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

We decided that the Plan does not have to pay for physician services provided on August 19, 2020 by an outof-
network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid.
You say that this was medically necessary. The Plan denied your request. The Plan says prior authorization was
not obtained by the member's primary care physician.
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 had network providers
available who could have provided 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 on August 19, 2020
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services you received on May 14, 2021.
You asked the Plan to waive the copayment for the lab services. You say that this lab work was part of your annual physical, so you should have no copayment. The Plan denied your request. The Plan says you were charged this copayment correctly because lab services are not included in the annual physical.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 copayment for lab services. You have been asked to pay a $10 copayment for the lab services. Your Evidence of Coverage clearly
delineates what services are included in an annual physical. Lab services are not part of the annual physical, so a copayment can apply. 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 lab services you received on May 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for vision services (99070, 92014, 92015) provided January 6, 2021.

You asked the Plan to pay for the vision services. You say that the services should be covered. The Plan denied your request. The Plan says this is not a covered service.

The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. 

The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we decided that the Plan does not have to pay for vision services (99070, 92014, 92015) provided January 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee brace provided on March 19, 2021.
You asked the Plan to pay for the knee brace. You say that this item should be covered. The Plan denied your request. The Plan says there was no proof of delivery or specific order form from the patient's provider to support payment for this brace.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.
The record does not contain a valid physician order or proof of delivery which support the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the knee brace provided on March 19, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic mammography (77065) and
the breast ultrasound (76642) provided March 18, 2021.
You asked the Plan to waive the copayment for the diagnostic services. You say that you are appealing
payment for the $171.51 invoice. The Plan denied your request. The Plan says the claim was processed with the
correct cost share applied per the Evidence of Coverage.
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 $150
copayment for diagnostic mammogram and $75 for ultrasounds.
You have been asked to pay $171.51 copay for the diagnostic services. The diagnostic 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 the diagnostic mammography (77065) and the breast ultrasound (76642) provided
March 18, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a breast implant removal from the contralateral breast.

You asked the Plan to pre-approve a contralateral breast implant removal. You say that the requested contralateral procedure is appropriate from a symmetry perspective. The Plan denied your request. The Plan says that rules for coverage have not been met because the requested procedure is cosmetic in nature.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a contralateral breast implant removal. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found that the record indicates that enrollee had breast augmentation in the distant past. The record indicates that the enrollee experienced trauma resulting in a cystic mass over the left breast that requires removal of the implant. Treatment of the contralateral unaffected breast is medically necessary. The elements of the coverage criteria are satisfied. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a contralateral breast implant removal have been met. Therefore, we decided that the Plan has to pre-approve a breast implant removal from the contralateral breast.

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 laboratory and x-ray services provided to the enrollee on May 24, 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 claim was not filed timely.

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 the services was not filed until April 27, 2021. 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 laboratory and x-ray services provided to the enrollee on May 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an accessory bar (K0108) and electronic connection
(E2310) for a power wheelchair.
You asked the Plan to pre-approve accessory bar and electronic connection. You say that this will drastically
improve the enrollee's life and allow him to complete activities of daily living. The Plan denied your request.
The Plan says the denial of authorization for these components is correct, because the accessory bar is not
covered by Medicare and the electrical connection is not medically necessary.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose. Medicare rules say that items and services that are not medically necessary are 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 accessory bar and electronic
connection. Our reviewer says that the requested electronic connection not considered medically reasonable
and necessary in this case. Our physician reviewer found the documentation does not support that the enrollee
lacks the upper extremity strength and ability to control the power wheelchair accessories with the separate
switches which are supplied.
We looked at this physician's review, the file, and Medicare rules. The requested accessory bar does not serve a
purpose that is primarily medical in nature. The requested electrical connection has been deemed not medically
necessary. Based on this information, we decided that Medicare rules for coverage of accessory bar and
electronic connection have not been met. Therefore, we decided that the Plan does not have to pre-approve an
accessory bar (K0108) and electronic connection (E2310) for a power wheelchair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on March
11, 2021, to March 14, 2021.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you were not expecting to
pay this much in cost-shares. You also say that you are expecting more medical bills and any help would be
appreciated. The Plan denied your request. The Plan says the copayment you are being charged is correct.
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 $275
copayment per day, for days 1-5 and $0 after day 5, for inpatient hospital care.
You have been asked to pay a $275 copayment per day for inpatient hospital care ($275 x 3 days = $825). The
EOC confirms that $275 is the required copayment for this service. 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 inpatient hospital care provided on March 11, 2021, to March 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the visit you had with a hematologist on April 13, 2021.

You asked the Plan to waive the copayment for the visit with a hematologist. You say that you were not expecting to pay this much cost sharing. The Plan denied your request. The Plan says you were charged this copayment correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for specialist visits. 

You have been asked to pay a $40 copayment for the visit with a hematologist. The visit with a hematologist falls within the specialist visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the visit you had with a hematologist on April 13, 2021. Please note that this decision is limited to the office visit on April 13, 2021. If you wish to appeal other services, please contact your plan directly.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (G0483) provided July 28, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.
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 G0483 is not supported in the medical record. Specifically, the place of service on the claim (81, laboratory) does not match the place of service detailed in the records (11, office setting). Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (G0483) provided July 28, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from March 12, 2021, through March 14, 2021.

You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says that an inpatient admission was not medically necessary. The medical records show that the enrollee's condition meets the medical necessity criteria for an observation level of care.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found, based on the medical records, that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier emergency department and/or observation care) would span two midnights. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from March 12, 2021, through March 14, 2021.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214), x-ray exam of the wrist (73100), cast supplies (Q4010), and the cast application (29075) rendered by the out-of-network (OON) provider on May 6, 2020.

You asked the Plan to pay for these items/services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the items/services were rendered by an out of network provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the items/services 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 (99214), x-ray exam of the wrist (73100), cast supplies (Q4010), and the cast application (29075) rendered by the out-of-network (OON) provider on May 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on October 9, 2020.

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 claim was billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. 

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on October 9, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the routine acupuncture services provided on January 22, 2021 and February 6, 2021.

You asked the Plan to pay for the routine acupuncture services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not covered.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. In this case, the Plan contract clearly states that enrollees are covered for up to 25 visits per calendar year for routine acupuncture services with a $0 copayment. We find that the Plan has not substantiated their reasoning for denial as the Plan offers a supplemental acupuncture benefit and the Plan has not provided any information showing that you have already received all 25 visits for the 2021 calendar year. Therefore, we decided that the Plan has to pay for the routine acupuncture services provided on January 22, 2021 and February 6, 2021.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on January 21, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.

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 had network providers available who could have provided 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 on January 21, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the computed tomography (CT) scan of the pelvis and the low osmolar contrast material you received on February 28, 2021.
You asked the Plan to waive the cost sharing for the CT scan and contrast material. You say that you do not agree with these charges. The Plan denied your request. The Plan says you were charged this cost sharing correctly. The Plan says that for the CT scan, the allowed amount ($169.83) is less than your copayment obligation, so you are responsible for the full allowed amount for that service. For the contrast material, the allowed amount is $9.90, so you are responsible for 20% coinsurance, which equals $1.98.
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 $200 copayment for CT scans and 20% coinsurance for Medicare Part B drugs.
You have been asked to pay a $200 copayment for the CT scan and 20% coinsurance for the contrast material. 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 cost sharing for the computed tomography (CT) scan of the pelvis and the low osmolar contrast material you received on February 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the digital breast tomosynthesis rendered on February 20,
2021.

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 are not covered.

The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid
for Medicare purposes.

We looked at the file and Medicare rules. Billed procedure code 77061 (digital breast tomosynthesis) has a
status indicator of I and is not valid for Medicare purposes. Therefore, we decided that the Plan does not have
to pay for the digital breast tomosynthesis rendered on February 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for current procedural terminology (CPT) code 99309-SA billed for date of service April 2, 2021.

You asked the Plan to pay for CPT code 99309-SA. You say that this service should be covered and you provided medical records to support payment. The Plan denied your request. The Plan says this service was billed with an incorrect modifier.

The Plan must follow Medicare rules. Medicare rules say that codes using the modifier -SA are not covered and not payable by Medicare. 

We looked at the file and Medicare rules. Based on this information, we decided that this service is not payable as billed. Therefore, we decided that the Plan does not have to pay for CPT code 99309-SA billed for date of service April 2, 2021.