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

We decided that the Plan does not have to waive the co-payment for emergency care services provided from October 6, 2020, through October 7, 2020, by an in-network provider.

You asked the Plan to waive the co-payment for the emergency care services. 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 co-payments, deductibles and coinsurance).

Review of the file show that you received emergency care services from October 6, 2020, through October 7, 2020 by an in-network provider. While you were in the emergency room you received computed tomography of the head and magnetic resonance imaging. These services are advanced imaging services. According to your 2020 EOC, "if advanced imaging services are received as part of an emergency department evaluation then you will only pay the advanced imaging co-payment, not the emergency room co-payment. Enrollees must pay a $225 co-payment for each in-network Medicare-covered advanced imaging service (not including x-rays)." Furthermore, while you were receiving emergency care you received self-administered drugs, and they are only covered under Part D benefits. You were asked to pay a $225 co-payment for the advanced imaging services and $75.50 for the non-covered self-administered drugs. 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 emergency care services provided from October 6, 2020, through October 7, 2020, by an in-network provider.

Benefits for the self-administered drugs 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99214) provided on December 30, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the office visit. You say that the enrollee wanted to see this doctor due to his great expertise and great service. She was satisfied with the doctor's services and extremely disappointed seeing the services denying for no authorization. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 the outpatient office visit (99214) provided on December 30, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve kyphoplasty.
You asked the Plan to pre-approve kyphoplasty. The Plan denied your request. The Plan says this is not
medically necessary.
The Plan follows Medicare rules. Medicare rules say that kyphoplasty is covered for the indications established
in the applicable LCD.
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 kyphoplasty. Our reviewer says that the
requested kyphoplasty is not medically reasonable and necessary in this case. Our physician reviewer found
that the enrollee had pain for approximately two weeks prior to presentation. The computed tomography (CT)
scan demonstrated an L2 vertebral fracture with retropulsion of bone causing moderate central spinal canal
stenosis. The enrollee has retropulsion of bone which is a contraindication to the requested service. The
elements of the coverage criteria are not 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 kyphoplasty have not been met. Therefore, we decided that the Plan does not
have to pre-approve kyphoplasty.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation and report on referred slides prepared elsewhere services coded 88321 provided on August 3, 2020.
You asked the Plan to pay for the consultation and report on referred slides prepared elsewhere services. 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 payable.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. In this case, the MUE for CPT code 88321 is 1. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the consultation and report on referred slides prepared elsewhere services have not been met. Therefore, we decided that the Plan does not have to pay for the consultation and report on referred slides prepared elsewhere services coded 88321 provided on August 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implant crown placement (D6056, D6010, D6065) for teeth #19 and #20, and a crown (D2740) for tooth #4.
You asked the Plan to pre-approve the dental services. The Plan denied your request. The Plan says these services are not medically necessary.
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 covers the dental services when the services are medically necessary and reasonable. 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 dental services. Our reviewer says that the requested implant crown placement services for teeth #19 and #20 and crown for tooth #4 are not medically reasonable and necessary. Our physician reviewer found that a review of the enrollee's dental record and radiographs did not indicate that that a removable prosthesis was contraindicated to replace the missing teeth on the mandibular left side. Also, tooth #4 did not exhibit the coronal breakdown requiring a crown restoration. The documentation provided did not meet the criteria for coverage for implant crown placement in teeth #19 and #20, and for a crown restoration for tooth #4. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does not have to pre-approve implant crown placement (D6056, D6010, D6065) for teeth #19 and #20, and a crown (D2740) for tooth #4.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug provided on December 19, 2020.

You asked the Plan to waive the coinsurance for a Medicare Part B drug. You say that you disagree with the charges and feel that you should only owe a $15 chemotherapy copayment instead. 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 20% coinsurance for Medicare Part B prescription drugs. 

You received a Medicare Part B drug on December 19, 2020. The allowed amount is $3,440.09 and 20% of that is $688.02. 

You have been asked to pay the total coinsurance amount of $688.02 for a Medicare Part B drug. A Medicare Part B drug falls within the Medicare Part B prescription drugs 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 a Medicare Part B drug provided on December 19, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for arthrocentesis (20611) provided on December 8, 2020.
You asked the Plan to pay for arthrocentesis. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that payment is not allowed for this service because it is not appropriate for the diagnosis billed
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. Specifically, the Plan has not forwarded any explanation or evidence as to why this service is not appropriate for the diagnosis code billed. It is the burden of the Plan to substantiate their denial with evidence. This denial has not been substantiated so we must find in your favor Therefore, we decided that the Plan has to pay for arthrocentesis (20611) provided on December 8, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services coded 99291 provided on October 13, 2020 and October 14, 2020.

You asked the Plan to pay for the critical care services. 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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes.

We find that CPT code 99291 is not supported in the medical record. Specifically, the documentation submitted did not support a critical care visit of 30-74 minutes was performed on the billed dates of service. The documentation does not include the time spent providing the service. Based on this information, we decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services coded 99291 provided on October 13, 2020 and October 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0483 provided on July 28, 2020.

You asked the Plan to pay for the 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 place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. 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 for the drug testing coded G0483 provided on July 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for the myocardial perfusion imaging and ultrasound provided on August 25, 2020.

You asked the Plan to waive the co-payment for the myocardial perfusion imaging and ultrasound. You say that three different people confirmed you would not be charged for the testing. The Plan denied your request. The Plan says the co-payments applied correctly.

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 $160 co-payment for each Medicare-covered radiological diagnostic service, not including x-rays. Examples include, but are not limited to, specialized scans, CT, SPECT, PET, MRI, MRA, nuclear studies, ultrasounds, diagnostic mammograms and interventional radiological procedures (myelogram, cystogram, angiogram, and barium studies).

You have been asked to pay a $160 co-payment for the myocardial perfusion imaging and a $160 co-payment for the ultrasound. The total amount you owe is $320 ($160/test x 2 tests = $320). The myocardial perfusion imaging and ultrasound 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 co-payment for the myocardial perfusion imaging and ultrasound provided on August 25, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the declotting of a central venous tube (36593) provided on November 17, 2020.
You asked the Plan to waive the copayment for the declotting of a central venous tube. You say that you should be charged the emergency room copayment instead. The Plan denied your request. The Plan says this processed 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 for surgical services provided in an outpatient hospital facility. You have been asked to pay a $325 copayment for the declotting of a central venous tube, which is considered a surgical 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 the declotting of a central venous tube (36593) provided on November 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiovascular risk assessment testing provided to the enrollee on August 25, 2020.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. The denial remains upheld as non-covered as Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular disease. Therefore, we decided that the Plan does not have to pay for cardiovascular risk assessment testing provided to the enrollee on August 25, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections.
You asked the Plan to pre-approve the facet joint injections. You say that you would like reconsideration
because the requested injection is medically necessary. The Plan denied your request. The Plan says there is no
documented pain for at least 3 months, no documentation of conservative treatment for 6 weeks or localized
pain in back.
The Plan must follow Medicare rules. 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 the facet joint injections. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the documentation does not reveal that the member's pain is predominantly axial. The
member has a diagnosis and exam findings of lumbar radiculopathy. There is no evidence of a facet joint
synovial cyst causing radiculopathy.
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 facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the abdomen and pelvis (74183, 72197).
You asked the Plan to pre-approve the MRI. You say that the MRI is medically necessary. The Plan denied your request. The Plan says coverage criteria is not met.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 the MRI. Our reviewer says that the MRI is not medically necessary. Our physician reviewer found the provided medical records indicate that a CT scan was planned. The record also indicates that a CT scan was performed in January 2021 with a recommended repeat in three months. The records provided do not support the MRI. 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the abdomen and pelvis (74183, 72197).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency department visit (99282) provided December 28, 2020.
You asked the Plan to waive the copayment for the emergency visit. You say that you drove your friend to the emergency room to get tested for COVID. When checking in you stated you would only get tested if she tested positive. You never intended to be seen or admitted. The $120 are neither fair or warranted. The Plan denied your request. The Plan says the claim was processed and the correct copayment was 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 $120 copay for each Medicare covered emergency room visit for Emergency care. You have been asked to pay $120 copay for each Medicare covered emergency room visit for the emergency visit. the emergency visit falls within the Emergency 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 emergency department visit (99282) provided December 28, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for rotary wing ambulance service, conventional air services, transport, one way (A0431) and rotary wing air mileage (A0436) provided October 21, 2020.
You asked the Plan to waive the coinsurance for the air ambulance services. You say that you were not given a choice and was taken to the hospital via air ambulance. The Plan denied your request. The Plan says you were charged this cost sharing 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% copayment for each air ambulance trip. You had 1 air ambulance trip(s). The Plan charged you $769.78 for these services. 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 rotary wing ambulance service, conventional air services, transport, one way (A0431) and rotary wing air mileage (A0436) provided October 21, 2020.