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

We decided that the Plan does not have to pay for additional medical care aboard a cruise ship on October 14,
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 plan has already reimbursed you for these services, with applicable cost-sharing according to
your benefits.
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 the denied CPT codes (CPT 99070, CPT 99080) and CPT 36000) are not supported in the medical
record. Specifically, payment for these codes are included in the payment for codes that have already been paid
by the plan. These codes have have no value in the fee schedule. 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 additional medical care aboard a cruise ship on October 14, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a skin biopsy provided on May 8, 2019.
You asked the Plan to waive the copayments for a skin biopsy. You say that you disagree with the charges because you received the bill a year after services took place. 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 $400 copayment for outpatient hospital surgery services for outpatient surgery, including services provided at hospital outpatient facilities. You received a skin biopsy on May 8, 2019. A skin biopsy is considered an outpatient surgical procedure. Furthermore, the provider is considered an outpatient hospital facility. Therefore, you are responsible to pay the allowed amount of $259.64, which is less than the $400 copayment. You have been asked to pay $259.64 for a skin biopsy. A skin biopsy 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 copayments for a skin biopsy provided on May 8, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the hematoma drainage procedure provided
on December 15, 2019.
You asked the Plan to waive the copayment for the hematoma drainage procedure. You say that you were not
aware that an emergency room admitted surgery had a much higher copayment. You say you have a low
income and this bill will be very difficult for you. 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 $325
copayment for surgical services at an in-network outpatient hospital facility.
You have been asked to pay a $325 copayment for the hematoma drainage procedure. The hematoma drainage
procedure 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 the
hematoma drainage procedure provided on December 15, 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 IRF admission is medically necessary. The Plan
denied your request. The Plan says the enrollee's needs can be met at a different level of care.
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 based on the medical records provided the complexity of the enrollee's nursing,
medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary
approach to rehabilitation care. The enrollee may require skilled physical therapy and occupational therapy but
based on the medical records provided the enrollee does not require treatment in an intensive rehabilitation
therapy program.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for male external catheter, with or without
adhesive, disposable, each (A4349) and urinary drainage bag, leg or abdomen, vinyl, with or without tube, with
straps, each (A4358) provided from April 13, 2020 through April 15, 2020.
You asked the Plan to waive the coinsurance for the DME. You say that previously you were allowed as many
bags The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 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 male external catheter, with or without adhesive, disposable, each
(A4349) and urinary drainage bag, leg or abdomen, vinyl, with or without tube, with straps, each (A4358)
provided from April 13, 2020 through April 15, 2020. You are asked to pay 20% coinsurance for the items.
Your EOC states, enrollees must pay 20% coinsurance for 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 male external catheter, with or without adhesive, disposable, each
(A4349) and urinary drainage bag, leg or abdomen, vinyl, with or without tube, with straps, each (A4358)
provided from April 13, 2020 through April 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a Hepatitis A vaccine (9047 and 90632) provided on March
9, 2020.
You asked the Plan to pay for the Hepatitis A vaccine. You say that you would like reconsideration because
this vaccine was ordered by your physician in preparation for a trip. The Plan denied your request.
The Plan says Hepatitis A vaccines are not listed as covered vaccines under Medicare Part B.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Hepatitis A
vaccine. The Plan follows the same rules.
Records do not show that you have been injured or directly exposed to any illness related to the Hepatitis A
vaccine. Therefore, we decided that the Plan does not have to pay for a Hepatitis A vaccine (9047 and 90632)
provided on March 9, 2020.
Benefits for the Hepatitis A vaccine 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: 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 IRF care is necessary to allow restoration of
function. The Plan denied your request. The Plan says the enrollee does not require an intensive therapy
program and can be treated in a skilled nursing facility.
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 enrollee does not require the intensity of services provided at an IRF.
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular
physician evaluation. The enrollee's care needs can be met at a lower level of 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for filter holder and integrated filter without adhesive, for use in a tracheostoma heat and moisture exchange system, each (A7507), tracheo-esophageal voice prosthesis, inserted by a licensed health care provider, any type (L8509), unlisted procedure for miscellaneous prosthetic services (L8499) and tracheostoma stent/stud/button, each (A7524) provided on March 16, 2020.
You asked the Plan to waive the coinsurance for the items. You say that last year you did not have to 20% coinsurance for codes A7507 and A7524. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 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 records show that you received prosthetic devices and medical supplies on March 16, 2020. Effective January 1, 2020, an update was made to the claims processing system so that claims for prosthetic devices and medical supplies will process and apply a 20% coinsurance. Previously, these services were set up to pay at 100%, however, it was determined that The Center for Medicare & Medicaid Services (CMS) considers prosthetic devices and medical supplies to be prosthetic devices. Based on this information the claim in question was processed correctly and applied the correct member cost-sharing for the service. You are still responsible for the cost-sharing associated with 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 filter holder and integrated filter without adhesive, for use in a tracheostoma heat and moisture exchange system, each (A7507), tracheo-esophageal voice prosthesis, inserted
by a licensed health care provider, any type (L8509), unlisted procedure for miscellaneous prosthetic services (L8499) and tracheostoma stent/stud/button, each (A7524) provided on March 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on March 26, 2019 by an out of
network (OON) provider.
You asked the Plan to pay for these OON services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says there was no referral for these services.
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 office visit provided on March 26, 2019 by an
out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing coded G0483 provided on October 23, 2019.You asked the Plan to pay forthe drug testing. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not supported by the documentation.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code G0483 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and 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; 22 or more drug class(es), including metabolite(s) if performed.We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation submitted did not include a valid physician order/lab requisition or medicalrecords signed by the ordering physician stating exactly what tests were to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met.Therefore, we decided that the Plan does not have to pay forthe drug testing coded G0483 provided on October 23, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve right-side facet joint nerve destruction (64635, 64636).
You asked the Plan to pre-approve right-side facet joint nerve destruction. You say that the requested procedures will be performed on the right side, and previously they were performed on the left. The Plan denied your request. The Plan says that this was performed on June 1, 2020.
The Plan follows Medicare rules. Medicare rules say that when dual MBBs provide at least 80% relief of the primary or index pain, with ability to perform previously painful movements consistent with the expected physiological effects of the agents utilized RF medial branch neurotomy be considered. 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 right-side facet joint nerve destruction. Our reviewer says that the criteria for coverage have been met. Our physician reviewer found the records show that dual MBBs provided at least 80% pain relief. While the enrollee previously received the requested services on the left side, these procedures are medically necessary for the right side as well. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of right-side facet joint nerve destruction have been met. Therefore, we decided that the Plan has to pre-approve right-side facet joint nerve destruction (64635, 64636).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services on April 23, 2020.
You asked the Plan to waive the copayment for ambulance services. You say that they did not transport you to
the hospital and you were able to take yourself to the urgent care center. The Plan denied your request. The
Plan says the claim was processed accordingly with your 2020 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 ambulance services on April 23, 2020. The Medicare-allowed
amount for the ambulance services is less than the set $200 copayment; therefore, you have been asked to pay
the lesser amount of $125 for the ambulance services. Your EOC states, enrollees must pay a $200 copayment
for each one-way Medicare-covered ambulance transport. 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 ambulance services on April 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoral - periapical first radiographic image (D0230)
provided on February 12, 2020.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the
denied charges. The Plan denied your request. The Plan says you exhausted your benefit frequency limit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Review of the file show that you received two (2) intraoral - periapical first radiographic image (D0220 and
D0230) on February 12, 2020. The Plan paid for one (1) intraoral - periapical first radiographic image (D0220).
You are responsible for the second intraoral - periapical first radiographic image (D0230). Your EOC states,
intraoral x-rays (inside the mouth) - frequency/limitations: one (1) procedure per calendar year. Therefore, we
decided that the Plan does not have to pay for intraoral - periapical first radiographic image (D0230) provided
on February 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the knee injection provided on February 4, 2020.
You asked the Plan to waive the copayment for the knee injection. You say that you have had this injection before and have never paid a $250 copayment that comes with outpatient surgery. 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 $250 copayment for Medicare-covered surgery or other services at an in-network outpatient hospital or an ambulatory surgical center, including but not limited to hospital or other facility charges and physician or surgical changes. You have been asked to pay a $250 copayment for the knee injection. The knee injection falls within the "Outpatient Surgery and Other Medical 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 the knee injection provided on February 4, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plandoes not haveto pay forhome INR monitoring material and equipment (HCPCS G0249) provided to the enrollee on January 14, 2020.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthis was not coded correctly.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers mustreport services with the appropriate CPT code.In this case, the CPT Code Manual definition of HCPCS code G0249 is "Provision of test materials and equipment for home INR monitoring of patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria; includes: provision of materials for use in the home and reporting of test results to physician; testing not occurring more frequently than once a week; testing materials, billing unitsof service include 4 tests."We looked at the file, and Medicare rules. The difference of days in this case was 9 days, rather than the required 25 days. Based on this information, we decided that Medicare rules for coverage of the services have not beenmet.Therefore, we decided that the Plandoes not haveto pay forhome INR monitoring material and equipment (HCPCS G0249) provided to the enrollee on January 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for inpatient hospital care from February 2,
2020 through February 5, 2020 provided by an in-network provider.
You asked the Plan to waive the coinsurance for inpatient hospital care. 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 2020 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 inpatient hospital care from February 2, 2020 through February 5,
2020 provided by an in-network provider. You are asked to pay 10% coinsurance for the stay. Your EOC
states, for each Medicare-covered hospital admission/stay, after your yearly deductible is met, you pay 10% per
in-network inpatient hospital care stay. 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 inpatient
hospital care from February 2, 2020 through February 5, 2020 provided by an in-network provider.