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

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network
provider on September 24, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network
deficiency 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 services at issue in this appeal. The Plan did not pre-approve the services at
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that
the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider
on September 24, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a neurostimulator for urinary retention (64561, 95972, 64581).
You asked the Plan to pre-approve the insertion of a neurostimulator for urinary retention. You say that this is medically necessary. The Plan denied your request. The Plan says the record does not show the patient is refractory to conventional therapy.
The Plan follows Medicare rules. Medicare rules say that patients with stress incontinence, urinary obstruction, and specific neurologic diseases (e.g., diabetes with peripheral nerve involvement) which are associated with secondary manifestations of the covered indications are excluded from coverage of sacral nerve stimulation. 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 insertion of a neurostimulator for urinary retention. Our reviewer says that the criteria for coverage of these procedures have not been met. Our physician reviewer found the records indicate that this patient has evidence of long-term bladder outlet obstruction/benign prostatic hyperplasia and may also have neurogenic bladder which exclude coverage. 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 insertion of a neurostimulator for urinary retention have not been met.
Therefore, we decided that the Plan does not have to pre-approve the insertion of a neurostimulator for urinary retention (64561, 95972, 64581).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on August 21, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the documentation
submitted did not include a valid physician order/lab requisition or medical records.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the
medical record, his or her intent that the test be performed.
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab
requisition stating exactly which testing was 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 Plan does not
have to pay for the drug testing services provided on August 21, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on January 28, 2020 by the responding provider.
You asked the Plan to pay for ambulance response and treatment, no transport. You say that the claim should be paid. The Plan denied your request. The Plan says the services billed are not covered by Medicare or the plan. Therefore, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on January 28, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on January 28, 2020 by the responding provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the physical therapy visit provided on
December 31, 2019.
You asked the Plan to reduce the copayment for the physical therapy visit. You say that your insurance card
says that you pay a $15 copayment for specialists. You say you do not feel you should pay more than what is
on your card. 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 $40
copayment for physical therapy at an in-network outpatient hospital.
You have been asked to pay a $40 copayment for the physical therapy visit. The physical therapy visit falls
within the "Outpatient rehabilitation 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 reduce the copayment
for the physical therapy visit provided on December 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the cystoscopy provided on December 11,
2019 and January 16, 2020.
You asked the Plan to waive the copayment for the cystoscopy. You say that you've never had to pay before.
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 $5
copayment for specialist visits. Covered services include medically necessary medical care or surgery services
furnished in a physician's office.
You have been asked to pay a $5 copayment for each cystoscopy. The total amount you owe is $10
($5/cystoscopy x 2 cystoscopies = $10). The cystoscopies fall 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
the cystoscopy provided on December 11, 2019 and January 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on February 19, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on February 19, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 7, 2019 to October 24, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that you were unaware that an authorization would be granted during the same time as the custodial care. The Plan denied your request. The Plan says authorization prior to rendering services was not obtained.
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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided on October 7, 2019 to October 24, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a Bone Scan (78306) provided August 14,
2019.
You asked the Plan to waive the copayment for the bone scan. You say that the copayment should be waived.
The Plan denied your request. The Plan says the correct cost sharing was 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). The enrollee's contract with the Plan clearly says that enrollees
must pay a $250 copayment for Advanced Radiology Services.
The enrollee has been asked to pay a $250 copayment for the bone scan. The bone scan falls within the
Advanced Radiology Services benefit category. This means that the enrollee has been asked to pay the correct
amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to
pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a
Bone Scan (78306) provided August 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost for the immunotherapy injections provided on
January 2, 2020, January 14, 2020 and January 30, 2020.
You asked the Plan to waive the cost for the immunotherapy injections. You say that you've never had to pay
for the shots before. The Plan denied your request. The Plan says the coinsurance 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 $40
copayment for in-network physician specialist services.
You have been asked to pay $2.03 for each immunotherapy injection. The total amount you owe is $6.09
($2.03/injection x 3 injections = $6.09). The immunotherapy injections fall 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 cost for the
immunotherapy injections provided on January 2, 2020, January 14, 2020 and January 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on December 20,
2019.
You asked the Plan to waive the copayment for the office visit. You say that you had a preventive visit. You
say that you shouldn't be charged a copayment. The Plan denied your request. The Plan says the copayment
applied correctly.
The rules say that a Cost plan must disclose in writing all benefits available under the Plan. The health plan
contract says that enrollees must pay $10 for Medicare-covered physician services.
You have been asked to pay a $10 copayment for the office visit. The office visit falls within the
"Physician/Practitioner services, including doctor's office visits" benefit category. The records show that you
were treated for a rash, hyperlipidemia and hip pain during the office visit. This means that you have been
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have
to waive the copayment for the office visit provided on December 20, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on January 13, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on January 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on August 28, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the documentation
submitted did not include a physician order/lab requisition or medical records stating exactly what tests are to
be performed.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the
medical record, his or her intent that the test be performed.
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab
requisition stating exactly which testing was 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 Plan does not
have to pay for the drug testing services provided on August 28, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal scaling and root planning (D4342x2) provided November 26, 2019.
You asked the Plan to pay for the dental services. You say that you went for your annual basic x-ray and cleaning and now you have received a bill for your visit and feel that the services should be covered. The Plan denied your request. The Plan says this is not covered under the plan 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, 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 periodontal scaling and root planning (D4342x2) provided November 26, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary. 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
services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital
with bilateral tibial plateau fractures. She is able to make his needs known and has no evidence of toxicity. She
is afebrile and needs mostly minimal assist for gait and mobility. She has no complex needs that require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. She may benefit from
further therapy but does not require an intensive therapy program 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 63048 provided on October 23, 2019.
You asked the Plan to pay for CPT code 63048. You say that you would like the Plan to reconsider their denial
of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We looked at the file and Medicare rules. Medicare rules say that CPT code 63048 is a Type 1 add-on code and
must be reported with a proper Primary Code. In this case, CPT code 63048 was billed with a Primary Code
that was denied for payment and is not payable separately. Therefore, we decided that the Plan does not have to
pay for CPT code 63048 provided on October 23, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on November 26, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were available in-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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on November 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four monitoring (95999) provided on October 25,
2019.
You asked the Plan to pay for the train of four monitoring. You say that you would like reconsideration
because these services were medically necessary. The Plan denied your request. The Plan says this service is
considered a bundled procedure as the cost is included in the cost of the primary procedure.
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 95999 is not supported in the record. Specifically, train of four monitoring is considered
integral to the primary procedure. Payment for train of four monitoring is bundled into the payment for the
approved primary procedure. Based on this information, we decided that Medicare rules for coverage of the
train of four monitoring have not been met. Therefore, we decided that the Plan does not have to pay for train
of four monitoring (95999) provided on October 25, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for transportation services provided May 19, 2019.
You asked the Plan to pay for the transport. You say that the transport was medically necessary due to the long distance. The Plan denied your request. The Plan says the service was not emergent. The vehicle used was not an ambulance and transport was not to the nearest hospital.
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. The Plan follows the same rule. We looked at your request, the records in the case file, and the rules. The record shows transport was non-emergency in nature, and was provided by a conversion van that does not meet Medicare's definition of an ambulance. Based on this information, we decided that the Medicare rules for coverage of the transport have not been met. Therefore, we decided that the Plan does not have to pay for transportation services provided May 19, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided to the enrollee from
January 1, 2020 to January 8, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says this is an invalid procedure code for this service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate code.
We find that HCPCS code S9328 is not supported in the medical record. Specifically, this code has a status
indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for
Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the services
have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328)
provided to the enrollee from January 1, 2020 to January 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or
heat exchanger (99190) provided on November 29, 2019.
You asked the Plan to pay for the assembly and operation of a pump with an oxygenator or heat exchanger.
You say that this was a required service. The Plan denied your request. The Plan says payment for this service
is included in the DRG.
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that
CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the
OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule.
The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of
"C" on Addendum B of the 2019 OPPS/ASC final rule. This means the service has been designated as
"inpatient only", and therefore must be billed as part of an inpatient admission. Therefore, we decided that the
Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger
(99190) provided on November 29, 2019.