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

We decided that the Plan does not have to waive the copayment for the outpatient surgical services rendered to you on August 19, 2019.You asked the Plan to waive the copayment forthese services. You say that you asked at the doctor's office if it would be covered and were told yes.The Plan denied your request. The Plan says the copayment was applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 copayment for Medicare-covered outpatient surgery after you pay your $1,000 deductible. Review of the file shows that you received outpatient surgical services on August 19, 2019. You have been asked to pay a $350 copayment for these services. These services fall within the Medicare-covered outpatient surgery after you pay your $1,000 deductible benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. The Plan has not denied coverage of these services. 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 outpatient surgical services rendered to you on August 19, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.You asked the Plan to pre-approvethe LTACH services. The Plan denied your request. The Plan says the enrollee is receiving appropriate care at the current acute care facility.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 that 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 BiPAP and supplemental oxygenation, neurological and seizure monitoring, surveillance laboratory studies, tube feeding, 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 current health 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 waive the copayment forthe outpatient surgical services rendered to you by "the provider" on August 6, 2019.You asked the Plan to waive the copayment forthese services. You say that you don't understand the charges.The Plan denied your request. The Plan says the copayment was applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 copayment for each Medicare-covered outpatient hospital facility or ambulatory surgical center visit. Review of the file shows that you received outpatient surgical services in the form of arthrocentesis. You have been asked to pay a $200 copayment for these services. These services fall within the Medicare-covered outpatient hospital facility or ambulatory surgical center visit 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 outpatient surgical services rendered to you by "the provider" on August 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe lumbar sacral orthosis provided on August 23, 2019.You asked the Plan to waive the coinsurance forthe orthosis. You say that you are being askedto pay too much.The Plan denied your request. The Plan says that you were charged correctlyThe 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 Durable medical equipment (DME) and related supplies. You have been asked to pay 20% coinsurance for the orthosis. the orthosis falls within the Durable medical equipment (DME) 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 forthe lumbar sacral orthosis provided on August 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on May 17, 2019 by out of network provider.You asked thePlan to pay forneurostimulator implantation. You say that you were informed by a Plan representative that prior authorization was not required and are appealing with medical records.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and the referring providers are also out-of-network with the Plan.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 medical services provided on May 17, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for injections provided by the Hospital on March 6, 2019 to March 20, 2019.
You asked the Plan to waive the coinsurance for injections. You say that you do not agree with these charges. The Plan denied your request. The Plan says the correct coinsurance has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 15% coinsurance for Medicare Part B prescription drugs/administered by a provider. You have been asked to pay less than your 15% coinsurance of the allowed amount for injections. The total allowed amount is $21,025.51. The total amount you are being asked to pay is $2,929.63 ($21,025.51 x 15% = $3,153.83). Injections fall within the Medicare Part B prescription drugs/administered by a provider 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 injections provided by the Hospital on March 6, 2019 to March 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran outpatient surgery provided by "the hospital" on July 3, 2019.You asked the Plan to waive the copayment foran outpatient surgery. You say that you don't understand why you have to pay so much and the Plan only paid $0.12.The Plan denied your request. The Plan says the correct copayment has been applied.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 copayment for outpatient surgery. You have been asked to pay a $300 copayment for an outpatient surgery. An outpatient surgery falls within the outpatient surgery 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 foran outpatient surgery provided by "the hospital" on July 3, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing coded 80307 and G0483 provided on May 16, 2019.You asked the Plan to pay forthe drug testing. 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 supported by the documentation.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 codes 80307 and G0483 are not supported in the medical record. Specifically, the documentation submitted did not include a valid physician order/lab requisition or medical records (signed by the ordering physician) stating exactly what tests were to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing havenot been met. Therefore, we decided that the Plan does not have to pay forthe drug testing coded 80307 and G0483 provided on May 16, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services for the enrollee.You asked the Plan to pre-approveIRF care. The Plan denied your request. The Plan says there is no need for a rehab physician 3 times a week.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 physician reviewer found that the enrollee has chronic right shoulder pain and will lean into his right shoulder causing further gait difficulty. He is at minimal assist for bed mobility, transfers, and toileting. He is at supervision to minimal assist for upper and lower body dressing. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee's medical status requires the intensity of an IRF stay with close physician or nursing supervision. He may benefit and participate in additional physical and occupational therapy, but does not require this on an intensive rehabilitation facility therapy program level in an IRF.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-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lab services (80048, 83036, and 85027) and an electrocardiogram (93005) provided on August 8, 2019 by out of network provider.You asked the Plan to pay forlab services and an electrocardiogram. You say that you were not aware you needed authorization.The Plandenied your request. The Plan says services from out-of-network providers require 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 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 lab services(80048, 83036, and 85027) and an electrocardiogram (93005) provided on August 8, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox.You asked the Plan to pre-approveBotox. The Plan denied your request. The Plan says this is not medically necessary.The Plan follows Medicare rules. Medicare rules say that Weasked 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 Botox. Our reviewer says that the requested injection of Botox is not medicallyreasonable and necessary. Our physician reviewer found that the medical records provided do not indicate inadequate response to or are intolerance to an anticholinergic medication.We looked at this physician's review, the file, and Medicare rules. Basedon this information, we decided that Medicare rules for coverage of Botox have not been met.Therefore, we decided that the Plan does not have to pre-approveBotox
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the technical component (TC) of the immunohistochemistry (IHC) stain provided on July 11, 2019 billed with code 88342-TC.
You asked the Plan to pay for the TC of the IHC testing. You say that this should be paid. The Plan denied your request. The Plan says that the global procedure for 88342 was paid for this date of service. Payment cannot be made for the TC on the same date.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has denied payment for the TC of this code stating that it was billed on the same date as the global procedure of code 88342. However, the Plan did not include any evidence that payment was made for 88342 on this date of service. There are not other apparent issues which would prevent claim payment. We find that without evidence of payment for the TC of this service on a separate claim, the denial is not supported. Therefore, we decided that the Plan has to pay for the technical component (TC) of the immunohistochemistry (IHC) stain provided on July 11, 2019 billed with code 88342-TC.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft (D4263), and the inhalation of nitrous oxide (D9230) provided on September 19, 2019.
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says the bone graft is only covered when performed in conjunction with other covered procedures. The Plan also says that inhalation of nitrous oxide is not 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 dental services you received are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the bone replacement graft (D4263), and the inhalation of nitrous oxide (D9230) provided on September 19, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve Magnetic Resonance Imaging (MRI) of the Pelvis (72197).You asked the Plan to pre-approvethe MRI. You say that the MRI is medically necessary.The Plan denied your request. The Plan says that coverage criteria was not met.The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 the MRI. Our reviewer says that coverage criteria has been met. Our physician reviewer found the enrollee has a history of Rectal Cancer, post-excision. NCCN guidelines allow for a surveillance MRI every 6 months for 5 years for this indication.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 MRI have been met.Therefore, we decided that the Plan has to pre-approveMagnetic Resonance Imaging (MRI) of the Pelvis (72197).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided  on June 16, 2019.
You asked the Plan to waive the copayment for ambulance services. You say that you cannot afford this and you were billed less for the hospital stay than the ride there. You say that's a lot of money for a ride in a truck with lights. The Plan denied your request. The Plan says ambulance services have a $235 copayment.
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 $235 copayment for ambulance services. You have been asked to pay a $235 copayment for ambulance services. This service falls within the ambulance services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services provided on June 16, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a esophagogastroduodenoscopy provided on September 5, 2019.
You asked the Plan to waive the copayment for an outpatient surgery. You say that you have had this procedure done more than 8 times. You say that you have never been charged as a surgery before. You say that you think this copayment is incorrect. The Plan denied your request. The Plan says the correct copayment has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $400 copayment for outpatient surgery/in-network/outpatient hospital surgery. You have been asked to pay a $400 copayment for an outpatient surgery. The procedure that was performed is considered an outpatient surgery; therefore, the correct copayment has been applied. An outpatient surgery falls within the outpatient surgery/in-network/outpatient hospital surgery 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 esophagogastroduodenoscopy provided on September 5, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay fordrug testing services provided to the enrollee on July 1, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthe billed services were not supported.The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be covered. The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were to be performed. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pay fordrug testing services provided to the enrollee on July 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe anesthesia services coded 00910 provided on May 30, 2019.You asked the Plan to pay forthe anesthesia services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services provided are not billed with the required information.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 00910 is anesthesia for transurethral procedures (including urethrocystoscopy); not otherwise specified.We find that CPT code 00910 is not supported in the medical record. Specifically, this code was billed with diagnosis code N35.911 (unspecified urethral stricture, male, meatal)is not typically performed foran enrollee whosegender is female.A required modifier is required to be billed with this code to identify services for transgender, ambiguous genitalia, and hermaphrodite enrollees. Based on this information, wedecided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay forthe anesthesia services coded 00910 provided on May 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services provided on May 6, 2019 to June 11, 2019 by out of network provider,"the provider". You asked the Plan to pay forthe laboratory services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plansays the services provided are not a covered benefit.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 laboratory services provided on May 6, 2019 to June 11,2019 by out of network provider, "the provider".