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

We decided that the Plan does not have to pay for oral surgery services (21248, 99152, 41899) provided on May 29, 2019 by a provider that has opted out of Medicare. You asked the Plan to pay for oral surgery services. You say that you needed this oral surgery prior to a valve replacement. The Plan denied your request. The Plan says you received this surgery from a provider who has opted out of Medicare. 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 has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This provider has opted out of the Medicare program. The file shows that the provider entered into a private contract with you regarding payment. Therefore, we decided that the Plan does not have to pay for oral surgery services (21248, 99152, 41899) provided on May 29, 2019 by a provider that has opted out of Medicare.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit and laboratory test provided,
on March 17, 2020.
You asked the Plan to waive the copayment for the office visit and laboratory test. You say that your questions
were unanswered. You say that you shouldn't be responsible. The Plan denied your request. The Plan says the
copayments 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 each specialist visit and a $10 copayment for diagnostic lab services.
You have been asked to pay a total of $38.61 for the office visit and laboratory test.
The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit
category. The laboratory test 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 office visit and laboratory
test provided, on March 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided November 1,
2019.
You asked the Plan to pay for the orthosis. You say that the medical records provided should support the
necessity of the service in dispute. The Plan denied your request. The Plan says there is no evidence of an
established relationship between the enrollee and the ordering physician, there was no claims submitted for an
evaluation and management service and there is no evidence of a prior telehealth service with the ordering
physician as required per CMS guidelines.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are
likewise noncovered. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis
(L0650) provided November 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on January 22, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was
submitted after the timely filing limit.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010
must be filed no later than one calendar year after the date of service.
The record shows that a claim for the services was not filed until February 19, 2020. This means that more than
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the
Plan does not have to pay for the services provided on January 22, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a cystourethroscopy provided on April 3,
2019.
You asked the Plan to waive the copayment for a cystourethroscopy. You say that you received a bill a year
later and disagree with the charges. The Plan denied your request. The Plan says the claims were processed
correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities.
You received a cystourethroscopy on April 3, 2019. A cystourethroscopy is considered an outpatient surgical
procedure. Therefore, you are responsible to pay the $150 copayment.
You have been asked to pay a $150 copayment for a cystourethroscopy. A cystourethroscopy falls within the
outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical
centers benefit category. This means that you have been asked to pay the correct amount based on your contract
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.
Therefore, we decided that the Plan does not have to waive the copayment for a cystourethroscopy provided on
April 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on February 10, 2020.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says nonemergent,
non-urgent services with out-of-network providers require prior authorization.
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 laboratory services provided on February 10, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an Echocardiogram reading (93010) provided October 11, 2019. You asked the Plan to pay for the echocardiogram. You say that the services were medically necessary. The Plan denied your request. The Plan says the code billed is 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. We find that CPT code 93010 is not supported in the medical record. Specifically, insufficient clinical documentation was provided to support the services billed. Based on this information, we decided that Medicare rules for coverage of the echocardiogram have not been met. Therefore, we decided that the Plan does not have to pay for an Echocardiogram reading (93010) provided October 11, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on October
16, 2019.
You asked the Plan to waive the copayment for laboratory services. You say that these were primary care
visits. You say that the cost shouldn't be so high. 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 $10
copayment per visit for laboratory tests.
You have been asked to pay a $10 copayment for the laboratory services. Laboratory services fall within the
"Outpatient diagnostic tests and therapeutic services and supplies" benefit category. Outpatient diagnostic tests
are considered a separate 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 laboratory services
provided on October 16, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from
March 29, 2020 to March 31, 2020.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you were admitted to
the hospital because of Covid-19. You say you do not have a job and cannot pay this amount. 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 $393
copayment for each Medicare-covered day for days 1-5 and a $0 copayment for each additional day for each
inpatient stay.
You have been asked to pay a $393 copayment for each day of the inpatient hospital stay. ($393 x 2 days =
$786). The inpatient hospital stay falls within the "Inpatient hospital care" 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 inpatient hospital stay provided from March 29, 2020 to March
31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to a tertiary-level neurology consult.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says the service is available within the primary network, and the services can be safely done with a preferred network provider.
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 the referral. Our reviewer says that the requested referral is not considered medically reasonable and necessary in this case. Our physician reviewer found at this time, the plan has identified an in-network provider who can evaluate and treat your condition. There is no indication in the records that there is an emergent need for a tertiary evaluation of the enrollee's condition. Given the availability of an in-network specialist, the requested tertiary level of care would otherwise be considered to exceed your needs at this time. Consequently, it cannot be stated that the request for a tertiary consult would meet the definition of medical necessity. 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 referral have not been met. Therefore, we decided that the Plan does not have to pre-approve a referral to a tertiary-level neurology consult.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for oral surgery (D7210) provided on January 28, 2020.
You asked the Plan to pay for oral surgery. You say that you believed the provider you received this service
from was in-network. The Plan denied your request. The Plan says this provider has opted-out of Medicare.
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 has opted out of the program except
in cases involving emergencies or urgently needed care. Medicare also 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's dental benefit specifically excludes services from opt-out providers.
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for
oral surgery (D7210) provided on January 28, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel-One.
You asked the Plan to pre-approve the Gel-One. You say that you would like reconsideration because this drug is medically necessary. The Plan denied your request. The Plan says the member does not meet step therapy exception criteria.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Gel-One. Our reviewer says that the member has not tried and failed a trial of Orthovisc and Monovisc. Our physician reviewer found the documentation does not support that Monovisc and Orthovisc (Hyaluronic acid) would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. 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 Gel-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Gel-One.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on
March 17, 2020.
You asked the Plan to pay for the pump assembly and operation. You say that you would like reconsideration
because it takes at least 30 minutes to set up the machine and the perfusionist is required to remain in the
operating room through the length of the procedure. The Plan denied your request. The Plan says payment for
this service is included in the DRG payment to the facility.
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier
other than the facility or hospital for services furnished to the beneficiary while an inpatient.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the pump assembly and operation have not been met. Specifically, payment for this service is
included in the DRG payment to the facility and is the responsibility of the facility to any vendor. Therefore,
we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on
March 17, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for six units of additional permanent adjustable transprostatic implants (52442) provided on October 16, 2019.
You asked the Plan to pay for six units of six units of additional permanent adjustable transprostatic implants. You say that the units are noted in the records. The Plan denied your request. The Plan says the documentation is insufficient to support the number of units billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code. 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 six units of six units of additional permanent adjustable transprostatic implants. Our reviewer says that the records do not support the units billed. Our physician reviewer found the medical records submitted note 6 anchors were placed. In the case of Urolift procedure, the first anchor is billed as 52441 and the others anchors are billed as 52442. If 6 anchors were placed, then only 5 units of 52442 should have been billed to the health plan. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of six units of six units of additional permanent adjustable transprostatic implants have not been met. Therefore, we decided that the Plan does not have to pay for six units of additional permanent adjustable transprostatic implants (52442) provided on October 16, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from March 18, 2020 to April 10, 2020. You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you disagree with the charges because you were treated for the coronavirus. 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 $492 copayment per day for days 1-4 for inpatient hospital care. You had an inpatient hospital stay from March 19, 2020 to April 20, 2020. Therefore, you are responsible to pay a $492 copayment for days 1-4 (March 19, 2020 to March 22, 2020). $492 (copayment) x 4 (inpatient days) = $1,968. You have been asked to pay the total copayment amount of $1,968 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital care 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 inpatient hospital stay from March 18, 2020 to April 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the specialist office visit, the outpatient
mental health care visits, and the emergency room visit provided from July 23, 2019 to September 11, 2019.
You asked the Plan to waive the cost sharing for the specialist office visit, the outpatient mental health care
visits, and the emergency room visit. You say that all of your claims have been denied. 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 $50
copayment for out-of-network physician specialist services, a $40 copayment for an in-network individual
session, a 45% coinsurance for out-of-network outpatient mental health services (group or individual), up to a
maximum $90 copayment for emergency care.
You have been asked to pay a total of $253.12 for the specialist office visit, the outpatient mental health care
visits, and the emergency room visit. The specialist office visit falls within the "Physician/Practitioner services,
including doctor's office visits" benefit category. The outpatient mental health care visits fall within the
"Outpatient mental health care visits" benefit category. The emergency room visit falls within "Emergency
care" benefit category. The record shows that these claims were not denied. See chart below.
Date of Service Service Allowed Amount Copayment/Coinsurance Member
Liability
July 23, 2019 Out-of-network
specialist office
visit
$108.99 $50.00 $50.00
August 7, 2019 In-network
mental health
care visit
$154.68 $40.00 $40.00
August 15, 2019 Emergency
room visit
$995.37 $90.00 $90.00
September 11, 2019 Out-of-network
mental health
care visits
$162.50 45% $73.12
Total $253.12
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 cost sharing for the specialist office visit, the outpatient mental health care
visits, and the emergency room visit provided from July 23, 2019 to September 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for observation care provided on October 15, 2019 by an out of
network (OON) provider.
You asked the Plan to pay for observation care. You say that you would like this claim reprocessed and
approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The
Plan says that the referring provider is also 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 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 observation care provided on October 15, 2019 by
an out of network (OON) provider.