August 7, 2020.
Your complaint about the high cost of your required copayment is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for podiatry services provided on June 16, 2020 by an out of network (OON) provider.
You asked the Plan to pay for podiatry services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the referring provider is out-of-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for podiatry services provided on June 16, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular genetic hereditary predictive screening testing provided to the enrollee on August 19, 2020.
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. The Plan says Medicare says tests with no relation to a medical diagnosis of disease for the health of the patient are not a benefit.
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 the testing. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found CxBladder is a Laboratory Developed Test (LDT). CxBladder has not been cleared or approved by the US Food and Drug Administration. In the absence of a controlling national or local coverage determination, coverage is controlled by the Section 1862 (a)1(A) and the 42 CFR Section 411.15(k). In this case, the case file indicates that a partial payment has been made. The medical records provided do not indicate that the test is medically necessary or reasonable at this time and as such cannot be recommended. 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for molecular genetic hereditary predictive screening testing provided to the enrollee on August 19, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that the enrollee did not
need to be in the hospital therefore the copayment should be waived. The Plan denied your request. The Plan
says per the enrollee's plan benefit, copayments cannot be waived.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees
must pay a $250 copayment per day, for days 1 - 7 for inpatient hospital care.
The enrollee has been asked to pay $750 in total copayments (a $250 copayment per day, for a three-day
inpatient hospital stay). This inpatient hospital stay falls within the inpatient hospital care benefit category. This
means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost
sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided
that the Plan does not have to waive the copayment for the inpatient hospital stay.