Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Partially Favorable

We decided that the Plan has to reduce the cost-sharing charges for an arthroscopy. We decided that the Plan does not have to reduce the cost-sharing charges for an arthroscopy.  
 
You asked the Plan to reduce the cost-sharing charges for an arthroscopy. You say that you disagree with the out-of-network charges. The Plan says that the claims were processed correctly and you are being charged the correct amount. 
 
We decided that the Plan has to reduce the cost-sharing charges for an arthroscopy from $963.71 to $952.12.  
 
The Plan contract says that you must pay 40% coinsurance for out-of-network outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. Therefore, the plan cannot ask you to pay more than $952.12 for an arthroscopy. Therefore, we decided that the Plan has to reduce the cost-sharing charges for an arthroscopy from $963.71 to $952.12. We also decided that the Plan does not have to reduce the cost-sharing charges for an arthroscopy to the amount you requested. 
 
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 40% coinsurance for an out-of-network arthroscopy. The allowed amount is $2,380.37 and 40% of that is $952.15. 
 
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and the supplies.
You asked the Plan to pre-approve the continuous glucose monitor and supplies. You say that the enrollee needs to check her blood sugars 3 times a day and her fingers do not have enough blood. You say that the enrollee is having to poke her fingers more than once to get a blood sugar check. The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage of the requested device and supplies. The plan says that medical necessity has not been established.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor. 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 continuous glucose monitor and supplies. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee is noted to be a diabetic who takes both oral medication and set-dose long-acting insulin to control her diabetes. While the enrollee is noted to test her blood glucose, clear documentation of how often she checks her blood glucose is not noted. Furthermore, there is no evidence that the enrollee uses the results of blood glucose testing to self-adjust insulin dosages multiple time per day. As such, the requested CGM is not shown to be medically necessary or reasonable. 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 continuous glucose monitor and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and the supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drug injections provided on December 3, 2019.
You asked the Plan to waive the coinsurance for Medicare Part B drug injections. You say that you 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 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay $179.73, which his less than the 20% coinsurance for Medicare Part B drug injections. Medicare Part B drug injections fall 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 Medicare Part B drug injections provided on December 3, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided June 7, 2019 to
December 2019.
You asked the Plan to pay for the dental services. You say that you needed the periodontal maintenance to save
your teeth and you request reconsideration of the denial The Plan denied your request. The Plan says this
service 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 maintenance (D4910) provided June 7, 2019 to December 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for self-administered drugs represented by CPT code A9270 for date of service November 28 - December 2, 2019. 
 
You asked the Plan to pay for the self-administered drugs. You say that  The Plan denied your request. The Plan says there is no Part B coverage for self-administered drugs. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered drugs. The CPT code that was referenced in your reimbursement requested was A9270 which is defined as a non-covered item or service. Therefore, we decided that the Plan does not have to pay for selfadministered drugs represented by CPT code A9270 for date of service November 28 - December 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a nasal endoscopy (CPT 31231 and CPT 31237). 
 
You asked the Plan to pay for the endoscopy. You say that you have periodically dealt with nasal congestion, facial pain, facial pressure and nasal drainage since 1962. The Plan denied your request. The Plan says Medicare rules do not allow CPT 31231 and CPT 31237 to be billed together. 
 
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 31237 is "Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement (separate procedure)." 
 
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 the endoscopy. Our reviewer says that the services at issue in this case are not represented correctly. Our physician reviewer found National Correct Coding Initiative and Medicare rules does not allow for CPT 31237 and 31231 to be billed together and there is no modifier is allowed to enable these codes to be billed together. The health plan has appropriately approved Current Procedural Terminology 31231 and Current Procedural Terminology (CPT) code 31237 does not meet the criteria for 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 endoscopy have not been met. Therefore, we decided that the Plan does not have to pay for a nasal endoscopy (CPT 31231 and CPT 31237).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the surgical pathology provided on October 20, 2019.
You asked the Plan to waive the deductible for the surgical pathology. You say that the doctor is in-network. The Plan denied your request. The Plan says the deductible applied correctly.
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 your deductible is $750, which applies to all items and services except those specifically excluded by the Plan's contract. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost of your covered services. Out-of-network services are not excluded from the deductible. The item or service you asked the Plan to waive the deductible for falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $750 deductible applies to out-of-network services. This cost sharing is a contractual obligation that had not been met at the time the surgical pathology was received on October 20, 2019. Therefore, we decided that the Plan does not have to waive the deductible for the surgical pathology provided on October 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on July 17, 2019.
You asked the Plan to waive the copayment for the office visit. You say that you were informed that no copayment was collected for a follow-up. You say that you shouldn't have to pay this. 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 $50 copayment for provider and professional services at an in-network specialist's office. You have been asked to pay a $50 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. There is no provision in the contract which indicates a copayment would be waived for services performed as a follow-up. 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 July 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for non-waterproof tape (A4450) provided on July 9, 2019. 
 
You asked the Plan to pay for the tape. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code A4450 was not billed with the required durable medical equipment modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report modifiers AU, AV and AW on claims for items identified by codes A4450 and A4452 that are furnished on or after January 1, 2005. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the tape have not been met. Specifically, CPT code A4450 was not billed with the required durable medical equipment modifier. Therefore, we decided that the Plan does not have to pay for non-waterproof tape (A4450) provided on July 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of intraoral x-rays provided on January 8, 2020.
You asked the Plan to pay for the complete series of intraoral x-rays. You say that you thought this service was covered. The Plan denied your request. The Plan says this service is not covered.
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. The contract states that only bitewing x-rays are a covered benefit. No other types of x-rays are listed as being covered. Therefore, we decided that the Plan does not have to pay for the complete series of intraoral x-rays provided on January 8, 2020.
Your complaint about being treated unfairly by the provider is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the specialist office visit and physical therapy visits provided from November 13, 2019 to December 12, 2019. 
 
You asked the Plan to waive the copayments for the specialist office visits and the physical therapy visits. You say that you should not be responsible for the copayment amounts because you met your maximum out-ofpocket 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $40 copayment per visit for Medicare-covered specialty care services and a $20 copayment for each Medicare-covered physical, occupational, or speech language therapy visit. The enrollee has been asked to pay a $40 copayment for the specialist office visit and a $20 copayment for the each of the physical therapy visits. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The physical therapy visits fall within the "Outpatient rehabilitation services" benefit category. The record shows the providers were out-of-network, which do not apply to the maximum out-of-pocket amount for in-network services. 
 
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 copayments for the specialist office visit and physical therapy visits provided from November 13, 2019 to December 12, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from October
4, 2019 o October 23, 2019.
You asked the Plan to pay for this claim. You say that this claim should be paid. The Plan denied your request.
The Plan says Effective January 1, 2019, report of the Federal Information Processing Standards (FIPS) code
is required to identify the county where the services were rendered. The claim cannot be reprocessed for
payment until a corrected claim is received
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 claim submitted has errors regarding the designation of the county the services were provided
in. The Plan states a corrected claim would be accepted. Medicare rules for coverage of this claim have not
been met. Therefore, we decided that the Plan does not have to pay for home health services provided to the
enrollee from October 4, 2019 o October 23, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical pathology services rendered on October 31, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that the TC and PC of diagnostic services is only separately payable when furnished in separate payment localities. 
 
We looked at the file and Medicare rules. The provider submitted a claim for procedure code 88305 with modifier -26 for separately payment of the PC; however, the file does not show that the TC and PC were performed in separate payment localities. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the surgical pathology services rendered on October 31, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from November 6, 2019 through November 18, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that you were admitted on November 6, 2019 and discharged on November 18, 2019. You were asked to pay a $372 copayment per day from November 6, 2019 through November 10, 2019, days 1-5 of your inpatient stay. There were no copayment charges from November 11, 2019, day 6 of your inpatient hospital care until your day of discharge November 18, 2019. Per your contract there is a $372 copayment per day required for days 1-5. 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 inpatient hospital care from November 6, 2019 through November 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a shower chair.
You asked the Plan to pay for a shower chair. You say that you have MS and have been in an electric wheelchair for over twenty years. You say that you used to be able to transfer with the help of your aide or husband, however your aides are not able to help you transfer for a shower or to use the bathroom at this time. You purchased a lift with a sling and a shower chair and you stated that the equipment works well for you. You submitted a request for the Plan to reimburse you for these items. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pay for a shower chair.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory services provided on September 18, 2019.
You asked the Plan to waive the copayment for the laboratory services. You say that this is routine exam lab work. You say that you shouldn't have a copayment. 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 for Medicare-covered lab services. You have been asked to pay a $10 copayment for the laboratory services. The 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 the laboratory services provided on September 18, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient stay and a placement of an anti-GERD device for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the doctor does not document a severe and/or life threatening condition, or prior surgery for GERD.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the LINX device received FDA premarketing approval, effective March 22, 2012. The approved indication was for patients with diagnosed GERD as defined by abnormal pH testing, and who continue to have chronic GERD symptoms despite maximal medical therapy for the treatment of reflux. There is no doubt that the enrollee has endoscopically-shown histologic evidence of mild esophagitis at the GE junction. However, the available records do not show any pH data to demonstrate acid reflux with symptom correlation. Further, no manometry or cine esophgram was provided to rule out esophageal dysmotility or to document LES dysfunction that warrants mechanical augmentation. Accordingly, whereas LINX implantation may meet FDA-indication and thus be appropriate for some sufferers with refractory GERD, the pre-operative evaluation as provided is incomplete to deem the procedure nor the associated hospitalization medically necessary 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient stay and a placement of an anti-GERD device for the enrollee.