Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided to the enrollee from December 31, 2019 through January 6, 2020.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing the member's cost-share responsibility for the services the member received due to the quality of care. The Plan denied your request. The Plan says the claim was processed accordingly with the member's 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 the enrollee was admitted on December 31, 2019 and discharged on January 6, 2020. The enrollee was asked to pay a $225 copayment per day from December 31, 2019 through January 5, 2020, days 1-6 of the enrollee's inpatient hospital care. The enrollee was discharged on January 6, 2020 and there was no copayment charge for the day of discharge. Per the enrollee's contract there is a $225 copayment per day required for days 1-8. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital care provided to the enrollee from December 31, 2019 through January 6, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from January 24, 2020 to February 4, 2020.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the service was not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.
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 skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from January 24, 2020 to February 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core buildup (D2950). 
 
You asked the Plan to pre-approve the core buildup. You say that a full coverage restoration is necessary to 
restore the tooth to optimum strength and function. The Plan denied your request. The Plan says this service is 
not a covered benefit. 
 
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 pre-approve a 
core buildup (D2950).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an outpatient surgery provided by a
participating outpatient hospital on October 22, 2019.
You asked the Plan to waive the coinsurance for an outpatient surgery. You say that you do not agree with this
coinsurance. 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 20%
coinsurance for outpatient surgery/outpatient hospital facility.
You have been asked to pay a 20% coinsurance of the allowed amount for an outpatient surgery. The total
allowed amount is $12,729.33. The total amount you are being asked to pay is $2,545.87 ($12,729.33 x 20% =
$2,545.87). An outpatient surgery falls within the outpatient surgery/outpatient hospital facility 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 an outpatient surgery provided by a
participating outpatient hospital on October 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), and crown (D2740) provided on March 5, 2020 and March 17, 2020.
You asked the Plan to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, and crown. You say that these services should be covered because they are common services. The Plan denied your request. The Plan says these services are not covered by the Plan. The Plan also says that you did not elect to purchase an optional supplemental benefit plan.
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 the problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), and crown (D2740) provided on March 5, 2020 and March 17, 2020.
Your complaint about your dissatisfaction with the Plan 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 23, 2019. 
 
You asked the Plan to pay for the laboratory 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 are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, 
however, the physician must clearly document, in the medical record, his or her intent that the test be 
performed. 
 
We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the 
medical record. We find that the issue of intent is not clear. There are no medical records in the case file in 
regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on December 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a comprehensive oral evaluation to be rendered by an OON provider.
You asked the Plan to pre-approve the comprehensive oral evaluation. You say that dental care is a priority to avoid any further complications. You also say that you have a leak in one of your front teeth, which is why you need an evaluation with the requested OON provider. The Plan denied your request. The Plan says the requested provider is not a participating provider with your health plan. The Plan also says that as a member with this Plan, you must use providers that are in the network for all of your services.
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 covered when they are received OON. Therefore, we decided that the Plan does not have to pre-approve a comprehensive oral evaluation to be rendered by an OON provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for an office visit provided on March 11, 2020. 
 
You asked the Plan to pay for office visit. You say that you provided medically necessary services in good 
faith. The Plan denied your request. The Plan says that the denial of payment for this service is correct, because 
this provider is out-of-network with the Plan and authorization was not obtained. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis, and 
pre-approved care.   
 
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 office visit. Our reviewer says that this 
service meets the Medicare criteria for urgent out-of-area care. Our physician reviewer found the enrollee could 
not have foreseen requiring this service prior to leaving the Plan's service area. The records indicate that the 
care provided was medically necessary. It would not have been medically reasonable to delay the service until 
the enrollee returned to the Plan's service area or up to 6 months. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of office visit have been met. Therefore, we decided that the Plan has to pay for an 
office visit provided on March 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the vision services provided on February 5, 
2020. 
 
You asked the Plan to waive the copayment for the vision 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 received vision services provided in an outpatient hospital facility setting 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 $170 
copayment for diagnostic procedures and tests provided in an outpatient hospital setting.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received vision services 
in an outpatient hospital facility setting on February 5, 2020. You have been asked to pay a $170 copayment for 
the vision services. The vision services when provided in an Outpatient hospital facility setting fall within the 
Outpatient diagnostic tests 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 vision 
services provided on February 5, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services. 
 
You asked the Plan to pay for the ambulance services. You say that you were volunteering at a local food 
pantry when you felt dizzy and you sat down on the floor. You say that the director was concerned and called 
for an ambulance to make sure that you were okay. When the paramedics arrived, they evaluated you and took 
your blood pressure. You stated that the paramedics asked you several questions, but you were not transported. 
You say that you received a bill from the provider and were initially told by the Plan that the claim was denied 
because it was coded incorrectly. You say that you do not believe you should be responsible for the cost and 
you asked the Plan to reconsider their denial. The Plan denied your request. The Plan says these services are 
not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on February 7, 2019. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical assistant services on a laparoscopy (47562) provided on March 5, 2020.
You asked the Plan to pay for surgical assistant services. You say that these services were medically necessary and requested by the primary surgeon. The Plan denied your request. The Plan says these services are not covered when provided by an LSA.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS. In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for surgical assistant services on a laparoscopy (47562) provided on March 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on December 27, 2019. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require 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 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 physician's services provided on December 27, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (CPT 80307 and HCPCS G0480) 
provided to the enrollee on August 20, 2019. 
 
 
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 the documentation submitted did not include a physician order/lab requisition or medical records 
(signed by the ordering physician) stating exactly what tests are to be performed. 
 
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 the denied codes is: 
 
CPT 80307: 
 
Drug test(s), presumptive, any number of drug classes, qualitative; any number of devices or procedures, by 
instrument chemistry and analyzers (e.g., utilizing immunoassay [EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), 
chromatography (e.g., GC, HPLC), and mass spectrometry either with or without chromatography, (DAT, 
DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when 
performed, per date of service 
 
HCPCS G0480: 
 
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 enzymatic methods (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; 1-7 drug class(es), including metabolite(s) if performed  
 
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 
services at issue in this case were not supported by the medical records. Our physician reviewer found the 
records did not contain a valid physician order or requisition to support the above codes. 
 
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 pay for drug testing services (CPT 80307 and HCPCS G0480) provided to the enrollee on August 20, 
2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 67850 provided on October 15, 2019.
You asked the Plan to pay for CPT code 67850. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the medical records do not support the billing of CPT code 67850.
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 67850 is Destruction of lesion of lid margin (up to 1 cm). We find that CPT code is not supported in the medical record. Specifically, the file does not include a surgical procedure report to verify if the correct CPT code was billed based on Medicare guidelines. Based on this information, we decided that Medicare rules for coverage of CPT code 67850 have not been met. Therefore, we decided that the Plan does not have to pay for CPT code 67850 provided on October 15, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an ambulance ride and an inpatient 
hospital stay provided from November 7, 2018 to November 13, 2018. 
 
You asked the Plan to waive the copayments for the ambulance ride and the inpatient hospital stay. You say 
that you just received these bills now and you say that these were paid last year. The Plan denied your request. 
The Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 
copayment for each one-way Medicare-covered trip and a $395 copayment each day for days 1 to 4 for 
Medicare-covered hospital care and a $0 copayment for additional Medicare-covered days.  
 
You have been asked to pay a $225 copayment for the ambulance ride. You have also been asked to pay 
$$1,580 for the inpatient hospital stay. ($395 x 4 days = $1,580). The ambulance ride falls within the 
Ambulance Services benefit category. The inpatient hospital stay falls within the Inpatient Hospital Care
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 for the ambulance ride and the inpatient hospital stay provided 
from November 7, 2018 to November 13, 2018.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat radiofrequency neurotomy (64635, 64636). 
 
You asked the Plan to pre-approve a repeat radiofrequency neurotomy. You say that the enrollee needs this. 
The Plan denied your request. The Plan says the submitted records do not show that coverage criteria have been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say repeat denervation procedures involving the same 
joint will only be considered medically necessary if the patient experienced at least 50% improvement of pain 
and improvement in patient specific Activities of Daily Living (ADLs) documented for at least 6 months. 
 
We looked at the file and Medicare rules. The submitted medical records do not show that the enrollee 
experienced 50% or more improvement of pain for 6 months. Based on this information, we decided that 
Medicare rules for coverage of a repeat radiofrequency neurotomy have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a repeat radiofrequency neurotomy (64635, 64636).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for inappropriately billed codes for ambulance transport provided on February 20, 2020.
You asked the Plan to pay for this transport. You say that this transport was necessary and should be covered by the Plan. The Plan denied your request. The Plan says the transport was covered under the Medicare billing guidelines. Those charges showing denied are billing errors by the provider and you are not responsible for payment of those charges. The Plan states the $270 copayment is based on the Plan contract agreement for ambulance transport.
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 $270 copayment for ambulance transport. You have been asked to pay the correct amount based on your contract with the Plan. You are not responsible for the oxygen and supplies inappropriately billed separately by the provider. The $270 copayment is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to pay for ambulance transport provided on February 20, 2020.