Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the out of network cost share for the periapical x-ray (D0220) and extraction (D7210) provided on November 19, 2020.

You asked the Plan to waive the out of network cost share for the dental services. You say that you went to get a tooth extracted. You say that your dentist realized the extraction had gone wrong and referred you to an oral surgeon. You also say that you would like the remaining balance to be paid. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that the referring provider is out of network too. The Plan says that dental services performed out of network may cost more. The Plan also says that out of network providers may bill you for the difference between what the provider billed and what the Plan pays.

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 and the services are listed as covered, dental services performed out of network have a higher cost share. This is a contractual obligation that you agreed to when you signed up for the plan. Therefore, we decided that the Plan does not have to waive the out of network cost share for the periapical x-ray (D0220) and extraction (D7210) provided on November 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oxygen concentrator.
You asked the Plan to pre-approve the concentrator. You say that this is medically necessary. The Plan denied your request. The Plan says medical necessity must be established for coverage.
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify for oxygen solely based on blood gas studies obtained during sleep. To qualify for home oxygen, the patient must meet one of the following blood gas levels: 1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during sleep for a patient who have hypoxia symptoms during sleep; 3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for patients who have hypoxia symptoms during exercise; 4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of dependent edema, pulmonary hypertension, or erythrocythemia. For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, there is a rebuttable presumption of non-coverage. 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 concentrator. Our reviewer says that the medical necessity of continued home supplemental oxygen has not been established. Our physician reviewer found you have severe chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF), with repeated hospitalizations for respiratory failure. The need for supplemental oxygen is based on a single ambulatory oximetry study in 2019. The records do not contain any room air oxygen studies or ambulatory oximetry studies since then. You have been hospitalized at least twice since then. It is reasonable to recertify the need for oxygen in your whose condition may have changed since 2019. 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 concentrator have not been met. Therefore, we decided that the Plan does not have to pre-approve an oxygen concentrator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe problem focused limited oral evaluation (D0140) provided on February 15, 2021.You asked the Plan to pay forthe problem focused limited oral evaluation. You say that you need all of your upper teeth removed, and replaced by dentures.The Plandenied your request. The Plan says this service is not a covered benefit under your dental plan.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 items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe problem focused limited oral evaluation (D0140) provided on February 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for infectious agent detection with 12-25 targets (87633) provided on December 3, 2020.
You asked the Plan to pay for infectious agent detection with 12-25 targets. You say that this is a Medicare-covered service. The Plan denied your request. The Plan says this test is excluded from coverage.
The Plan must follow Medicare rules. Medicare rules say that multiplex Polymerase Chain Reaction (PCR) respiratory viral panels of 6 or more pathogens are non-covered. We looked at the file and Medicare rules. The testing at issue had 12-25 targets, which is more than 6 and is non-covered. Based on this information, we decided that Medicare rules for coverage of infectious agent detection with 12-25 targets have not been met. Therefore, we decided that the Plan does not have to pay for infectious agent detection with 12-25 targets (87633) provided on December 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from October 26, 2020 to October 29, 2020.
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 this was not billed correctly.
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 ICD-10 definition of the billed diagnosis code (T42.4X2) is "Poisoning by benzodiazepines, intentional self-harm." We find that the denied inpatient services are not supported in the medical record. Specifically, the above billed diagnosis code cannot be used as a primary/principal diagnosis 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 inpatient hospital services provided to the enrollee from October 26, 2020 to October 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit and related services provided on July 9, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe OON services. The Plan denied your request. The Plan says the services were not urgent, emergent, or approved in advance.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Planhas 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 services at issue in this appeal. The Plan did not pre-approve the servicesat 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 forthe office visit and related services provided on July 9, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the computed tomography (CT) scan provided on January 18, 2021.
You asked the Plan to waive the copay for the CT scan. You say that the service should be covered. The Plan denied your request. The Plan says the decision was made based on your plan 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). Your contract with the Plan clearly says that you must pay a 20% coinsurance up to $75 for Medicare-covered diagnostic radiology services. You have been asked to pay $26.27 for the CT scan. The CT scan falls within the outpatient diagnostic tests 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 copay for the computed tomography (CT) scan provided on January 18, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the HHA or CNA, providing care in the home provided from December 16, 2020, to December 31, 2020.
You asked the Plan to pay for the HHA or CNA. You say that you believed you would be reimbursed for all of the charges. The Plan denied your request. The Plan says the services were rendered by a provider who is not under contract with the health plan and is not certified for Medicare.
The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered Medicare items or services, a provider or supplier must be enrolled in the Medicare program. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the HHA or CNA have not been met. Therefore, we decided that the Plan does not have to pay for the HHA or CNA, providing care in the home provided from December 16, 2020, to December 31, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on October 13, 2020 by an out of network (OON) provider.
You asked the Plan to pay for lab work. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says there are in-network laboratories available 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 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 lab work provided on October 13, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for dermatology services provided on January 18, 2021 by an out of network provider.

You asked the Plan to pay for the dermatology services. You say that the Plan should pay this claim.The Plan denied your request. The Plan says you did not request 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 dermatology services provided on January 18, 2021 by an out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 9, 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 claim was billed incorrectly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT
codes describing the component test results.
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the
laboratory services rendered on January 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe office visit provided on December 23, 2020.You asked the Plan to waive the copayment forthe office visit. You say that you cannot pay this amount.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 thatyou must pay a $40 copayment for each specialist in-person office visit.You have been asked to pay a $40 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show the office visit was with a specialist. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment forthe office visit provided on December 23, 2020.
Appeal type: Drugs
Decision: Favorable

You asked the Plan to pre-approve Injectafer, injection, ferric carboxymaltose, 1 mg (J1439). You say that the enrollee needs Injectafer for his anemia medication to be therapeutic. The Plan denied your request. The Plan says that there are no extenuating services such that the service is medically necessary for this enrollee.

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 Injectafer, injection, ferric carboxymaltose, 1 mg (J1439). Our reviewer says that the drug is medically reasonable and necessary. Our physician reviewer found patient with documented anemia of chronic kidney disease and documented low iron stores. Injectafer is indicated and considered standard 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 Injectafer, injection, ferric carboxymaltose, 1 mg (J1439) have been met. Therefore, we decided that the Plan has to pre-approve Injectafer.

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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for an inpatient hospital stay provided by a participating provider on January 8, 2021, to January 12, 2021.

You asked the Plan to waive the co-payment for an inpatient hospital stay. You say that you have never paid a co-payment for this before. The Plan denied your request. The Plan says the correct co-payment has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 co-payment per day for days 1-5. There is a $0 co-payment for additional days for inpatient hospital care.

You have been asked to pay a $325 co-payment per day for days 1-4 for an inpatient hospital stay. The total
amount you are being asked to pay is $1,300 ($325 x 4 days = $1,300). The correct co-payment has been applied to the services that were provided. An 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 co-payment for an inpatient hospital stay provided by a participating provider on January 8, 2021, to January 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for an intravitreal injection provided on February 1, 2021.

You asked the Plan to waive the co-payment for an intravitreal injection. You say that you are being charged because the provider works at another facility. 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 co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 co-payment for outpatient surgery and other medical services provided at hospital outpatient facilities.

The record shows that you received an intravitreal injection at an outpatient hospital facility on February 1, 2021. Therefore, you are responsible to pay the $275 co-payment.

You have been asked to pay a $275 co-payment for an intravitreal injection. An intravitreal 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 co-payment for an intravitreal injection provided on February 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe crown (D2740) provided on January 28, 2021, and the cleaning (D1110) provided on February 15, 2021.You asked the Plan to pay forthe crown and cleaning. You say that this provider is charging too much.The Plan denied your request. The Plan says they paid for part of the crown, but as of this payment you have met your annual maximum allowance for dental services in 2021 and are responsible for any remaining charges.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. The Plan can cover up to $2,000 for dental services. Though the Plan offers a dental benefit in excess of Medicare coverage, items or services in excess of the $2,000 annual maximum are not among those covered under this benefit. Documentation shows that the Plan paid for services provided earlier in January in the amount of $1,108. The Plan paid $892 for the crown provided on January 28, 2021; however, at this point the Plan has paid the full $2,000 maximum. You are responsible for the remaining cost of the crown and the cleaning as these exceed the maximum allowance. Therefore, we decided that the Plan does not have to pay forthe crown (D2740) provided on January 28, 2021, and the cleaning (D1110) provided on February 15, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the pulmonary therapy services provided on January 8, 2021,
billed with four units of G0238.
You asked the Plan to pay for the pulmonary services as billed. You say that this was medically necessary and
should be paid. The Plan denied your request. The Plan says the records do not support the billing of these
services.
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 G0238 is therapeutic procedures to improve respiratory
function, other than described by G0237, one on one, face to face, per 15 minutes (includes monitoring). We asked our coding 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 the pulmonary services as billed. Our
reviewer says that the record submitted does not support the reporting of this code. Our coding reviewer found
the procedure note does not include a description of a therapeutic procedure performed on January 8,
2021. Services cannot be confirmed as performed and, as such, cannot be covered.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the pulmonary services as billed have not been met. Therefore, we decided that
the Plan does not have to pay for the pulmonary therapy services provided on January 8, 2021, billed with four
units of G0238.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an automatic blood pressure monitor (A4670), provided on February 25, 2021.
You asked the Plan to waive the coinsurance for an automatic blood pressure monitor. You say that the item should be covered. The Plan denied your request. The Plan says the cost share was 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 20% coinsurance for durable medical equipment (DME) and supplies. You have been asked to pay a 20% coinsurance for an automatic blood pressure monitor. This service falls within the durable medical equipment (DME) 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 coinsurance for an automatic blood pressure monitor (A4670), provided on February 25, 2021.