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

We decided that the Plan does not have to waive the coinsurance for physician services provided by an out-of-network provider on February 5, 2020, to May 20, 2020.You asked the Plan to waive the coinsurance for physician services. You say that these charges are not fair. The Plan denied your request. The Plan says the correct coinsurance has been applied.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 45% coinsurance for physician/practitioner services/out-of-network. You have been asked to pay less than a 45% coinsurance of the allowed amount. The total allowed amount is $151.56. The total coinsurance amount is $68.20 ($151.56 x 45% = $68.20). You have been asked to pay the lesser amountof $59.10 for physician services. Physician services fall within the physician/practitioner services/out-of-network 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 physician services provided by an out-of-network provider on February 5, 2020, to May 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on July 6, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare coverage criteria were not met based on the medical records provided. The Plan states the provider confirmed that the this was the enrollee's first biopsy and a repeat biopsy is not being considered. Therefore, Medicare coverage criteria are not met.
The Plan must follow Medicare rules. Medicare has specific coverage criteria for this type of testing. Based on the medical records, the enrollee did not meet all of the criteria as stated above as required for coverage.
Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on July 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) 
for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee is not medically appropriate for transfer to the LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation provided necessitating admission to a LTACH. The 
enrollee still requires acute hospital level of care services and is receiving appropriate care at the present acute 
care hospital. The enrollee does not require services at the LTACH that are not available at the acute care 
hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee 
requires that are not available at the health care setting being offered by the health plan. The requested LTACH 
services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 
and able to be furnished safely and effectively only on an inpatient basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visits provided from February 6, 2020, to February 
21, 2020 by an out of network provider. 
 
You asked the Plan to pay for the office visits. You say that the Plan should pay these claims. The Plan denied 
your request. The Plan says you do not have out-of-network benefits. 
 
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 service 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 office visits provided from February 6, 2020, to February 21, 2020 by an out 
of network provider.  
 
Please note, your complaint for date of service March 4, 2020 is not a valid appeal for medical coverage. You 
were not enrolled in this Plan on the date of service in question.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approvea computed tomography (CT) scan of the chest (71260).You asked the Plan to pre-approvea CT scan of the chest. You say that the services are necessary.The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a CT scan of the chest. Our reviewer says that the services are medically necessary. Our physician reviewer found as the enrollee now has evidence of tumor recurrence staging for the tumor recurrence is necessary. Especially in this case with the site of the original tumor being in close proximity to the diaphragm. The CT of the chest is reasonable and should be approved.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CT scan of the chest have been met.Therefore, we decided that the Plan has to pre-approvea computed tomography (CT) scan of the chest (71260).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory tests provided on July 23, 2020.
You asked the Plan to waive the copayment for laboratory tests. You say that laboratory tests are included in physician visits and you should not owe a copayment. 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 $10 copayment for laboratory tests. The record shows that you received laboratory tests on July 23, 2020. Laboratory tests are not included in physician visits and are subject to separate cost-sharing charges. You have been asked to pay the allowed amount of $9.71, which is less than the $10 copayment for laboratory tests. Laboratory tests fall within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for laboratory tests provided on July 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided. 
 
You asked the Plan to waive the copayment for the office visit. You say that you didn't know you would be 
charged a copayment for a telehealth visit. 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 $40 
copay for visits to specialists. Covered services include a brief virtual (for example, via telephone or video 
chat) 5-10-minute check-ins with your doctor- if you are an established patient and the virtual check-in is not 
related to an office visit within the previous 7 days.  
 
You have been asked to pay a $40 copayment for the office visit. The office visit falls 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 office visit provided.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the insertion of an interbody biomechanical device (22853) provided 
on July 9, 2020. 
 
You asked the Plan to pay for the insertion of an interbody biomechanical device. You say that this was billed correctly. 
The Plan denied your request. The Plan says this code was not documented in the operative report narrative. 
 
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 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 insertion of an interbody biomechanical device. Our reviewer 
says that this code is not supported by the records. Our physician reviewer found the medical records provided do not 
include sufficient documentation to verify that an insertion of interbody biomechanical device(s) (eg, synthetic cage, 
mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to intervertebral 
disc space in conjunction with interbody arthrodesis, each interspace (List separately in addition to code for primary 
procedure) was performed on Mr. Kearney on July 9, 2020, therefore this service cannot be verified. 
 
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 an interbody biomechanical device have not been met. Therefore, we decided that 
the Plan does not have to pay for the insertion of an interbody biomechanical device (22853) provided on July 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the spinal injection services provided on May 14, 2019 billed with code 
64479-RT-59. 
 
You asked the Plan to pay for the spinal injection. You say that this claim should be paid. The Plan denied your request. 
The Plan says one unit of 64479 was already been paid for the Left side. Only one unit of this procedure is allowed per 
day according to the MUE. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the 
MUE value for the HCPCS/CPT code will be denied. The rules also say that the proper coding for bilateral procedures is 
one unit using the -50 modifier. 
 
In this case, the MUE for CPT code 64479 is 1. You billed 2 units of this code, exceeding the MUE. Based on this 
information, we decided that Medicare rules for coverage of the spinal injection have not been met. Therefore, we 
decided that the Plan does not have to pay for the spinal injection services provided on May 14, 2019 billed with code 
64479-RT-59.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the BLS non-emergency ambulance (A0428) and ground 
mileage (A0425) provided June 18, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that an ambulance was the only safest, 
medically and appropriate way for this patient to be transported due to his health condition. The Plan denied 
your request. The Plan says this service is not a Medicare covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctor?s office is not a covered destination.  
 
The services you have asked the Plan to pay for are ambulance transport services to a doctor?s office. 
Therefore, we decided that the Plan does not have to pay for the BLS non-emergency ambulance (A0428) and 
ground mileage (A0425) provided June 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the vitrectomy chair provided. 
 
You asked the Plan to reimburse you for the vitrectomy chair. You say that the vitrectomy chair was medically necessary. 
The Plan denied your request. The Plan says vitrectomy chairs are not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say face-down positioning devices are non-covered because they do not 
fall within a Medicare benefit category.  
 
Medicare will not pay for precautionary equipment. Therefore, we decided that the Plan does not have to reimburse you 
for the vitrectomy chair provided.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Avoy Autoinjector. 
 
You asked the Plan to pre-approve the Avoy Autoinjector. The Plan denied your request. The Plan says the 
requested drug is intended for self-administration. The Plan says that the enrollee does not have Part D 
coverage through them. 
 
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 an Avoy Autoinjector.  
 
Benefits for the Avoy Autoinjector may be available under Medicare Part D. Contact the 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 the medical services provided by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent 
nor urgent and prior authorization was not obtained to provide out-of-network care. 
 
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 by an out of network (OON) 
provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 13, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior 
authorization was not obtained to provide out-of-network care. 
 
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 February 13, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the injection provided on August 4, 2020. 
 
You asked the Plan to waive the coinsurance for the injection. 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 received an injection on the date of service at issue in this appeal. The Plan 
says that the correct coinsurance 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received an injection on 
August 4, 2020. You have been asked to pay a 20% coinsurance for the injection, totaling $368.34. The 
injection falls 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 injection provided on August 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on May 12, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the CPAP. You say that you were misinformed that the services were in network. 
The Plan denied your request. The Plan says you must get prior authorization if you get an out of network 
provider. 
 
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 May 12, 2020 by 
an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental x-rays (D0274, D0230) provided. 
 
You asked the Plan to pay for the dental x-rays. You say that this service should be covered. The Plan denied 
your request. The Plan says the benefit for x-rays was exhausted at the time the services were provided. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, coverage for x-rays is limited to 2 per 
year. The record shows 2 x-rays had already been provided at the time these services were rendered, therefore, 
the benefit was exhausted. Therefore, we decided that the Plan does not have to pay for dental x-rays (D0274, 
D0230) provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cast supplies with CPT code Q4010 provided. 
 
You asked the Plan to pay for CPT code Q4010. 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. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code Q4010 is Cast supplies, short arm cast, adult (11 years +), 
fiberglass. 
 
We find that CPT code Q4010 is not supported in the medical record. Specifically, the medical records 
provided did not include documentation of cast supplies. Based on this information, we decided that Medicare 
rules for coverage of CPT code Q4010 have not been met. Therefore, we decided that the Plan does not have to 
pay for the cast supplies with CPT code Q4010 provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the scaling and root planing, tooth 8 (D4342) provided 
August 10, 2020. 
 
You asked the Plan to pay for the dental services. You say that you feel that the scaling and root planing should 
be covered as you was never told and it is  not mentioned in any of your paperwork that it is only a benefit once 
every 36 months. The Plan denied your request. The Plan says this benefit has been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. This service is limited to once 
per quadrant, every 36 months. The records show this service was provided on November 9, 2017. 
 
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 at this time. Therefore, we decided that the Plan does not have to pay 
for the scaling and root planing, tooth 8 (D4342) provided August 10, 2020.