Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waivethe copayment for the outpatient surgery services you received from July 2, 2019, to August 31, 2019.You asked the Plan to waivethe copayment. You say that the services were billed incorrectlyThe Plan denied your request. The Plan says you are responsible for the 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 $275 copayment for each outpatient surgery service. Review of the file shows that you received surgery serviceson several dates of service from July 2, 2019, to August 31, 2019. You have been asked to pay a $275 copayment for each of these services. The 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 waivethe copayment for the outpatient surgery services you received from July 2, 2019, to August 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on August 22, 2019.
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from 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 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 a domiciliary, rest home visit provided on August 22, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing coded G0483 provided on November 4, 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.In this case, the CPT Code Manual definition of code G0483 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymaticmethods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) ifperformed.We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation submitted did not include a physician order/lab requisition or medical records stating exactly what tests were to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met.Therefore, we decided that the Plan does not have to pay forthe drug testing coded G0483 provided on November 4, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forinpatient hospital care from November 14, 2019 through November 17, 2019 provided by an in-network provider.You asked the Plan to waive the copayment forinpatient hospital care. You say that you never had such a high copayment for any hospital stay.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 14, 2019 and discharged on November 17, 2019. You were asked to pay a $275 copayment per day from November 14, 2019 through November 16, 2019, days 1-3 of your inpatient hospital care. You were discharged on November 17, 2019 and there was no copayment charge for the day of discharge. Per your contract there is a $275 copayment per day required for days 1-6 for in-network inpatient hospital care. 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 forinpatient hospital care from November 14, 2019 through November 17, 2019 provided by an in-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visits or waive the coinsurance for the daptomycin injections provided from March 22, 2019 through April 9, 2019.
You asked the Plan to waive the copayment for the specialist office visits and waive the coinsurance for the daptomycin injections. You say that had you known you would be charged differently than what you were told, you would have chosen alternative antibiotic treatment. The Plan denied your request. The Plan says that cost-sharing is a contractual obligation and cannot be waived.
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 $25 copayment for services obtained from a specialist and a 20% coinsurance for each Medicare-covered Part B drug. You have been asked to pay a $25 copayment for each specialist office visit and a 20% coinsurance for each daptomycin injection. The specialist office visits fall within the services obtained from a specialist benefit category and the daptomycin injections fall within the Medicare-covered Part B drug 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 specialist office visits and waive the coinsurance for the daptomycin injections provided from March 22, 2019 through April 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 25, 2019 to December 18, 2019 by an out of network (OON) provider.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 were rendered by an out-of-network provider without prior 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 for the medical services provided on November 25, 2019 to December 18, 2019 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible forthe diagnostic colonoscopy provided on January 15, 2020.You asked the Plan to waive the deductible forthe diagnostic colonoscopy. You say that you were under the impression that the colonoscopy was completely covered. You say you do not recall the representative mentioning that it could turn into a surgical procedure.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. Your contract with the Plan says that there is a $750 deductible that applies towards a diagnostic colonoscopy. The diagnostic colonoscopy you asked the Plan to waive the deductible for falls within the "Outpatient hospital services" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible that applies towards diagnostic colonoscopies. The medical record shows a polyp was removed which makes the colonoscopy diagnostic in nature. This cost sharing is a contractual obligation that had not been met at the time the diagnostic colonoscopy was received on January 15, 2020.Therefore, we decided that the Plan does not have to waive the deductible for a diagnostic colonoscopy provided on January 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided by provider on October 24, 2019.You asked the Plan to pay for the lumbar-sacral orthosis (L0650). You say that the orthosis was medically necessary.The Plan denied your request. The Plan says there is a misrepresentation of services.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The medical records do not mention,or support medical necessity, for the lumbar-sacral orthosis. Based on this information, we decided that Medicare rules for coverage of the lumbar-sacral orthosis (L0650) have not been met.Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis provided by provider on October 24, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), prophylaxis (D1110),
the bitewing x-rays (D0272), the initial periapical x-ray (D0220), the additional periapical x-ray (D0230), and
the 2 resin based composites (D2391) for teeth # 12 and 13 provided on November 13, 2019.
You asked the Plan to pay for the dental services. You say that you have insurance. You say that you are
disabled and have no money to pay this bill. The Plan denied your request. The Plan says the dental services
that you received are not listed as 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 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
periodic oral evaluation (D0120), prophylaxis (D1110), the bitewing x-rays (D0272), the initial periapical x-ray
(D0220), the additional periapical x-ray (D0230), and the 2 resin based composites (D2391) for teeth # 12 and
13 provided on November 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to enrollee on October 10, 2018.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 procedure code 99497 is not supported.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 99497 is advance care planning by the physician or other qualified health care professional, first 30 minutes.We find that CPT code 99497 is not supported in the medical record. Specifically, the documentation does not show that advance care planning for the first 30 minutes was performed for the enrollee. 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 services rendered to enrollee on October 10, 2018.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services rendered to the enrollee on October 29, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 95937 is not supported.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 95937 is neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method.We find that CPT code 95937 is not supported in the medical record. Specifically, the documentation shows that train of four testing was performed, and there is a more appropriate code for these services. 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 forthe services rendered to the enrollee on October 29, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveNUPLAZID.You asked the Plan to pre-approveNUPLAZID. The Plan denied your request. The Plan says that this is not covered under Part B.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveNUPLAZID.Benefits for NUPLAZIDmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for electrical stimulation therapy (97014), mechanical traction therapy (97012), and manual therapy (97140) provided by a chiropractor on October 2, 2019.
You asked the Plan to pay for electrical stimulation therapy, mechanical traction therapy, and manual therapy. You say that these services should be covered. The Plan denied your request. The Plan says these services are not covered when provided by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for electrical stimulation therapy (97014), mechanical traction therapy (97012), and manual therapy (97140) provided by a chiropractor on October 2, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xifaxan for the enrollee.
You asked the Plan to pre-approve this drug. The Plan denied your request. The Plan says that this is not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xifaxan for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay forhospital physician services provided from September 11, 2019 to September 13, 2019.You asked the Plan to pay forhospital physician services. You say that these services were medically necessary.The Plan denied your request. The Plan says that the denial of payment for these services is correct, because the referral for service was not authorized by an attending physician.The Plan must follow Medicare rules. The rules say that an emergency exists based on a prudent layperson standard, not a retrospective medical review. For symptoms to be considered emergent in nature, they must be such that a prudent layperson with an average knowledge of medicine would reasonably expect the absence of immediate medical attention would result in serious jeopardy to their health. We decided that this case does meet prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine would reasonably expect the absence of immediate medical care to seriously jeopardize their health in this case.Therefore, we decided that the Plan has to pay forhospital physician services provided from September 11, 2019 to September 13, 2019.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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox.
You asked the Plan to pre-approve Botox. You say that The Plan denied your request. The Plan says that the use of this drug requires that you have had an inadequate response to or intolerance of anticholinergic medications, and that you do not have an acute urinary tract infection (UTI) and/or acute urinary retention.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Botox. Our reviewer says that Botox is not medically reasonable and necessary in this case. The use of Botox in this case requires that you have had an inadequate response to or intolerance of anticholinergic medications, and that you do not have an acute urinary tract infection (UTI) and/or acute urinary retention. The medical records included do not provide any information regarding this. Our physician reviewer found that your does not meet criteria for coverage of Botox. We looked at this physician's review, the file, and Medicare rules. Based on 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-approve Botox.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forprophylaxis -adult (D1110) performed on December 16, 2019.You asked the Plan to pay forthe dental services. You say that you need additional cleanings due to keep gum and teeth under control. You state that every six (6) months is not enough.The Plan denied your request. The Plan says you exhausted your benefit frequency limit.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.You exhausted your benefit frequency limit, because you had the same service done on March 13, 2019 and May 20, 2019Therefore, we decided that the Plan does not have to pay forprophylaxis -adult (D1110) performed on December 16, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve the endodontic therapy (D3330), a prefabricated post and core in addition to a crown (D2954) and a crown (D2751).
You asked the Plan to pre-approve the dental services. You say that you really need a root canal, crown, and a partial. The Plan denied your request. The Plan says that the requested dental services are not covered.
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 did not provide a copy of the applicable Evidence of Coverage for this case. We asked for this document but it was not provided to us. Without this information we cannot determine that the Plan's coverage rules support the denial of authorization in this case, or that the enrollee has been adequately notified of the Plan's coverage rules and benefits. Therefore the Plan has not substantiated their denial of authorization in this case. Therefore, we decided that the Plan has to pre-approve the endodontic therapy (D3330), a prefabricated post and core in addition to a crown (D2954) and a crown (D2751).
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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forPT provided from December 12, 2019 to January 14, 2020.You asked the Plan to waive the copayments forPT. You say that you disagree with the charges because you suffered damage from a nerve block.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 thePlan clearly says that you must pay a $40 copayment for outpatient rehabilitation services. You received PT from December 12, 2019 to January 14, 2020 for a total of 7 visits. Therefore, you are responsible to pay a $40 copayment per each visit. The total amount you owe is: $40 (copayment) x 7 (PT services) = $280.You have been asked to pay the total copayment amount of $280 for PT. PT 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 waive the copayments forPT provided from December 12, 2019 to January 14, 2020.