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

We decided that the Plan does not have towaive the copayment forthe wound care provided on July 30, 2019.You asked the Plan to waive the copayment forthe wound care. You say that there were two visits to the doctor's office and that you were never an outpatient. The Plandenied 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 $275 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges. You have been asked to pay a $275 copayment for the wound care. The wound care falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The record shows you were billed by the outpatient hospital.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 forthe wound care provided on July 30, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Prolia injection provided on October 2, 2019.You asked the Plan to waive the coinsurance for the injection. You say that you can't pay this bill.The Plan denied your request. The Plan says that the coinsurance is your responsibility.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 Medicare Part B prescription drugs. You have been asked to pay a 20% coinsurance for the injection. The injection falls within the Medicare Part B prescription drugs 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 Prolia injection provided on October 2, 2019
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fortheCT scan provided on November 4, 2019.You asked the Plan to waive the copayment forthe chest CT scan. You say that you received approval for the CT scan and was told by your doctor that it would be covered in full. 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 $175 copayment for each Medicare-covered service. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $175 copayment for the CT scan.You have been asked to pay a $154.11 copayment for the chest CT scan. The chest 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 forthe CT scan provided on November 4, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLTACH services.You asked the Plan to pre-approvethe LTACH services. The Plan denied your request. The Plan says transfer of the enrollee to another institution is not in the enrollee's best interest.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our physician reviewer found LTACHs are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include respiratory support with tracheostomy care, surveillance laboratory studies, telemetry monitoring, close fluid balance with diuretics, tube feedings, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the currenthealth care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost share forthe chemodenervation of the larynx and the Part B injection provided on November 7, 2019.You asked the Plan to reduce the cost share forthe larynx chemodenervation and the Part B injection. You say that you have received the injections before and your copayment has been $45. You say you should not be responsible for the higher cost at the different location. 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 $300 copayment for outpatient surgery services and 20% of the cost for Part B covered chemotherapy and other Part B covered drugs. You have been asked to pay a total of $235.46 for the larynx chemodenervation and the Part B injection. The larynx chemodenervation falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The Part B injection falls within the "Medicare Part B prescription drugs" benefit category. See chart below. ate of ServiceServiceAllowed AmountCoinsurance/CopaymentMember LiabilityNovember 7, 2019Larynx chemodenervation$230.09$300.00$230.09November 7, 2019Part B injection$26.8520%$5.37Total$235.46This 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 reduce the cost share forthe chemodenervation of the larynx and the Part B injection provided on November 7, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lactose breath test.You asked the Plan to pre-approve the requested testing. You say that the providers plan includes a breath test to correctly diagnose your condition and treat it.The Plan denied your request. The Plan says the test is not covered to diagnose a possible bacterial imbalance in your intestine.The Plan must follow Medicare rules. Medicare rules say that the lactose breath hydrogen test is covered to detect lactose malabsorption.We looked at the file and Medicare rules. The requested test is not covered for diagnosing small bowel bacterial overgrowth. 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 pre-approvea lactose breath test.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment forthe oromaxillary surgery provided on August 9, 2019.You asked the Plan to reduce the copayment forthe oromaxillary surgery. You say that you would like the $150 extraction benefit applied to your $250 surgery 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 $250 copayment for each outpatient surgery and/or services at an ambulatory surgical center or outpatient hospital facility. You have been asked to pay a $250 copayment for the oromaxillary surgery. The oromaxillary surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows you were billed for the oromaxillary surgery and the dental allowance cannot be applied towards the surgery.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 reduce the copayment forthe oromaxillary surgery provided on August 9, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe set up and operation of the heart lung machine for the enrollee's open heart surgery provided on October 21, 2019.You asked the Plan to pay forthe set up and operation of a heart lung machine. You say that it takes a half hour to an hour to set up the heart lung machine. You say that the perfusionist is required to be in the operating room during the length of the procedure. You say that , per hospital protocol, it is mandatory that the surgeon, anesthesiologist, and perfusionist transport the enrollee to the unit and be there until the enrollee is in stable condition.The Plan denied your request. The Plan saysthe enrollee received the services in dispute in the facility during inpatient hospitalization and payment for the  services would be included in the part-A DRG payment to the facility. The Plan says that payment for this service is the responsibility of the facility to any vendor.The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary during an inpatient hospitalization. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers.We looked at the file and Medicare rules. The records show that the services in dispute were provided during an inpatient hospital stay. Payment for this service would have been included under the facility claim. Payment to you for this service is the responsibility of the facility or hospital. Based on this information, we decided that Medicare rules for coverage of the set up and operation of a heart lung machine have not been met.Therefore, we decided that the Plan does not have to pay forthe set up and operation of the heart lung machine for the enrollee's open heart surgery provided on October 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the ophthalmological services and scanning computerized ophthalmic diagnostic imaging provided on October 31, 2019 by an OON provider.
You asked the Plan to pay for the vision services. You say that you waited to get these services to make sure that a year had passed so you would not be billed. You also say that this was a preventive screening and should be covered at 100%. The Plan denied your request. The Plan says the services were rendered by an OON provider. The Plan also says that there was no authorization on file for the services provided.
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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the ophthalmological services and scanning computerized ophthalmic diagnostic imaging provided on October 31, 2019 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided by Dr. on July 2, 2019.You asked the Plan to waive the copayment for an office visit. You say that you disagree with the charges because the doctor only changed your medicine.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 $10 copayment per visit for primary care provider visits. You have been asked to pay a $10 copayment for an office visit. An office visit falls within the physician/practitioner services, including doctor's office visits 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 office visit provided by Dr. on July 2, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approveupper partial dentures.You asked the Planto pre-approveupper partial dentures. The Plan denied your request. The Plan says that the enrollee has enough teeth in the back of her mouth that touch with the approved lower partial denture.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. The Plan covers upper partial dentures when the services are medically necessary and reasonable.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 upper partial dentures. Our physician reviewer found that an appeal is being made for the denial of coverage for a maxillary removable partial denture replacing teeth #'s 12 and 13. The mandibular partial would provide adequate masticatory function on the right side only. Replacing the missing maxillary teeth on the left side would give adequate bilateral mastication stabilizing the occlusion and increasing function. Therefore, the requested denture is reasonable and necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of upper partial dentures have been met. Therefore, we decided that the Plan has to pre-approveupper partial dentures.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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay foran arthroplasty (27703) and a tenotomy (27606) provided on August 1, 2019.You asked the Plan to pay foran arthroplasty and a tenotomy. You say that these services were necessary.The Plan denied your request. The Plan says these codes are 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 27703 is arthroplasty, ankle; revision, total ankle and 27606 is tenotomy, percutaneous, Achilles tendon (separate procedure); general anesthesia.We asked our physician reviewer to carefully review thecase file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for an arthroplasty and a tenotomy. Our reviewer says that CPT 27703 is not supported. The medical records submitted do not include documentation of an arthroplasty, ankle; revision, total ankle, therefore, the service cannot be verified. Our physician reviewer also found that CPT 27606 is not supported.  The medical records provided do indicate that a tenotomy, percutaneous, Achilles tendon (separate procedure); general anesthesia was performed. However, an Osteotomy; calcaneus (e.g., Dwyer or Chambers type procedure), with or without internal fixation (CPT code 28300) was also performed on the same date of service, in the same anatomical area on the same side of the body and was reimbursed by the health plan. The tenotomy percutaneous, Achilles tendon (separate procedure); general anesthesia was performedin the same anatomically related area;therefore,it should not be billed separately. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an arthroplasty and a tenotomy have not been met.Therefore, we decided that the Plan does not have to pay foran arthroplasty (27703) and a tenotomy (27606) provided on August 1, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay forthe PT services provided on September 11, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe PT services. You say that you were instructed that services could still be provided by an out-of-network provider.The Plan denied your request. The Plan says 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.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 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 forthe PT services provided on September 11, 2019 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on October 1, 2019.You asked the Plan to waive the copayment for the ambulance transport. You say that transport was medically necessary.The Plan denied your request. The Plan says that the cost share 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 $300 copayment for each Medicare-covered ambulance trip. You have been asked to pay a less than a $300 copayment for the ambulance transport. The ambulance transport falls within the Medicare-covered ambulance trip benefit category. This means that you have been asked to pay less than 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 forthe ambulance transport provided on October 1, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea second Zilretta injection.You asked the Plan to pre-approvea second Zilretta injection. You say that the first injection helped your pain immensely.The Plan denied your request. The Plan says a repeat injection is not recommended.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 second Zilretta injection. Our reviewer says that a second Zilretta injection is not supported. Our physician reviewer found this would be an off-label use of this medication as the effectiveness has been proven only for a single injection and theissue of the final deposition of the microspheres used in the compound has not been explored for multiple injections. Therefore, this request cannot be considered medically 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 a second Zilretta injection have not been met.Therefore, we decided that the Plan does not have to pre-approvea second Zilretta injection.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on November 15, 2019 by an out of network (OON) provider.You asked the Plan to pay for an office visit. You say that you did not know that the doctor was out-of-network.The Plan denied your request. The Plan says no prior authorization was obtained for these services. The Plan says that there are in-network providers available for these services.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 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 foran office visit provided on November 15, 2019 by an out of network (OON) provide