Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgical services provided on
February 4, 2021.

You asked the Plan to waive the copayment for the outpatient surgical services. You say that you feel you
should not be responsible for this cost share amount and you would like the Plan to reconsider your request.
The Plan denied your request. The Plan says you had an outpatient surgical service provided in an outpatient
hospital facility on the date of service at issue in this appeal. The Plan says that the correct copayment has
applied per your contract with the Plan.

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 $365
copayment for Outpatient surgery provided in an outpatient hospital facility.

We looked at the file, the Plan's contract and Medicare rules. The file shows that you had outpatient surgical
services provided in an outpatient hospital facility on February 4, 2021. You have been asked to pay a $365
copayment for the outpatient surgical services. The outpatient surgical services fall 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 for the outpatient surgical
services provided on February 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the immune globulin injection provided on November 12, 2020 and December 10, 2020.

You asked the Plan to waive the coinsurance for the immune globulin injections. You say that you asked if the infusions were covered prior to your treatment and you were assured you would not have to make a payment. You say that you are appealing these two large bills. 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 20% coinsurance for each Medicare-covered Part B drug from an in-network provider.

You have been asked to pay $1,389.60 for the immune globulin injections.

Date of Service
Service
Allowed Amount
Coinsurance
Member Liability

November 12, 2020
Immune Globulin Injection
$3,177.02
20%
$635.40

December 10, 2020
Immune Globulin Injection
$3,771.02
20%
$754.20

TOTAL:
$1,389.60

The immune globulin 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 the immune globulin injection provided on November 12, 2020 and December 10, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve twenty-four (24) additional routine transportation trips.

You asked the Plan to pre-approve twenty-four (24) additional routine transportation trips. You say that you need additional transportation to your doctor's appointments and have no other means to getting back and forth. The Plan denied your request. The Plan says that you have exceeded your benefit limit.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of thirty-six (36) trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we
decided that the Plan does not have to pre-approve twenty-four (24) additional routine transportation trips.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hereditary cardio screening provided on November 16,
2020.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says Medicare
denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
We looked at the file and the rules. The test at issue in this appeal was requested for screening purposes.
Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to
pay for the hereditary cardio screening provided on November 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on January 7, 2021.
You asked the Plan to waive the copayment for the specialist office visit. You say that you have never paid a copayment in your life. You say you were under the impression that your plan covered doctor visits as long as the doctor was in-network. The Plan denied your request. The Plan says you have been asked to pay 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 $10 copayment for specialty care physician. You have been asked to pay a $10 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows you had an annual follow-up visit with a vascular surgeon.
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 specialist office visit provided on January 7, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hereditary cardiovascular test provided on August 10, 2020.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation. We looked at the file and the rules. The documentation in the case file shows that the ordering physician listed on the claim form did not order the testing at issue. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the hereditary cardiovascular test provided on August 10, 2020.
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 admission to an IRF is medically necessary. The Plan denied your request. The Plan says there are no acute or new medical conditions that require care. Medical conditions are well controlled. Documentation does not indicate that the enrollee needs an intensive therapy program with multiple visits each week from a rehab doctor. The enrollee can safely receive the services you need in other settings, such as a skilled nursing facility, home with home health and home physical therapy.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically necessary services can be provided in a different level of care. 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound (51798) provided on
December 2, 2020.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to
the service provided.
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 $20
copayment per visit for laboratory tests, non-radiological diagnostic tests, flat film x-rays, and ultrasounds.
You have been asked to pay a $12.38 copayment for the ultrasound provided. This is the Plan's allowed
amount and is less than the applicable copayment for this 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 ultrasound (51798) provided on
December 2, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for FoundationOne CDX liquid panel testing provided to the enrollee on November 11, 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 that pancreatic cancer is not an approved indication for this testing.
The Plan must follow Medicare rules. Medicare rules say that services are covered if 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 pay for the services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is noted to have had an advanced stage, solid organ tumor. TMB (tumor mutation burden) testing is indicated for such tumors and the results may affect treatment. There is no evidence that the enrollee had previously had such testing. The enrollee was seeking further treatment. As such, the performed testing was medically necessary and 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 services have been met. Therefore, we decided that the Plan has to pay for FoundationOne CDX liquid panel testing provided to the enrollee on November 11, 2020.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for arthrocentesis provided on January 8, 2021.
You asked the Plan to waive the copayment for arthrocentesis. You say that you only received an injection and disagree with how the procedure was billed as a surgical procedure. You also feel that the provider is money hungry. 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 $275 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities. You received arthrocentesis on January 8, 2021, at an outpatient hospital facility. Arthrocentesis is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $275 copayment.
You have been asked to pay a $275 copayment for arthrocentesis. Arthrocentesis falls within the outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for arthrocentesis provided on January 8, 2021.
We note your complaint that you feel that the provider is only looking for money. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the multiplex PCR testing provided on August 28, 2020.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered service.
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 pay for the testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found that multiplex PCR respiratory viral panels of 6 or more pathogens are non-covered. The pathogen targets that compose the panels are determined by the manufacturers that make them, and do not represent specific pathogens that cause a common syndrome, or the organisms that commonly are found in a specific sample type or patient population or reflect seasonal variations. The fixed nature of these multiplex panels includes pathogens that cause infections different enough that simultaneous testing for these pathogens should be rare. This is not a COVID-19 test. This was not an emergency test. There was no clinical rationale to support the obtained laboratory studies. 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for the multiplex PCR testing provided on August 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pontics (D6241) for teeth #19 and #20 and retainer crowns (D6751) for teeth #18 and #21.
You asked the Plan to pre-approve the bridgework. You say that these services are necessary. The Plan denied your request. The Plan says The requested posterior three-unit fixed bridge is beyond the scope of the policy benefit coverage.
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. The Plan covers the bridgework when the services are medically necessary and reasonable. The Plan will only cover a fixed bridge to replace one or two adjacent anterior teeth. 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 bridgework. Our reviewer says that criteria for a fixed covered bridge are not met. Our physician reviewer found that the requested service is beyond the scope of the Plan. There is no coverage for the replacement of posterior teeth by fixed bridge in most circumstances. There is no indication that a removable appliance is contraindicated due to physical or psychological issues. The documentation 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 the Plan's rules for coverage of the bridgework have not been met. Therefore, we decided that the Plan does not have to pre-approve pontics (D6241) for teeth #19 and #20 and retainer crowns (D6751) for teeth #18 and #21.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the low osmolar contrast material coded Q9967, arthrocentesis services coded 20610, and the hyaluronan injection coded J7320 provided on July 23, 2020.

You asked the Plan to pay for the low osmolar contrast material, arthrocentesis services, and the hyaluronan injection. 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 Q9967, 20610, and J7320 are not supported in the medical record. Specifically, the documentation submitted did not include documentation of the Low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml was performed; therefore, code Q9967 cannot be verified. The documentation submitted did not include documentation of the Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance was performed; therefore, code 20610 cannot be verified. The documentation submitted did not include documentation of the Hyaluronan or derivative, GenVisc 850, for intra-articular injection, 1 mg was performed; therefore, code J7320 cannot be verified.

Based on this information, we decided that Medicare rules for coverage of the low osmolar contrast material, arthrocentesis services, and the hyaluronan injection have not been met. Therefore, we decided that the Plan does not have to pay for the low osmolar contrast material coded Q9967, arthrocentesis services coded 20610, and the hyaluronan injection coded J7320 provided on July 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost for the wound debridement and unna boot strapping provided from October 6, 2020, through December 29, 2020.

You asked the Plan to waive the cost for the wound debridement and unna boot strapping. You say that you had no alternative other than seeking treatment for the wounds through private means. You say that if he remained in the rehab center the treatment would have remained part of the COVID claim and the charges should be reimbursed. The Plan denied your request. The Plan says the cost share 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $40 copayment for surgery services at an in-network specialist's office.

The enrollee has been asked to pay a total of $264.98 for the wound debridement and unna boot strapping.

Date of Service
Service
Standard Copayment
Member Liability

October 6, 2020
Wound Debridement
$40
$40

October 13, 2020
Wound Debridement
$40
$40

October 27, 2020
Wound Debridement
$40
$40

December 16, 2020
Unna Boot Strapping
$40
$24.98

December 18, 2020
Wound Debridement
$40
$40

December 22, 2020
Wound Debridement
$40
$40

December 29, 2020
Wound Debridement
$40
$40

TOTAL:
$264.98

The wound debridement and unna boot strapping fall within the "Physician/Practitioner services, including doctor's office visits" 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 cost for the wound debridement and unna boot strapping provided from October 6, 2020, through December 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia for open procedures involving hip joint (01210).

You asked the Plan to pay for the anesthesia for open procedures involving hip joint. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says the record does not support the services as billed.

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 01210 is Anesthesia for open procedures involving hip
joint; not otherwise specified.

We asked our coder 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 anesthesia for open procedures involving hip joint. Our
reviewer says that the requested services as billed are not supported by the medical records. Our physician
reviewer found that the enrollee is an 84-yr old female who received services on June 29, 2020, for CPT 01210
Anesthesia for open procedures involving hip joint; not otherwise specified. Documentation submitted was
reviewed and the criteria for this billed service have not been met. Based on the medical records of the service
performed, the units billed of 01210 is incorrect and is greater than the actual anesthesia services received.

We looked at the coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the anesthesia for open procedures involving hip joint have not been met.
Therefore, we decided that the Plan does not have to pay for the anesthesia for open procedures involving hip
joint (01210).