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

We decided that the Plan does not have to waive the deductible for the diagnostic mammogram and ultrasound
provided on February 18, 2020.
You asked the Plan to waive the deductible for the diagnostic mammogram and ultrasound. You say that you
were under the impression that this was a routine screening. You say that you would consider this a follow-up
since you haven't had any procedures done. The Plan denied your request. The Plan says the deductible applied
correctly.
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 your deductible is $750. This is the amount you have to pay out-of-pocket
before we will pay our share for your covered medical services. Until you have paid the deductible amount,
you must pay the full cost of your covered services. Outpatient diagnostic imaging is not excluded from the
deductible.
The item or service you asked the Plan to waive the deductible for falls within the "Outpatient diagnostic tests
and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly
disclosing in the contract that your $750 deductible applies to outpatient diagnostic imaging. This cost sharing
is a contractual obligation that had not been met at the time the diagnostic mammogram and ultrasound were
received on February 18, 2020. Therefore, we decided that the Plan does not have to waive the deductible for
the diagnostic mammogram and ultrasound provided on February 18, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an EGD provided on December 9, 2019. You asked the Plan to waive the copayment for an EGD. You say that you were not informed of the charges ahead of time. 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 $325 copayment for surgical services provided at an outpatient hospital facility. You have been asked to pay a $325 copayment for an EGD. An EGD falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an EGD provided on December 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an annual wellness visit provided on January 14, 2020.You asked the Plan to waive the coinsurance for an annual wellness visit. You say that you disagree with the charges because you were told it would be covered.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 40% coinsurance for out-of-network annual wellness visits. You received an annual wellness visit on January 14, 2020 with an out-of-network provider. The allowed amount is $153.86 and 40% of that is $61.54. You have been asked to pay the total coinsurance amount of $61.54 for an annual wellness visit. An annual wellness visit falls within the annual wellness visit 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 annual wellness visit provided on January 14, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay more for the periodic oral evaluation and prophylaxis provided on February 19, 2020.You asked the Plan to pay more for the periodic oral evaluation and prophylaxis. You say that you were under the impression that the Plan would deduct $25.00 for each service and reimburse the difference, which would have been $106.00 total. You also say that you would like to be reimbursed the remaining $47.00.The Plan denied your request. The Plan says that the claim was processed correctly, and you were reimbursed up to the approved amount less any copay.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 does not say in clear and accurate terms that the Plan will only pay up to the allowed amount less the copayment for preventive dental services. We looked at your contract with the Plan. We did not see where the contract clearly states that the enrollee will only be reimbursed up to the allowed amount less the copayment for preventive dental services. It was reasonable for you to believe you would only be responsible for the $25 copayment for each service. Based on this information, we decided that the Plan's rules for coverage of the periodic oral evaluation and prophylaxis have been met.Therefore, we decided that the Plan has to reimburse you $47 more for the periodic oral evaluation and prophylaxis provided on February 19, 2020. If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (G0481) provided on August 29, 2019.
You asked the Plan to pay for the services. You say that The Plan denied your request. The Plan says the billed code 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 G0481 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 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; 8-14 drug class(es), including metabolite(s) if performed". We find that CPT code G0481 is not supported in the medical record. Specifically, the records provided do not show that definitive drug testing was provided for 8-14 drug classes on August 29, 2019. 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 the drug testing services (G0481) provided on August 29, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0483 and 80307) provided to the enrollee on
February 18, 2020.
You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your
request. The Plan says there were insufficient medical records submitted to show the enrollee met the required
criteria at the time of testing.
The Plan must follow Medicare rules. Medicare has specific documentation requirements for this type of
testing. The physicians order and the medical records must specifically show how this testing will be used to
treat illness or disease present in the enrollee at the time of service as opposed to this testing being done for
screening purposes. The records provided lack any of the detailed information required for coverage of this
testing. Based on the records provided, the required Medicare criteria are not met. Therefore, we decided that
the Plan does not have to pay for drug testing (G0483 and 80307) provided to the enrollee on February 18,
2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that you would like reconsideration because
the member will continue to have unplanned readmission if admitted to a lower level of care. The Plan denied
your request. The Plan says the member can receive the necessary services at a lower level of care.
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 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.
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 long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on January 15, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were available in-network.
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 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 the medical services provided to the enrollee by an out-of-network provider on January 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on March 9, 2020.
You asked the Plan to waive the copayment for the office visit. You say that the visit was directly related to your original surgery. You say that you are requesting a coding review. 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 $50 for each Medicare-covered visit with an in-network specialist. You have been asked to pay a $50 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. There is no provision in the contract which indicates a copayment would be waived if performed as a follow-up to a surgical procedure. 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 on March 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration because the IRF admission is medically necessary. The Plan denied your request. The Plan says the member can safely receive the necessary services in other settings.
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 the complexity of the member's nursing, medical and rehabilitation needs require an acute hospital inpatient stay with an interdisciplinary approach rehabilitation care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on October 4, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were available in-network.
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 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 the medical services provided to the enrollee by an out-of-network provider on October 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forwound care provided on December 4, 2019 by an out of network (OON) provider.You asked the Plan to pay forwound care. You say that these services were medically necessary.The Plan denied your request. The Plan says no prior authorization was obtained.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 forwound care provided on December 4, 2019 by an out of network (OON) provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on
October 9, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your
request. The Plan says the documentation does not indicate services are necessary for treatment of the
enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis
(L0650) provided to the enrollee on October 9, 2019.
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 records do not indicate that there are significant, or complex medical/nursing issues
that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other
medication management, wound care, and daily therapy can be provided at a SNF. In this case, you are mostly
standby assist for functional transfers and activities of daily living (ADL's) and a less intensive, longer duration
of therapy will allow for measurable gains to be attained within a reasonable period.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a chest x-ray (71045) provided on January 31, 2020.
You asked the Plan to pay for the chest x-ray. You say that you would like reconsideration because this claim
was denied as a duplicate in error. The Plan denied your request. The Plan says CPT code 71045 is a column II
code to CPT code 32555 and has not been billed with a modifier to indicate these procedures were distinct and
independent to one another.
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, we have confirmed that code the
chest x-ray has a bundled relationship with code 32555 and cannot be paid as billed. This code cannot be paid
as a separate line item. Additionally, CPT code 71045 has not been billed with a modifier that indicates these
services were distinct and independent of one another. Based on the claim submitted, Medicare billing criteria
have not been met. Therefore, we decided that the Plan does not have to pay for a chest x-ray (71045) provided
on January 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided by an out of network (OON)
provider on March 23, 2020.
You asked the Plan to pay for physician services. You say that you were referred to this doctor. You say that
you assumed the doctor was in-network. The Plan denied your request. The Plan says no prior authorization
was obtained.
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 physician services provided by an out of network
(OON) provider on March 23, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has waive the deductible for anesthesia services (00731) provided on November 11, 2019. You asked the Plan waive the deductible for the anesthesia services. You say that you would like reconsideration because you went to an in-network facility and this bill creates financial hardship. The Plan denied your request. The Plan says that the Plan has not addressed the issue of your deductible amount. The Plan must follow Medicare rules. Medicare rules say that a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles and coinsurance). We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have been met. Specifically, the Health Plan contract clearly states that your deductible does not apply to services rendered in-network. The record indicates that the member received these services at an in-network facility and there is no indication that the member did not reasonably believe these services would be covered. Therefore, we decided that the Plan has waive the deductible for anesthesia services (00731) provided on November 11, 2019. Please note, we are unable to make a decision regarding the duplicate claim denial because there is no evidence that you are being held liable. 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on January 28, 2020.
You asked the Plan to pay for the drug testing services.. The Plan denied your request. The Plan says the billed services cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that 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. The records provided do not contain documentation of the ordering physician's intent that the tests be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services. have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on January 28, 2020.