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

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided to the enrollee from October 21, 2019 through October 24, 2019 by an in-network provider.
You asked the Plan to waive the copayment 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 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that the enrollee was admitted on October 21, 2019 and discharged on October 24, 2019. The enrollee was asked to pay a $289 copayment per day from October 21, 2019 through October 23, 2019, days 1-3 of their inpatient hospital care. The enrollee was discharged on October 24, 2019 and there was no copayment charge for the day of discharge. Per the enrollee's contract there is a $289 copayment per day required for days 1-6 for in-network inpatient hospital care. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital care provided to the enrollee from October 21, 2019 through October 24, 2019 by an in-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from November 20, 2019 to November 21, 2019.You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you were charged a $250 copayment for your inpatient hospitalization. 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 per day for days 1-7. You have been asked to pay a $250 copayment for the inpatient hospital stay. The inpatient hospital stay falls within the "Inpatient hospital care" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from November 20, 2019 to November 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the services rendered to you on March 4, 2019.
You asked the Plan to waive the deductible for these services. You say that the deductible is a financial hardship. The Plan denied your request. The Plan says the deductible was 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 there is $1,600 yearly deductible for your covered medical services. The item or service you asked the Plan to waive the deductible for falls within the out-of-network specialist visit benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $1,600 yearly deductible for your covered medical services. This cost sharing is a contractual obligation that had not been met at the time these services were received on March 4, 2019. Therefore, we decided that the Plan does not have to waive the deductible for the services rendered to you on March 4, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on July 30, 2019.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care and the services were ordered by a non-plan 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 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 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 lab services provided to the enrollee on July 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided to the enrollee on September 9, 2019.You asked the Plan to pay forthe lab services. The Plan denied your request. The Plan says the documentation submitted did not include a physician order/lab requisition or medical records stating exactly what tests are to be performed.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 a valid physician order or lab requisition stating exactly which testing was to be performed. 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 forthe lab services provided to the enrollee on September 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endosteal implants (D6010 x 3), prefabricated abutments (D6056 x 3), abutment supported retainers for porcelain/ceramic fixed partial dentures (D6068 x 2), and an abutment supported porcelain crown (D6058).
You asked the Plan to pre-approve the dental services. You say that the requested dental services are medically necessary and are needed. The Plan denied your request. The Plan says implants, prefabricated abutments, abutment supported retainers for porcelain/ceramic fixed partial dentures, and an abutment supported porcelain crown are not listed as covered services.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve endosteal implants (D6010 x 3), prefabricated abutments (D6056 x 3), abutment supported retainers for porcelain/ceramic fixed partial dentures (D6068 x 2), and an abutment supported porcelain crown (D6058).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intra-articular injection Hyaluronan (J7324).You asked the Plan to pre-approve intra-articular injection Hyaluronan. You say that the records provided should support the necessity of the services in dispute.The Plan denied your request. The Plansays the requested service is considered not reasonable and necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 intra-articular injection Hyaluronan. Our reviewer says that this enrollee does not meet the Medicare criteria. Our physician reviewer found the enrollee has been diagnosed with right knee pain and medial meniscus tear, with no documentation that he has been diagnosed with right knee osteoarthritis. There is no radiographic evidence of osteoarthritis of the knee documented in the submitted medical records. There is no clear evidence that the enrollee had failed at least 3 months of conservative therapy. Therefore, the medical records do not show that all the Medicare coverage criteria have been met to support this request for Orthovisc injections. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of intra-articular injection Hyaluronan have not been met.Therefore, we decided that the Plan does not have to pre-approve intra-articular injection Hyaluronan (J7324)
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for specialist visits provided on October 2, 2019 and October 3, 2019. You asked the Plan to waive the copayments for specialist visits. You say that you were under an observation stay and should not be responsible for the charges. 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 $40 copayment for services obtained by a specialist. Covered services include medically necessary medical are provided in a physician's office, certified ambulatory surgical center, hospital outpatient department or any other location. You received specialist services on October 2, 2019 and October 3, 2019. Specialist services rendered during an outpatient hospital stay are subject to cost-sharing charges. Therefore, you are responsible to pay a $40 copayment per each visit. The total amount you owe is: $80. You have been asked to pay the total copayment amount of $80 for specialist visits. Specialist visits fall within the physician/practitioner services, including doctor's office 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 copayments for specialist visits provided on October 2, 2019 and October 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for low osmolar contrast material (Q9966) provided on
September 30, 2019.
You asked the Plan to pay for low osmolar contrast material. You say that you would like reconsideration
based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does
not support the service that was 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.
In this case, the CPT Code Manual definition of code Q9966 is low osmolar contrast material, 200-299 mg/ml
iodine concentration, per ml .
We asked our coder 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 low osmolar contrast material. Our reviewer says that CPT
code Q9966 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical
records provided do not include documentation of the concentration of low osmolar contrast material, mg/ml
iodine that was administered during the procedure performed.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of low osmolar contrast material have not been met. Therefore, we decided that the
Plan does not have to pay for low osmolar contrast material (Q9966) provided on September 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoperative neurological monitoring performed during multilevel lumbar spinal fusion surgery (95999) provided to the enrollee on August 28, 2019.You asked the Plan to pay for this claim. You say that these services were medically necessary and should be covered by the Plan.The Plan denied your request. The Plan says the issue was not medical necessity but that the claim contained codes that have a bundled relationship and cannot be paid as 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. In this case, code 95999 has created an error on the claim preventing payment due to its relationship with other codes reported. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay for intraoperative neurological monitoring performed during multilevel lumbar spinal fusion surgery (95999) provided to the enrollee on August 28, 2019
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the spirometry rendered to the enrollee on November 2, 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 procedure code 94016 is not covered. The Plan must follow Medicare rules. Medicare rules say that procedure code 94016 is denied as not medically necessary. We looked at the file and Medicare rules. The services at issue are spirometry billed with code 94016. Therefore, we decided that the Plan does not have to pay for the spirometry rendered to the enrollee on November 2, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forsurgical services provided to the enrollee on July 29, 2019 and billed under codes 22854, 63090 and 63091.You asked the Plan to pay forthese services. You say that this claim should be paid and that your application of modifier 59 was correct.The Plan denied your request. The Plan says procedure codes22854-80-59 is not supported by the medical records submitted. The medical records did not include documentation of an insertion of intervertebral biomechanical device(s) (synthetic cage, mesh), with integral anterior instrumentation for device anchoring (screws, flanges) when performed, to vertebral corpectomy(ies) (vertebral body resection, partial or complete) defect, in conjunction with interbody arthrodesis, for each contiguous defect (Listed separately in addition to code for primary procedure); therefore this code cannot be verified.The Plan states procedure code 63090-80-59 is not supported by the medical records submitted. The medical records did not include documentation of a partial or complete vertebral corpectomy (vertebral body resection), by a transperitoneal or retroperitoneal approach with decompression of spinal cord, cauda equina or nerve root(s), for a single lower thoracic, lumbar, or sacral segment; therefore this code cannot be verified.The Plan further states procedure code 63091-80-59 is not supported by the medical records submitted. The medical records did not include documentation of a partial or complete vertebral corpectomy (vertebral body resection), by a transperitoneal or retroperitoneal approach with decompression of spinal cord, cauda equina or nerve root(s), for each additional lower thoracic, lumbar, or sacral segment (Listed separately in addition to code for primary procedure); therefore this code cannot be verified. Finally, the Plan states that when two primary surgeons are required, a co-surgery scenario exists. Both surgeons report the primary procedure with modifier 62 and submit supporting documentation.This description was not documented in the medical records submitted. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT codeand modifier when necessary. The rules also state that specific medical records to support the services billedmay be required. In this case, the medical records provided are limited and do not provide the specific documentation required for payment of this claim. 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 forsurgical services provided to the enrollee on July 29, 2019 and billed under codes 22854, 63090 and 63091.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99190) provided on November 12, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for this service would be included in the Part A DRG payment to the facility.The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. Payment for all fees related to this service would have been included under the facility claim.Therefore, we decided that the Plan does not have to pay for the services (CPT 99190) provided on November 12, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from April 18, 2019 through April 22, 2019.You asked the Plan to waive the copayment for the inpatient stay. You say that you were charged an additional$650 because you could not be transferred to the rehab facility. You say that you should not be charged the additional two days.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 $325 copayment per day, days 1 to 5, at an in-network inpatient hospital.The day before you are discharged is your last inpatient day.You have been asked to pay a $1,300 copayment for the inpatient stay. ($325/day x 4 days = $1,300). The inpatient stay falls within the "Inpatient hospital care" benefit category. The records show that you were an inpatient for 4 days. 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 inpatient stay provided from April 18, 2019 through April 22, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bilateral shoe lifts (L3310 x 2).
You asked the Plan to pre-approve bilateral shoe lifts. You say that bilateral shoe lifts are medically necessary. The Plan denied your request. The Plan says that you do not meet Medicare criteria for coverage of bilateral shoe lifts.
Medicare rules state that supportive devices for the feet (such as bilateral shoe lifts) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although bilateral shoe lifts may be appropriate for you, neither Medicare nor the Plan provides coverage of bilateral shoe lifts for your condition. Therefore, we decided that the Plan does not have to pre-approve bilateral shoe lifts (L3310 x 2).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 88307) provided to the enrollee on August 26, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that for all services (with two (2) exceptions), the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. The two exceptions are for enrollees who are registered hospital inpatients or outpatients, in which case, the inpatient or outpatient hospital POS code would be reported regardless of where the face-to-face service takes place. We looked at the file and Medicare rules. The records show that the enrollee was under inpatient status on the date of service in question. This means that the services in question must be billed with inpatient place of service code. 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 services (CPT 88307) provided to the enrollee on August 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyewear and warranty provided on September 25, 2019.
You asked the Plan to pay for the eyewear and warranty. You say that you were sent a check on October 16, 2019 for $150 and your EOC benefit is $250. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits. Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the eyewear and warranty have not been met. The $25 warranty is denied as warranties are not a covered benefit. You received a refund of $150 for the frame/lens. The discount is $195.80. The total charges are $729. There is a $250 allowance. $729-$250 = $479 - .20% = $383.20. If you subtract the covered charges of $345.80 from $729 = $383.20 which is your coinsurance. Therefore, we decided that the Plan does not have to pay for the eyewear and warranty provided on September 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services provided on November 14, 2019 by an
out of network (OON) provider.
You asked the Plan to pay for outpatient services. You say that you would like this claim reprocessed and
approved for payment. The Plan denied your request. The Plan says there is no referring provider on file. The
Plan says that 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 outpatient services provided on November 14,
2019 by an out of network (OON) provider.