Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided from November 25,
2019 to December 2, 2019.
You asked the Plan to pay for home infusion therapy. You say that this is a valid code. The Plan denied your
request. The Plan says this code is not valid for Medicare purposes.
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 code S3928 is not supported in the medical record. Specifically, this code has a status
indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this
information, we decided that Medicare rules for coverage of home infusion therapy have not been met.
Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) provided from
November 25, 2019 to December 2, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Computed Tomography (CT) of the lower extremity (73700) provided November 13, 2019.You asked the Plan to waive the copayment for the CT scan. You say that the copayment should be waived.The Plan denied your request. The Plan says the correct copayment was applied.The rules say a plan must disclose to its enrolleesin 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 $325 copayment for diagnostic radiology. You have been asked to pay a $136.44 copaymentfor the CT scan. This is based on the Medicare allowable amount, which is less than the $325 that is stipulated in the contract. The CT scan falls within the diagnostic radiology 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 Computed Tomography (CT) of the lower extremity (73700) provided November 13, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forSNF care from November 29, 2019 through December 23, 2019.You asked the Plan to waive the copayment forSNF care. You say that the insurance should have covered the entire thing and that you should not have a copayment.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 show that you received SNF care from November 29, 2019 through December 23, 2019. Your EOC clearly states, for each admission you pay $20 per day for days 1-20 of a benefit period, $60 per day for days 21-44, and $0 per day for days 45 -100 of a benefit period. You areasked to pay a $20 copayment per day from November 29, 2019 through November 31, 2019, a $20 copayment per day from December 1, 2019 through December 19, 2019 and a $60 copayment per day from December 20, 2019 through December 23, 2019. 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 forSNF care from November 29, 2019 through December 23, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing provided to the enrollee on November 8, 2019.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the documentation did not include a valid physician order, or medical records 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 code G0483 is definitive drug testing of 22 or more drug classes. We find that CPT code G0483 is not supported in the medical record. Specifically, there were insufficient records provided to show the results of this testing would be used to determine a specific diagnosis or determine a specific treatment strategy for disease or illness present in the enrollee at the time of service. 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 definitive drug testing provided to the enrollee on November 8, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance transport provided on December 5, 2019.You asked the Plan to waive the copayment forthe ambulance transport. You say that the EMS was called on your behalf. You say that you are appealing the charge because this was an emergency.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 $300 copayment per one-way trip for  emergency ambulance services and non-emergency ambulance services.You have been asked to pay a $300 copayment for the ambulance transport. The ambulance transportfalls within the "Ambulance 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 copayment forthe ambulance transport provided on December 5, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for upper extremity fracture orthosis, radius/ulnar, prefabricated, includes fitting and adjustment (L3982) provided on March 22, 2019.
You asked the Plan to waive the coinsurance for the DME. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received an orthotic on March 22, 2019. You have been asked to pay 20% coinsurance of the allowed amount for DME. The allowed amount is $295.12. The total you owe is $59.02 ($295.12 x 20% = $59.02). 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 upper extremity fracture orthosis, radius/ulnar, prefabricated, includes fitting and adjustment (L3982) provided on March 22, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services coded 71045 provided on January 26,
2019.
You asked the Plan to pay for the x-ray services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services billed are a duplicate.
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 71045 is radiologic examination, chest; single view.
We find that CPT code 71045 is not supported in the medical record. Specifically, this claim is a duplicate. The
documentation does not support that the claim is different than the one already processed by the plan. Based on
this information, we decided that Medicare rules for coverage of the x-ray services have not been met.
Therefore, we decided that the Plan does not have to pay for the x-ray services coded 71045 provided on
January 26, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy provided from December 11, 2019 to December 18, 2019. You asked the Plan to pay for home infusion therapy (S9328). You say that the code is valid and the Plan should pay this claim. The Plan denied your request. The Plan says this code is not valid for Medicare purposes. 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 S9328 is Home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem. We find that CPT code S9348 is not a valid code for Medicare purposes. S codes are unique temporary codes established by BCBSA and HIAA for private payor use. They are not valid nor payable by Medicare. Medicare uses another code for reporting of, and payment for, these services. Based on this information, we decided that Medicare rules for coverage of home infusion therapy management have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy provided from December 11, 2019 to December 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on March 12, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 drug testing rendered on March 12, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says that there is no clear benefit of inpatient skilled nursing as opposed to an alternative setting for care. 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 pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for continued SNF services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
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 the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 there is no reason to think that an intensive rehabilitation therapy program would significantly impact the enrollee's condition differently compared with therapy provided at a less intense level. The enrollee's care can be appropriately provided at a skilled nursing facility (SNF) level.We lookedat 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: Imaging
Decision: Favorable

We decided that the Plan has to waive the coinsurance fora Low Dose Computed Tomography (LDCT) Lung Cancer Screening (G0297) provided December 4, 2019.You asked the Plan to waive the coinsurance for the LDCT Lung Cancer Screening. You say that you were not happy with the service and the coinsurance should be waived.The Plan denied your request. The Plan says that the correct 20% coinsurance was applied for Diagnostic Radiology Services.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 there is no coinsurance for Lung Cancer Screenings. The in-network provider billed the service as a Low Dose CT Lung Cancer screening (G0297). You have been asked to pay a $103.09 coinsurance for the LDCT Lung Cancer Screening. The plan has applied the coinsurance for Diagnostic Radiology Procedures. The incorrect coinsurance has been applied.Therefore, we decided that the Plan has to waive the coinsurance fora Low Dose Computed Tomography (LDCT) Lung Cancer Screening (G0297) provided December 4, 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the air ambulance transportation services provided to the enrollee on September 21, 2019.
You asked the Plan to pay for the air ambulance services. You say that the claim was denied incorrectly. The Plan denied your request. The Plan says the enrollee's primary carrier paid more than the Medicare allowable fee maximum.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. The Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer.
The Plan has confirmed that payment made by the primary insurer was what would have been paid by Medicare. As the secondary insurer, the Plan cannot be held responsible for this transport as no further reimbursement is available under the Medicare payment guidelines. Therefore, we decided that the Plan does not have to pay for the air ambulance transportation services provided to the enrollee on September 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the wound debridement and office visits
provided from November 13, 2019 through January 8, 2020.
You asked the Plan to waive the copayment for the wound debridement and office visits. You say that you
were never charged a fee for the wound clinic before. The Plan denied your request. The Plan says the
copayments 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 $200 for
each in-network, Medicare-covered outpatient hospital facility visit and $50 for each in-network, Medicarecovered
visit.
You have been asked to pay a total of $850 for the wound debridement and office visits.
Date of Service Service Allowed Amount Standard Cost Member Liability
November 13, 2019 Wound Debridement $297.10 $200 $850
November 13, 2019 Office Visit $75.85 $50 $50
November 27, 2019 Wound Debridement $297.10 $200 $200
November 27, 2019 Office Visit $50.77 $50 $50
December 11, 2019 Wound Debridement $297.10 $200 $200
December 11, 2019 Office Visit $50.77 $50 $50
December 26, 2019 Office Visit $50.77 $50 $50
January 8, 2020 Office Visit $51.10 $50 $50
TOTAL: $850
Wound debridement falls within the "Outpatient surgery, including services provided at hospital outpatient
facilities and ambulatory surgical centers" benefit category. The office visits fall within the "Podiatry 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 copayment for the wound debridement and
office visits provided from November 13, 2019 through January 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the knee orthotics purchased on October 30, 2019.You asked the Plan to waive the coinsurance for the orthotics. You say that you are appealing your cost-share responsibility for the services you received.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received the knee orthotics purchased on October 30, 2019. You have been asked to pay 20% coinsurance of the allowed amount for the orthotics. The allowed amount is $752.57. The total you owe is $150.51 ($752.57 x 20% = $150.51). 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 knee orthotics purchased on October 30, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on November 6, 2019.You asked the Plan to waive the copayment for laboratory services. You say that you disagree with the $7.18 charge because your husband was never charged for it.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 $20 copayment for laboratory tests. You have been asked to pay $7.18, which is less than the $20 copayment for laboratory services. Laboratory services 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 services provided on November 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the ostomy supplies provided from January 19, 2020 through February 20, 2020.
You asked the Plan to waive the coinsurance for the DME. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received the ostomy supplies provided from January 19, 2020 through February 20, 2020. It was confirmed that catheter and ostomy supplies are considered prosthetic devices/medical supplies. You are asked to pay 20% coinsurance for the prosthetic devices and medical supplies. 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 ostomy supplies provided from January 19, 2020 through February 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye exam (92004) provided on February 16, 2018.
You asked the Plan to pay for an eye exam. You say that you did not receive the information needed to file the claim timely. The Plan denied your request. The Plan says claims must be submitted no more than a year after the date of service.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service. The record shows that a claim for an eye exam was not filed until March 16, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for an eye exam (92004) provided on February 16, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapproveintermittent limb compression device (E0675).You asked the Plan to preapproveintermittent limb compression device. You say that the compression pump helps with wound care therapy.The Plan denied your request. The Plan says pneumatic compression devices are not covered by Medicare for any indication.The Plan follows Medicare rules. The rules state that this type of pump is not covered. The rules say there is not enough proof that this kind of pump helps. Since we cannot approve the pump, we cannot approve the supplies. Therefore, we decided that the Plan does not have to preapproveintermittent limb compression device (E0675).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the transtelephonic rhythm strip pacemaker evaluation rendered on September 18, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not medically necessary.
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. There is no documentation to support that the services were medically necessary 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 transtelephonic rhythm strip pacemaker evaluation rendered on September 18, 2019.