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

We decided that the Plan does not have to waive the deductible for the ultrasound behind abdominal cavity (76775) provided May 20, 2020.

You asked the Plan to waive the deductible for the ultrasound behind abdominal cavity. You say that this was a preventative service. The Plan denied your request. The Plan says the ultrasound was not done as a screening but as a diagnostic measure; therefore, your claim was processed with the deductible.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $975 deductible for outpatient diagnostic tests. 

The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient diagnostic tests. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $975 deductible for outpatient diagnostic tests. This cost sharing is a contractual obligation that had not been met at the time the ultrasound behind abdominal cavity was received on May 20, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the ultrasound behind abdominal cavity (76775) provided May 20, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar sacral facet joint block for the enrollee.

You asked the Plan to pre-approve the block. You say that this is medically necessary. The Plan denied your request. The Plan says there was no examination demonstrating that the facet joint is the source of pain.

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 block. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no physical exam documentation supporting the finding of facet arthropathy. This does not meet the criteria of the LCD. Therefore, the request is deemed to be not medically reasonable or 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 the block have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar sacral facet joint block for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for hernioplasty.

You asked the Plan to waive the coinsurance for hernioplasty. You say that if you were inpatient you would
have owed a lesser copayment and disagree with the high charges for outpatient surgery. 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 20%
coinsurance for outpatient surgery, including services provided at hospital outpatient facilities.

You received hernioplasty at an outpatient hospital facility. The total allowed amount is $6,316.01 and 20% of that is $1,263.20.

You have been asked to pay the total coinsurance amount of $1,263.20 for hernioplasty. Hernioplasty falls
within the outpatient surgery, including 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 coinsurance for hernioplasty.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a segmented pneumatic compression device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation of a trial and failure of a basic pump.

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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of a failure of the standard pump. There are no unique characteristics identified that would indicate the segmented pump over the standard pump.

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve a segmented pneumatic compression device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a knee orthosis provided on September 22, 2020.

You asked the Plan to waive the coinsurance for knee orthosis. You say that you did not request this item and if you had known the charge you would have refused it. The Plan denied your request. The Plan says the coinsurance amount you are being charged is correct.

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 knee orthosis. The allowed amount of the claim is $662.49, resulting in a coinsurance obligation of $132.49. 

You have been asked to pay 20% coinsurance for knee orthosis. Knee orthosis falls within the Prosthetic Devices and Related 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 coinsurance for a knee orthosis provided on September 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation, first intraoral periapical x-ray, four additional intraoral periapical x-rays, panoramic x-ray, caries risk assessment and documentation, prophylaxis, oral hygiene instructions, and interim caries arresting medicament application provided on October 14, 2020 by an OON provider.

You asked the Plan to pay for the dental services. You say that the provider's office told you that they accepted your insurance. You also say that you thought this dental office would be cheaper with your insurance. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that you have no OON benefits.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for 100% of the cost for dental services received OON. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation, first intraoral periapical x-ray, four additional intraoral periapical x-rays, panoramic x-ray, caries risk assessment and documentation, prophylaxis, oral hygiene instructions, and interim caries arresting medicament application provided on October 14, 2020 by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a Single-Photon Emission Computed
Tomography (SPECT) test.

You asked the Plan to waive the copayment for SPECT test. You say that you paid less for the same service in
the past. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.

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 $150
copayment for SPECT test.

You have been asked to pay $150 copayment for SPECT test. SPECT 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 a Single-Photon Emission Computed Tomography (SPECT) test.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the left eyelid surgery.

You asked the Plan to pre-approve the left eyelid surgery. You say that this service is medically necessary. The Plan denied your request. The Plan says Medicare criteria for the requested service is not met.

The Plan follows Medicare rules. Medicare rules say that the enrollee must meet specific criteria for visual field loss.

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 left eyelid surgery. Our reviewer says that the service is not medically reasonable and necessary. Our physician reviewer found the physical exam did not document corneal reflex margin to reflex distance measurements, as is required by the Medicare LCD. The photographs do not show left corneal reflex that approaches the required 2.5 mm from the eyelid margin.

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 left eyelid surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve the left eyelid surgery.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical assistant services.

You asked the Plan to pay for the surgical assistant services. You say that the operative report supports the
services in dispute. The Plan denied your request. The Plan says 27437 is not a valid code for assistant at
surgery services.

The Plan must follow Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator
of 1, assistant surgeon services are not covered.

We looked at the file and Medicare rules. In this case, you billed assistant surgery services for CPT code
27437. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means
that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based
on this information, we decided that Medicare rules for coverage of the surgical assistant services have not
been met. Therefore, we decided that the Plan does not have to pay for surgical assistant services.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to hold you harmless for hospital services.

You asked the Plan to hold you harmless for the hospital services. You say that you would like reconsideration
because you should not be held financially responsible for the actions taken by a medical professional. The
Plan denied your request. The Plan says that these services could have been rendered in a lower level of care.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract
provider are considered approved by the plan unless notice is provided that the services will not be covered.
The Plan follows these rules.

You were referred for the hospital services by a contract provider. The file does not show that the Plan
provided notice that the hospital services would not be covered. Under Medicare rules, this means the hospital
services is considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for
hospital services.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an esophagogastroduodenoscopy (43239).

You asked the Plan to waive the copayment for the outpatient procedure. You say that you did not realize there would be a copay for this service, and you would not have had it done if you knew. The Plan denied your request. The Plan says there is a $350 copayment for outpatient procedures.

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 $350 copayment for outpatient procedures, surgery and services.

You have been asked to pay a $350 copayment for an outpatient procedure. The esophagogastroduodenoscopy procedure falls within the outpatient procedures, surgery and 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 esophagogastroduodenoscopy (43239).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services coded 71045.

You asked the Plan to pay for the x-ray services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services billed are not payable.

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 71045 is radiologic examination, chest; single view.

We find that CPT code 71045 is not supported in the medical record. Specifically, this service was billed with
place of service 22 (outpatient). However, the documentation supports that the enrollee was inpatient for this
date of service. Payment cannot be made on this outpatient claim while the enrollee was inpatient. Based on
this information, we decided that Medicare rules for coverage of the x-ray services have not been met.
Therefore, we decided that the Plan does not have to pay for the x-ray services coded 71045.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture services.

You asked the Plan to pay for the acupuncture services. You say that the Plan should pay this claim. The Plan denied your request. The Plan says records do not document the auxiliary provider was under the supervision of a physician, PA or NP/CNS.

The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year.

We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the services were not provided by a physician licensed to perform the service or supervised auxiliary personnel. Therefore, we decided that the Plan does not have to pay for acupuncture services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay.

You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were in the emergency room overnight and were only inpatient 3 days not 4. 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 $325 copayment for days 1-5 for inpatient hospital care.

The record shows that you had an inpatient hospital stay. Therefore, you are responsible to pay a $325 copayment for days 1-4. $325 (copayment) x 4 (inpatient days) = $1,300.

You have been asked to pay the total copayment amount of $1,300 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.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for The Tempus gene panel.

You asked the Plan to pay for the Tempus gene panel. You say that you would like reconsideration because this
panel is useful for patients at initial diagnosis and patients with refractory disease. The Plan denied your
request. The Plan says this service has not been billed correctly.

The Plan must follow Medicare rules. Medicare rules say that the Tempus "xF" Gene Panel has not undergone
the required technical assessment and is therefore not covered by Medicare.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the Tempus gene panel have not been met. Specifically, this test is not a Medicare covered benefit.
Therefore, we decided that the Plan does not have to pay for The Tempus gene panel.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140).

You asked the Plan to pay for the dental service. You say that you have never paid any copayments for dental.
You say that you have a very limited income and cannot afford to pay this bill. You say that you are
experiencing pain. You also say that you want your last two teeth to be extracted so that you can get dentures.
The Plan denied your request. The Plan says limited oral evaluation is not listed as a covered service.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
limited oral evaluation (D0140).
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 you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not medically necessary. Our physician reviewer found the enrollee is currently receiving care in a skilled nursing facility after hospitalization for syncope, cardiac arrest, respiratory failure, cryptogenic stroke, and chronic obstructive pulmonary disease (COPD) exacerbation. He does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. His medical conditions are stable. There are no complex nursing or rehabilitation needs. He does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. 

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Denosumab injection (J0897) administered.

You asked the Plan to waive the coinsurance for the drug injection. You say that this service should be covered in full. The Plan denied your request. The Plan says Medicare Part B drug services have a 20% coinsurance.

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 Medicare Part B prescription drugs. 

You have been asked to pay 20% coinsurance for the drug services. The Plan allowed amount for this service is $1,207.20 ($1,207.20 x 20% = $241.44). A Denosumab 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 Denosumab injection (J0897) administered.