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

We decided that the Plan does not have to waive the copayment for outpatient surgical services received on February 8, 2018.
You asked the Plan to waive the copayment for the services. You say that you are unable to pay. The Plan denied your request. The Plan says the copayment was applied correctly according to your benefits and the services rendered.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 copayment for outpatient surgery. You have been asked to pay a $275 copayment for the services. The service falls within the outpatient surgery 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 outpatient surgical services received on February 8, 2018.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on June 17, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the claim was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of
service (POS) code.
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing
rendered on June 17, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure (22899) for the enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the clinical value and effectiveness of intraosseous basivertebral nerve ablation in the setting of lumbar spondylosis has not been demonstrated in the peer-reviewed literature.
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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The Intracept procedure remains experimental for the treatment of back pain. More research is needed to show safety and efficacy. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services. We looked at this physician's review, the file, and Medicare rules. 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 pre-approve the Intracept procedure (22899) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for bacteremia after recent lumbar spinal surgery. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for chemodenervation and does not have to waive the coinsurance for a Medicare Part B drug injection provided on November 19, 2020.
You asked the Plan to waive the copayment for chemodenervation and to waive the coinsurance for a Medicare Part B drug injection. 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 $15 copayment for specialist services. Your contract with the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs. You received chemodenervation on November 19, 2020. Therefore, you are responsible to pay the $15 copayment. You received a Medicare Part B drug on November 19, 2020. The total allowed amount is $1,216 and 20% of that is $243.20. The total amount you owe is: $258.20. You have been asked to pay the total amount of $258.20 for chemodenervation and a Medicare Part B drug injection. Chemodenervation falls within the physician/practitioner services, including doctor's office visits benefit category. A Medicare Part B drug injection 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 copayment for chemodenervation and does not have to waive the coinsurance for a Medicare Part B drug injection provided on November 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of CPAP therapy.
You asked the Plan to pre-approve the continuation of CPAP therapy. You say that you would like reconsideration because this service is medically necessary. The Plan denied your request. The Plan says the member does not meet Medicare coverage criteria.
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 continuation of CPAP therapy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the CPAP was returned because the patient did not follow-up with the provider for a face-to-face evaluation. 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 continuation of CPAP therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of CPAP therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for and pay for an eye examination and
refraction provided on December 23, 2020.
You asked the Plan to waive the copayment for and pay for eye exam and refraction. You say that you do not
think you should have to run around during a pandemic looking for a certain provider to get a refraction when
this provider already does a routine refraction. The Plan denied your request. The Plan says the copayment
amount you are being charged is correct, and the denial of payment for the refraction is correct because this
provider is not a Plan routine vision care network provider.
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 Medicare-covered vision visit. 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. The Plan covers a refraction when
performed by a Plan routine vision care network provider.
You have been asked to pay $35 copayment for eye exam. Eye exam falls within the Vision 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. The refraction service you received is not covered because it was not performed by a Plan routine vision care network provider. Therefore, we decided that the Plan does not have to waive the copayment for and pay for an eye examination and refraction provided on December 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services provided from August 13, 2020, to August 14, 2020.
You asked the Plan to pay for the inpatient hospital services. You say that this was billed correctly and should be paid. The Plan denied your request. The Plan says the date span reported only supports one day of covered care.
The Plan must follow Medicare rules. Medicare rules say that the date of admission is counted for billing purposes, but the date of discharge or death is not. In this case, the enrollee was admitted on August 13, 2020, and passed away the next day. This means that only one day of inpatient care can be reported for this hospital stay. Value code 80 reports two covered days on this claim, which is not supported. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services provided from August 13, 2020, to August 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on September 17, 2020.
You asked the Plan to pay for drug tests. You say that you are appealing with supporting documents. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the documentation submitted does not support the Place of Service (POS) code billed on this claim.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service. We looked at the file and Medicare rules. The documentation submitted shows that the sample for this testing as taken in an office setting, therefore the POS code 81 - indicating an independent laboratory setting - is not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of drug tests have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on September 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CPAP, heated humidifier and tubing to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve these items. You say that these items are medically necessary. The Plan denied your request. The Plan says that you must use network providers to get medical care and services when there are network providers available.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a CPAP, heated humidifier and tubing to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment from $65 to $50 for the urgent care visit
(99214) provided on December 15, 2020.
You asked the Plan to adjust the copayment. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to
the service provided.
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 $65
copayment per visit for Medicare-covered urgently needed services.
You have been asked to pay a $65 copayment for the urgent care visit provided. 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 adjust the copayment from $65 to $50 for the urgent care visit (99214) provided on December 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible and copayment for the insertion of a sacral nerve neurostimulator provided on December 15, 2020.
You asked the Plan to waive the deductible and copayment for the insertion of a sacral nerve neurostimulator. You say that you paid the $300 copayment and were not aware of the additional $1,000 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. Your contract with the Plan says that there is a $1,000 deductible. Your contract with the Plan also says that after the $1,000 deductible has been met, enrollee's must pay a $350 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You received the insertion of a sacral nerve neurostimulator on December 15, 2020. The record shows that you had paid $0 toward the $1,000 deductible prior to receiving the services. Therefore, you are responsible to pay the $1,000 deductible. Now that the $1,000 deductible has been met, you are also responsible to pay a $350 copayment. The total amount you owe is: $1,350. The item or service you asked the Plan to waive the deductible and copayment for falls within the benefit category outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,000 deductible for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. This cost sharing is a contractual obligation that had not been met at the time the insertion of a sacral nerve neurostimulator was received on December 15, 2020. Therefore, we decided that the Plan does not have to waive the deductible and copayment for the insertion of a sacral nerve neurostimulator provided on December 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewings - four radiographic images (D0274) received October 6, 2020.
You asked the Plan to pay for the bitewing radiographic images. You say that the plan did not give you a list of network dental providers, so you went to see your old dental provider. The Plan denied your request. The Plan says the requested service is not covered under your supplemental benefit.
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 for the bitewings - four radiographic images (D0274).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion (B4153) provided October 6, 2020 to November 4, 2020.
You asked the Plan to pay for the home infusion services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the number of units billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code. We find that 294 units of CPT code B4153 are not supported in the medical record. The medical record only supports 245 units of CPT code B4153. Based on this information, we decided that Medicare rules for coverage of the home infusion services have not been met. Therefore, we decided that the Plan does not have to pay for home infusion (B4153) provided October 6, 2020 to November 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for an indoor cycling stationary bike provided on December 12, 2020.
You asked the Plan to reimburse you for the indoor cycling stationary bike. The Plan denied your request. The Plan says exercise equipment is not a covered benefit.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
The Plan's rules for coverage of gym benefits have not been met because exercise equipment is not a covered benefit. Therefore, we decided that the Plan does not have to reimburse you for an indoor cycling stationary bike provided on December 12, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for surgical services (22614, 22326, 22600) provided September 9, 2020.
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The Plan denied your request. The Plan says that the claim included an inappropriate modifier.
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. The plan's denial does not explain what modifier was missing and/or invalid. The plan did not cite Medicare rules that support the denial. Therefore, we decided that the Plan has to pay for surgical services (22614, 22326, 22600) provided September 9, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you an additional amount for eyeglasses with polycarbonate lens provided on January 4, 2021.
You asked the Plan to reimburse you an additional amount for the eyeglasses with polycarbonate lens. The Plan denied your request. The Plan says you are responsible for all costs over and above the allowance amount. Claim processed correctly. Polycarbonate lens is not covered by Medicare or the Plan.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Medicare rules say lenses made of polycarbonate or other impact-resistant materials are covered only for beneficiaries with functional vision in only one eye.
We looked at the file, the Medicare rules and the Plan's rules. The Plan's eyewear benefit does not cover polycarbonate lenses. Medicare rules say lenses made of polycarbonate or other impact-resistant materials are covered only for beneficiaries with functional vision in only one eye. Therefore, we decided that the Plan does not have to reimburse you an additional amount for eyeglasses with polycarbonate lens provided on
January 4, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided by a Licensed Professional Counselor (LPC) on January 6, 2021.
You asked the Plan to pay for office visit. You say that the Plan's website state that this type of provider is covered. The Plan denied your request. The Plan says the denial of payment for this service is correct, because a Licensed Professional Counselor (LPC) is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered services, a provider must be enrolled in the Medicare program. Medicare rules also say that a Licensed Professional Counselor (LPC) is not eligible to enroll in the Medicare program. We looked at the file and Medicare rules. This service was received from a Licensed Professional Counselor (LPC) which is not a Medicare eligible provider type. Based on this information, we decided that Medicare rules for coverage of office visit have not been met. Therefore, we decided that the Plan does not have to pay for an office visit provided by a Licensed Professional Counselor (LPC) on January 6, 2021.