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

We decided that the Plan does not have to waive the copayment for an ambulance trip provided on September 10, 2019.You asked the Plan to waive the copayment for an ambulance trip. You say that you disagree with 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 $350 copayment for ambulance services. You have been asked to pay a $350 copayment for an ambulance trip. An ambulance trip falls within the ambulance services 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 an ambulance trip provided on September 10, 2019.
Appeal type: ER
Decision: Partially Favorable

We decided that the Plan has to pay for CPT 93010. We decided that the Plan does not have to pay for CPT 99282.
You asked the Plan to pay for the denied codes. You say that this should be paid for. The Plan says that Medicare does not pay separately for CPT 99282, and CPT 93010 is a duplicate of a charge considered on a previous claim.
We decided that the Plan has to pay for CPT 93010. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The CPT Code Manual definition of CPT 93010 is "Electrocardiogram, routine ECG with at least 12 leads." 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 for CPT 93010. Our reviewer says that the records support the coding of this service. Our physician reviewer found that the denial of this code should be overturned. Two separate EKGs were performed - one at the sending emergency department, and one at the receiving emergency department. The performance of serial EKGs on a patient with heart block is medically reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CPT 93010 have been met. Therefore, we decided that the Plan has to pay for CPT 93010.
We also decided that the Plan does not have to pay for CPT 99282. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The CPT Code Manual definition of CPT 99282 is "New or Established Patient Emergency Department Services." 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 for CPT 99282. Our reviewer says that this service was not coded correctly. Our physician reviewer found a standard ED E&M code (99282) cannot be billed in addition to a critical care code (99291). CPT 99282 is a column II procedure to the column I procedure already billed on this claim - CPT 99291. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CPT 99282 have not been met. Therefore, we decided that the Plan does not have to pay for CPT 99282.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance fordialysis provided from May 2, 2019 through September 16, 2019.You asked the Plan to waive the coinsurance fordialysis. You say that she was in end stage renal disease. You say that this should be fully covered.The Plan denied your request. The Plan says the coinsurance 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). The enrollee'scontract with the Plan clearly says that enrollee'smust pay 20% coinsurance for services to treat kidney disease. Covered services include outpatient dialysis treatments and inpatient dialysis treatments. Dialysisfalls within the "Services to treat kidney disease" benefit category. This means that the enrollee hasbeen asked to pay the correct amount based on thecontract with the Plan. This cost sharing is a contractual obligation the enrolleeagreed to pay when enrollingin the Plan.Therefore, we decided that the Plan does not have to waive the coinsurance fordialysis provided from May 2, 2019 through September 16, 2019
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient mental health visit provided on December 12, 2019.You asked the Plan to waive the copayment for an outpatient mental health visit. You say that you were inpatient and disagree with 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 mustpay a $15 copayment for outpatient mental health care. The medical records show that you received an outpatient mental health visit during an outpatient hospital stay on December 12, 2019. Therefore, you are responsible to pay the $15 copayment. You have been asked to pay a $15 copayment for an outpatient mental health visit. An outpatient mental health visit falls within the outpatient mental health 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 foran outpatient mental health visit provided on December 12, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance ride provided on May 23, 2019.
You asked the Plan to waive the copayment for the ambulance ride. You say that you are overwhelmed with medical bills and cannot pay this copayment. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $250 copayment for ground travel. The enrollee has been asked to pay a $250 copayment for the ambulance ride. The ambulance ride falls within the "Ambulance services" benefit category. 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 the ambulance ride provided on May 23, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist services provided on January 8, 2020.You asked the Plan to waive the copayment for the specialist services. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request.The Plan denied your request. The Plan says you received specialist services on the date of service at issue in this appeal. The Plan states the correct copayment has applied per your contract with the Plan.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 $50 copayment for specialist services. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received services provided by a specialist on January 8, 2020. You have been asked to pay a $50 copayment for the specialist services. The specialist services fall within the Physician/Practitioner services 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 forthe specialist services provided on January 8, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approveAxumin (fluciclovine F-18) positron emission tomography (PET) imaging.You asked the Plan to pre-approvethe Axumin PET scan. You say that this imaging should be allowed as this is the best tool to find metastatic sites of prostate cancer patients.The Plan denied your request. The Plan says this is not covered for newly diagnosed prostate cancer.The Plan must follow Medicare rules. Medicare rules say that local MACs are now allowed to provide coverage for PET scans using radiopharmaceuticals for their FDA approved labeled indications. Axumin is FDA-approved for position emission tomography (PET)imaging in men with suspected prostate cancer recurrence based on elevated blood prostate specific antigen (PSA) levels following prior treatment. In this case, there is no concern for recurrence of prostate cancer and there has been no prior treatment. The use of Axumin imaging is not FDA-approved for newly diagnosed prostate cancer.Therefore, we decided that the Plan does not have to pre-approveAxumin (fluciclovine F-18) positron emission tomography (PET) imaging.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the implanted supported porcelain crown (D6065) for tooth #19 provided on November 21, 2019.
You asked the Plan to reimburse you for the dental service. You say that the implant supported crown should be covered. You say that the Evidence of Coverage shows that crowns over an implant body are covered with a 50% coinsurance. You also say that you do not see where it states this service is only covered for anterior teeth. The Plan denied your request. The Plan says implant supported crowns are not covered for posterior teeth.
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 implant supported crown is not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the implanted supported porcelain crown (D6065) for tooth #19 provided on November 21, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CPAP device and supplies.
You asked the Plan to pre-approve a CPAP device and supplies. You say that you have a hard time falling
asleep and wake gasping for air. The Plan denied your request. The Plan says the record does not show the
indications in the guideline.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at the file and Medicare rules. The sleep study shows the AHI is under 5 events and the diagnostic
report says no sleep apnea seen. Based on this information, we decided that Medicare rules for coverage of a
CPAP device and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve
a CPAP device and supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on January 7, 2019 by an out of
network (OON) provider.
You asked the Plan to pay for an office visit. You say that you would like this appeal reprocessed and approved
for payment. The Plan denied your request. The Plan says 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 an office visit provided on January 7, 2019 by an
out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waivethe copayment for the office visit you had on October 29, 2019.You asked the Plan to waivethe copayment. You say that this should be covered 100%.The Plan denied your request. The Plan says you are responsible for the cost share.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Yourcontract with the Plan clearly says that you must pay a $25 copayment for each in-network office visit. Review of the file shows that you had an office visit with an out-of-network provider on October 29, 2019. The plan reprocessed the claim to apply in-network cost sharing. You have been asked to pay a $25 copayment for the visit. The visit falls within the physician services 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 waivethe copayment for the office visit you had on October 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a myoelectric ankle.
You asked the Plan to pre-approve L5637- total contact, bk, addition, L5629- socket, bk, acrylic, addition, L5301- Blw knee md socket, shin, sach Ft, L5620- Test Socket, bk Addition. You say that a myoelectric ankle is necessary for proper movement. The Plan denied your request. The Plan says they have approved a standard lower limb prosthetic which meets your current needs.
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 L5637- total contact, bk, addition, L5629- socket, bk, acrylic, addition, L5301- Blw knee md socket, shin, sach Ft, L5620- Test Socket, bk Addition.. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee requires replacement of the prosthetic socket due to a change in residual limb. There is no indication for upgrading the prosthetic ankle as standard components have met the enrollee's needs. The myoelectric ankle being requested is not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of L5637- total contact, bk, addition, L5629- socket, bk, acrylic, addition, L5301- Blw knee md socket, shin, sach Ft, L5620- Test Socket, bk Addition. have not been met. Therefore, we decided that the Plan does not have to pre-approve a myoelectric ankle.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a white blood cell scan with bone marrow images for the enrollee.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says that this is an experimental and premature procedure without any clinical note indication of current serologic evidence of infection or inflammation.
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 the scan. Our reviewer says that the requested scan considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee presents with a complicated right shoulder history. She underwent right shoulder arthroscopy on 1/31/19 and developed a post-operative infection, possible necrotizing fasciitis. She underwent multiple washout procedures with final irrigation and debridement with wound closure on 2/18/19. She presented with worsening right shoulder pain and disability in November 2019. MRI findings have documented significant loss of articular cartilage consistent with osteoarthritis, and extensive edema throughout the glenoid. She has failed to response to oral anti-inflammatory medications. Given her history of septic arthritis, there was concern for osteomyelitis in the glenoid. Under consideration is a request for white blood cell scan along with bone marrow images (CPT code 78802). Current evidence based medical literature supports the use of the requested diagnostic test as the nuclear medicine test of choice for diagnosing complicating osteomyelitis. Therefore, this request for bone marrow imaging is medically reasonable and necessary. 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 scan have been met. Therefore, we decided that the Plan has to pre-approve a white blood cell scan with bone marrow images for the enrollee.
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 waive the copayments forpodiatry services provided on May 15, 2019 and May 28, 2019.You asked the Plan to waive the copayments forpodiatry services. You say that these claims should be processed at the in-network rate.The Plan denied your request. The Plan says the copayment amounts you are being charged are 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 $35 copayment for each in-network podiatry visit. There were 2 visits, resulting in a total copayment obligation of $70.You have been asked to pay $35 copayment for each podiatry visit. Podiatry services fall within the Podiatry Services 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 podiatryservices provided on May 15, 2019 and May 28, 2019
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forthe acute inpatient hospital care provided May 29 to June 6, 2019.You asked the Plan to pay for acute inpatient hospital care. You say that inpatient care was medically necessary.The Plan denied your request. The Plan says that coverage criteria was not met.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 the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED 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 forthe acute inpatient hospital care provided May 29 to June 6, 2019.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 toopen the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan has to pre-approvea maxillary partial denture (D5213).You asked the Plan to pre-approvethe dental item. The Plan denied your request. The Plan says that the maxillary partial denture is not medically necessary. The Plan also says the remaining maxillary teeth have sever bone loss and have poor prognosis as abutment for the partial denture.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 item 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 item. Our reviewer says that the service is medically necessary. Our physician reviewer found the documentation provided shows that the remaining maxillary teeth have adequate bone support of 50% or more to serve as abutments for a maxillary removable partial denture. Therefore, the reviewer found that the criteria for coverage for a partial denture have been met.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 item have been met.Therefore, we decided that the Plan has to pre-approvea maxillary partial denture (D5213)
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan rendered on December 1, 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 the claim is a duplicate.The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied.We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the Plan on a separate claim for the same date of service. 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 for the computed tomography (CT) scan rendered on December 1, 2019.