Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on December 20, 2019 by an out of network (OON) provider.You asked the Plan to pay for the OON services. You say that the services are an extension of the initial visit.The Plan denied your request. The Plan says there is no network deficiency for services, and alternate network providers were found.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 and the ordering provider in this case are not network providers 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 services at issue. We found no exception that would require the Plan to pay for these OON services.Therefore, we decided that the Plan does not have to pay for the lab services provided on December 20, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for periodic oral exam (D0120) and
prophylaxis (D1110) provided February 3, 2020 by an out of network provider.
You asked the Plan to waive the copayment for the dental services. You say that according to your enrollment
guide you should have zero copay. You should have 100% coverage for preventive and diagnostic services and
routine cleanings. The Plan denied your request. The Plan says the correct copayment was applied. The charges
exceeds the allowable for this procedure.
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 $40
copay for each visit to out of network dental provider. You may be billed more by an out of network provider if
the charge is greater than the Maximum Allowable Charge (MAC).
You have been asked to pay $40 copay for the dental services. The services fall within the Dental 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 periodic oral exam (D0120) and
prophylaxis (D1110) provided February 3, 2020 by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the hydration infusion provided on December 14, 2019.
You asked the Plan to waive the copayment for the hydration infusion. You say that you didn't see the doctor on either date. You say that there was no code billed that would warrant a copayment. The Plan denied your request. The Plan says the copayment 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 $35 copayment for services obtained from a specialist, or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's office. You have been asked to pay a $35 copayment for the hydration infusion. The hydration infusion falls within the "Physician/Practitioner Services, Including Doctor's Office Visits" benefit category. The hydration infusion is considered a physician service. 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 hydration infusion provided on December 14, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the imaging services provided on January 30, 2020.
You asked the Plan to pay for the services provided. You say that the records support that the procedure was performed by the provider. The Plan denied your request. The Plan says the services were previously approved and paid.
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined to be exact duplicates of another claim are denied.
The file shows the enrollee received a screening mammogram and tomosynthesis. The documentation shows the services at issue were previously billed and paid for by the plan. There is no documentation to show that additional procedures were performed on the date of service at issue. 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 imaging services provided on January 30, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy provided on December 10,
2019.
You asked the Plan to waive the copayment for the colonoscopy. You say that you do not agree with the code
that was used for the procedure. 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 $395
copayment for Medicare-covered surgery or other services provided to you at an ambulatory surgical center,
including but not limited to hospital or other facility charges and physician or surgical charges. For this date of
service, you have been asked to pay the allowed amount of the claim because this amount is less than the $395
copayment for the colonoscopy.
You have been asked to pay a $310.52 copayment for the colonoscopy. The colonoscopy falls within the
"Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory
Surgical Centers" benefit category. The medical record shows a personal history of colon polyps which makes
the colonoscopy diagnostic in nature.
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 colonoscopy provided on December 10, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the chemical cauterization procedure provided on June 6, 2019.
You asked the Plan to waive the copayment for the chemical cauterization procedure. You say that you are asking the Plan to reconsider paying $168.65. You say the service should be considered as an outpatient service. 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 $325 copayment for surgical services at an in-network outpatient hospital facility. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $325 copayment for the chemical cauterization procedure.
You have been asked to pay a $168.65 copayment for the chemical cauterization procedure. The chemical cauterization procedure falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows that the chemical cauterization procedure is considered an outpatient surgical procedure.
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 chemical cauterization procedure provided on June 6, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan provided on October 3, 2019. You asked the Plan to waive the copayment for the CT scan. You say that you didn't know about a copayment. You say that you don't have the money to pay the bill. The Plan denied your request. The Plan says the copayment 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 an $85 copayment for covered diagnostic radiology services in a provider's office or freestanding radiology center. You have been asked to pay an $85 copayment for the CT scan. The CT scan 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 CT scan provided on October 3, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 3, 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 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 above, are not covered. The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on January 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee brace and sleeve (L1833 and L2397) provided on December 13, 2019.You asked the Plan to pay for the knee brace and sleeve. You say that you would like reconsideration because the supplied equipment is medically necessary.The Plan denied your request. The Plan says the documentation submitted did not indicate the provider discussed the need for the billed supply codes.The Plan must follow Medicare rules. Medicare rules say that for any DMEPOS item to be covered by Medicare, the patient's medical record must contain sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use or replacement (if applicable). We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the knee brace and sleeve have not been met. Specifically, the record indicates that the Plan requested documentation to validate an established relationship with the ordering physician along with documentation of the duration of the member's condition, clinical course (worsening or improving), prognosis,nature and extent of functional limitations, other therapeutic interventions and results and previously purchased DME items related to the billed items. The submitted documentation does not include medical records to validate the billed supply codes.Therefore, we decided that the Plan does not have to pay fora knee brace and sleeve (L1833 and L2397) provided on December 13, 2019.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve Total Knee Arthroplasty. You asked the Plan to pre-approve Total Knee Arthroplasty. You say that the procedure is medically necessary. The Plan denied your request. The Plan says that rules for coverage are not met. The Plan follows Medicare rules. Medicare rules say that Total Knee Arthroplasty is covered when medically necessary. 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 Total Knee Arthroplasty. Our reviewer says that coverage criteria has been met. Our physician reviewer found there is severe pain and functional disability. There is radiographic evidence of advanced right knee joint disease. There is evidence of failed long-term conservative treatment, and additional treatment is not indicated based on bone-on-bone findings. Therefore, this request for right total knee arthroplasty is medically reasonable and 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 Total Knee Arthroplasty have been met. Therefore, we decided that the Plan has to pre-approve Total Knee Arthroplasty.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Amitiza capsules.
You asked the Plan to pre-approve Amitiza. You say that the enrollee has tried and failed several other drugs.
You also say that Amitiza seems to be the only medication that works well for the enrollee. The Plan denied
your request. The Plan says this drug is not covered for the enrollee's condition by Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Amitiza capsules.
Benefits for Amitiza may be available under Medicare Part D. Contact the Plan that administers Part D benefits
for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on January 20, 2020.You asked the Plan to pay forthe assembly and operation of a pump with an oxygenator or heat exchanger. You say that this service was necessary.The Plan denied your request. The Plan says payment for this service is included in the DRG.The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule. The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of "C" on Addendum B of the 2020 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission.Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on January20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the CYP gene panel provided on September 5, 2019.
You asked the Plan to pay for the CYP gene panel. 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 CYP gene panels are not covered. We looked at the file and Medicare rules. In this case, the file shows you billed for a CYP gene panel. These panels should be billed with a single code - CPT 81479. CYP gene panels that test for multiple CYP genes are not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the CYP gene panel have not been met. Therefore, we decided that the Plan does not have to pay for the CYP gene panel provided on September 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora specialist office visit (99213) provided on February 5, 2020.You asked the Plan to waive the copayment fora specialist office visit. You say that you should not be responsible for a copayment because you did not receive an injection during this visit.The Plan denied your request. The Plan says this processed 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 $30 copayment for specialist visits. You have been asked to pay a $30 copayment for a specialist office visit. 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 fora specialist office visit (99213) provided on February 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary, rest home visit provided on February 18,
2020.
You asked the Plan to pay for the domiciliary, 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 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 the domiciliary, rest home visit provided on February 18, 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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. 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 you were medically stable with no evidence of need for supervision by a physical medicine and rehabilitation (PMR) Physician or needs acute rehab nursing care. Functionally given you are at contact guard assist (CGA) and hand held assist (HHA) for mobility, you do not need acute rehab therapy. You may benefit from further physical therapy (PT) and occupational therapy (OT) but do not require an intensive therapy program. IRF admission is not medically necessary based on your current functional status and medical stability. 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical assistant services on a computer-assisted surgical navigational procedure (20985) provided on September 3, 2019.
You asked the Plan to pay for surgical assistant services on a computer-assisted surgical navigational procedure. You say that this should be covered. The Plan denied your request. The Plan says surgical assistant services are not covered.
The Plan follows Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare rules say that for procedures with an assistant surgery indicator of 0, the payment restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to establish medical necessity. In this case, you billed assistant surgery services for CPT code 20985. The Medicare Fee Schedule Database contains a surgical indicator of 0 for this procedure. 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 surgical assistant services on a computer-assisted surgical navigational procedure. Our reviewer says that the criteria for coverage of these services has not been met. Our physician reviewer found the medical records show that this is an uncomplicated surgery. There is no documented need for an assistant surgeon.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of surgical assistant services on a computer-assisted surgical navigational procedure have not been met. Therefore, we decided that the Plan does not have to pay for surgical assistant services on a computer-assisted surgical navigational procedure (20985) provided on September 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for wound care services provided on January 8, 2020.You asked the Plan to pay for the wound care services. The Plan denied your request. The Plan says services from non-participating providers are not covered under open access unless pre-authorized.Medicare rules say that plans can require enrollees to get care from network providers. Thecontract 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 thePlan. The Plan did not pre-approve the servicesat 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 wound care services provided on January 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe compression stockings identified with code A6549 that were issued on July 2, 2019.You asked the Plan to pay forthe compression stockings. You say that the provider who supplied you the compression stockings has no idea who this other provider is.The Plandenied your request. The Plan says this item is not covered under any normal circumstances.The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are non-covered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan.Therefore, we decided that the Plan does not have to pay forthe compression stockings identified with code A6549 that were issued on July 2, 2019.