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

We decided that the Plan does not have to waive the coinsurance for the laryngoscopy procedure you had at an outpatient hospital facility on March 8, 2021.

You asked the Plan to waive the coinsurance for the laryngoscopy procedure. You say that you don't believe you should have to pay a separate cost sharing amount for this service since it was done in a regular patient room. The Plan denied your request. The Plan says you were charged this coinsurance correctly

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for surgery or observation room service in an outpatient hospital. 

You have been asked to pay 20% coinsurance for the laryngoscopy procedure. The facility where you had this service is considered an outpatient hospital facility, so the laryngoscopy procedure falls within the surgery or observation room service in an outpatient hospital benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the laryngoscopy procedure you had at an outpatient hospital facility on March 8, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient diagnostic test and diagnostic radiology services provided by a participating provider on March 8, 2021.

You asked the Plan to waive the copayment for an outpatient diagnostic test and diagnostic radiology services. You say that this was your annual pap screening. You say that you should not have a copayment for this. The Plan denied your request. The Plan says the correct copayments have been applied to the diagnostic tests that were 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 $50 copayment for outpatient diagnostic tests/outpatient diagnostic tests and a $110 copayment for outpatient diagnostic tests/diagnostic radiology services.

You have been asked to pay a $50 copayment and a $110 copayment for an outpatient diagnostic test and diagnostic radiology services. The total amount you are being asked to pay is $160 ($50 + $110 = $160). An outpatient diagnostic test and diagnostic radiology services falls within the outpatient diagnostic tests/outpatient diagnostic tests and outpatient diagnostic tests/diagnostic 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 copayment for an outpatient diagnostic test and diagnostic radiology services provided by a participating provider on March 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on January 13, 2021.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. 

The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on January 13, 2021.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve a diagnostic colonoscopy.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says that the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that a diagnostic colonoscopy is covered for specific indications only. 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 these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee's colonoscpy on October 30, 2015 revealed pan-colonic diverticulitis and three diminutive colon polyps. Two transverse polyps were tubular adenoma and the right colon polyp was non-dysplastic polypoid mucosa. There is also a family history of colon cancer. The diagnostic colonoscopy is reasonable and medically necessary given the enrollee's history of adenomas and family history of colon cancer. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-approve a diagnostic colonoscopy.
Appeal type: Home Health
Decision: Unfavorable

We decided the Plan does not have to pay for home health services provided to the enrollee on February 2, 2021.

You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says you are not listed as Medicare eligible provider.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who is not a Medicare eligible provider. The records provided do not show that you are a Medicare eligible provider. Therefore, we decided that the Plan does not have to pay for home health services provided to the enrollee on February 2, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy services.

You asked the Plan to pre-approve physical therapy services. You say that you cannot walk without a cane. The Plan denied your request. The Plan says additional services are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 physical therapy services. Our physician reviewer found that the additional physical therapy is not generally accepted as effective therapy for your condition beyond what was approved by the health plan.

The records do not demonstrate that the unique skills of a professional therapist are required to provide treatment, that the services can be performed only by a therapist, or under the supervision of a therapist. You have been instructed in a home exercise program. The requested services are not part of a maintenance program. The specialized skill of a qualified therapist is not required to establish or deliver a program to maintain your current condition or to prevent or slow further deterioration. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Nodify CDT testing (81599) provided on December 17, 2020.
You asked the Plan to pay for Nodify CDT testing. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that MolDX will review all new test/assay clinical information to determine if a test meets Medicare's reasonable and necessary requirement. Labs must submit a comprehensive dossier on each new test/assay prior to claim submission. MolDX will only cover and reimburse tests that demonstrate analytical and clinical validity, and clinical utility at a level that meets the Medicare reasonable and necessary requirement.
We looked at the file and Medicare rules. MolDX has determined that the testing at issue does not meet the Medicare reasonable and necessary requirement. Based on this information, we decided that Medicare rules for coverage of Nodify CDT testing have not been met. Therefore, we decided that the Plan does not have to pay for Nodify CDT testing (81599) provided on December 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit and fundus photography you received from an ophthalmologist on April 27, 2021.

You asked the Plan to waive the copayment for the ophthalmology services. You say that you do not believe you should have a copayment because this was an annual eye exam. 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 $40 copayment for diagnosis and treatment for diseases and conditions of the eye (including diabetic retinopathy). 

You have been asked to pay a $40 copayment for the ophthalmology services. Medical records show that you were referred to the ophthalmologist for an evaluation for possible diabetic retinopathy, not for a routine annual eye exam. That is why these ophthalmology services fall within the diagnosis and treatment for diseases and conditions of the eye (including diabetic retinopathy) 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 office visit and fundus photography you received from an ophthalmologist on April 27, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance service, advanced life support, non-emergency transport, level 1 (A0426) and ground mileage, per statute mile (A0425) provided April 2, 2021.

You asked the Plan to waive the copayment for the ambulance transport. You say that the cost should be covered because you had coronavirus. The Plan denied your request. The Plan says this service is not covered under the coronavirus waiver and 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 $325 copayment for each Medicare-covered one-way trip via ground ambulance. 

You have been asked to pay a $325 copayment for the ambulance transport. This transport falls within the Ambulance 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 ambulance
service, advanced life support, non-emergency transport, level 1 (A0426) and ground mileage, per statute mile
(A0425) provided April 2, 2021.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a K3 foot, all lower extremity prostheses, multi-axial rotation unit (L5986).

You asked the Plan to pre-approve a K3 foot. You say that you are confident that within one month after the enrollee receives his prosthesis, he will ambulate at a K3 level. The Plan denied your request. The Plan says the request for a K3 foot exceeds the member's need and does not meet the Medicare criteria of reasonable and 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 pre-approve a K3 foot. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review has determined that the requested K3 foot, all lower extremity prostheses, multi-axial rotation unit (L5986) is not medically necessary or reasonable. 

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 K3 foot have not been met. Therefore, we decided that the Plan does not have to pre-approve a K3 foot, all lower extremity prostheses, multi-axial rotation unit (L5986).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services that you provided from
December 25, 2020, through December 27, 2020.
You asked the Plan to pay for the physician's services. 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 member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee- for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on December 23, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for physician's services that you provided from December 25, 2020, through December 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the follow-up visit with a surgeon you had on March 1, 2021.
You asked the Plan to waive the copayment for the surgical follow-up visit. You say that you were in a rehabilitation facility that the time, so this copayment is not correct. The Plan denied your request. The Plan says this copayment was charged correctly. The Plan says that although you were in a nursing facility, you were transferred to the surgery clinic on March 1, 2021, for a surgical follow-up visit. Because you were physically seen in the surgery clinic, this copayment applies.
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 $30 copayment for medical care or surgery services in a Specialty physician's office.
You have been asked to pay a $30 copayment for the surgical follow-up visit. The surgical follow-up visit falls within the medical care or surgery services in a Specialty physician's office 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 follow-up visit with a surgeon you had on March 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the neurosurgery visit you had on May 4,
2021.
You asked the Plan to waive the copayment for the neurosurgery visit. You say that you went to the
neurosurgery office because you saw an ad on television. You stated that you only saw a nurse practitioner
while there, so you shouldn't have to pay a copayment. The Plan denied your request. The Plan says you were
charged this copayment correctly. You received services in a specialist's office, so the correct copayment was
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 $30
copayment for visits with a specialist physician or practitioner.
You have been asked to pay a $30 copayment for the neurosurgery visit. The neurosurgery visit falls within the
visits with a specialist physician or practitioner 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 neurosurgery visit you had on May 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan and a facility fee provided by a participating provider on March 9, 2021.
You asked the Plan to waive the copayment for a CT scan and a facility fee. You say that you do not agree with these copayments. The Plan denied your request. The Plan says the correct copayments have 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 $125 copayment for outpatient diagnostic tests/radiological diagnostic services and a $175 copayment for outpatient surgery/outpatient hospital charge.
You have been asked to pay a $125 copayment for a CT scan and a $175 copayment for a facility fee. The total amount you are being asked to pay is $300 ($125 + $175 = $300). A CT scan falls within the outpatient diagnostic tests/radiological diagnostic services benefit category and a facility fee falls within the outpatient surgery/outpatient hospital charge 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 CT scan and a facility fee provided by a participating provider on March 9, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on October 22, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the 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 out of network physician services provided to the enrollee on October 22, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on October 29, 2020.

You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the 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 out of network physician services provided to the enrollee on October 29, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health care provided to the enrollee from April 8, 2020
to April 30, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid by the Plan. The Plan denied
your request. The Plan says the provider did not bill with correct Q code on the claim. Per Medicare guidelines,
HHAs must report an additional line item with the same revenue code and date of service, reporting one of the
three Q codes (Q5001, Q5002, and Q5009), one unit and a nominal covered charge (e.g., a penny).
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate codes. In this case, this claim cannot be paid due to the
omission of the required "Q" code. Medicare coverage criteria are not met. Therefore, we decided that the Plan
does not have to pay for home health care provided to the enrollee from April 8, 2020 to April 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on March 1, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider on March 1, 2021.