Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the remote pacemaker reading provided on August 29, 2019.
You asked the Plan to waive the copayment for the remote pacemaker reading. You say that there should not be a copayment on this service because you did not have copayments in 2017 or 2018. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for specialty care physician. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $40 copayment for the remote pacemaker reading.
You have been asked to pay a $30.06 copayment for the remote pacemaker reading. The remote pacemaker reading falls within the "Physician/Practitioner services, including doctor's office visit" 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 remote pacemaker reading provided on August 29, 2019.
Our decision is only about the 2019 service. If you have any questions about prior years billing, please contact the plan directly.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided from August 19, 2019 through September 30, 2019.
You asked the Plan to waive the copayment for physical therapy. You say that your previous treatments did not work. You say that if insurance covered more of these appointments, it might get rid of your tinnitus. The Plan denied your request. The Plan says the copayments 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 copayment for each visit for Medicare-covered outpatient rehabilitation services. You have been asked to pay a total of $100 for physical therapy.
Date of Service
Service
Allowed Amount
Standard Copayment
Member Liability
August 19, 2019
Physical Therapy
$30.76
$20
$20
August 26, 2019
Physical Therapy
$30.76
$20
$20
September 6, 2019
Physical Therapy
$30.76
$20
$20
September 16, 2019
Physical Therapy
$30.76
$20
$20
September 30, 2019
Physical Therapy
$30.76
$20
$20
TOTAL:
$100
Physical therapy falls within the "Outpatient rehabilitation 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 physical therapy provided from August 19, 2019 through September 30, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the ambulance ride provided on August 10, 2019.
You asked the Plan to waive the coinsurance for the ambulance ride. You say that you had no choice and had to call the ambulance. You say you are being billed $1,075.41. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 5% coinsurance per date of service regardless of the number of trips for in-and-out-of-network ambulance services. You have been asked to pay $19.15 which is 5% of the allowed amount for the ambulance ride. The allowed amount is $383.02. ($383.02 x 5% = $19.15). The ambulance ride 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 coinsurance for the ambulance ride provided on August 10, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cytopathology services rendered on July 15, 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 services are not payable.
The Plan must follow Medicare rules. Medicare rules say that modifier -26 is required for separate payment of the PC of diagnostic services when furnished in a different payment locality than the TC. We looked at the file and Medicare rules. The file shows that code 88173 (cytopathology) was billed in a facility setting. The file does not show that the PC and TC were furnished in different payment localities. Therefore, we decided that the Plan does not have to pay for the cytopathology services rendered on July 15, 2019.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for Cxbladder testing provided on April 11, 2019.
You asked the Plan to pay for Cxbladder test. You say that this testing is supported by studies and you disagree with the Plan's decision that it is not covered. The Plan denied your request. The Plan says that the denial of payment for this service is correct, because prior authorization was not obtained and this test is not covered by Medicare.
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. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. 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 has not specified whether the ordering physician The provider is in-network or out-of-network with the Plan, nor has the Plan submitted documentation of prior notice that this testing would not be covered. Without this information, we cannot determine whether the lab order made by the provider constitutes plan-directed care, which would support coverage of this claim. Furthermore, Cxbladder testing was not statutorily excluded from Medicare coverage on this date of service. Therefore, the Plan has not shown that their decision to deny payment for this claim is correct or justified by Medicare rules. Therefore, we decided that the Plan has to pay for Cxbladder testing provided on April 11, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan provided on August 26, 2019.You asked the Plan to waive the copayment forthe CT scan. You say that the Plan paid less than you are required to pay. You say that the bill should be adjusted.The Plan denied your request. The Plan says the copayment applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 copayment for advanced imaging services at an in-network specialist's office.You have been asked to pay a $150 copayment for the CT scan. The CT scan falls 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 copayment forthe CT scan provided on August 26, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the closed treatment of a radial fracture on September 11, 2019.
You asked the Plan to waive the copayment for the closed treatment of a radial fracture. You say that you disagree with the surgical 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 $400 copayment for outpatient surgery services provided in an outpatient hospital facility. You received the closed treatment of a radial fracture on September 11, 2019. The closed treatment of a radial fracture is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $400 copayment. You have been asked to pay a $400 copayment for the closed treatment of a radial fracture. The closed treatment of a radial fracture falls within the outpatient surgery, including 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 copayment for the closed treatment of a radial fracture provided on September 11, 2019.
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.You asked the Plan to pre-approve IRF care. You say that the enrollee would benefit from an aggressive low-level stroke program at an IRF that cannot be provided in a lower level of care.The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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.Our physician reviewer found the complexity of the enrollee's nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit from and participate in additional therapies of physical therapy and occupational therapy, but the enrollee does not require or appear totolerate this therapy on an intensive rehabilitation facility therapy program level in an IRF.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 notbeen met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Molecular Intelligence (MI) Profile testing rendered to the enrollee on September 11, 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 testing is not covered.
The Plan must follow Medicare rules. The rules say that MolDX will reimburse approved tests. The test at issue was not approved through the MolDx program for the date of service at issue. Therefore, we decided that the Plan does not have to pay for the Molecular Intelligence (MI) Profile testing rendered to the enrollee on September 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar sacral orthosis provided on August 9, 2019 by out of network provider, Contracting Services of America.
You asked the Plan to pay for the lumbar sacral orthosis (L0648). You say that the orthosis was medically necessary. 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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item at issue. We found no exception that would require the Plan to pay for this item. Therefore, we decided that the Plan does not have to pay for the lumbar sacral orthosis provided on August 9, 2019 by out of network provider, Contracting Services of America.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CPAP and humidifier.
You asked the Plan to pre-approve these services. The Plan denied your request. The Plan says that current documentation of the members clinical condition must be provided in order to assess the medical necessity of this device.
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 a CPAP and humidifier are not medically reasonable and necessary in this case. Submitted records include sleep study results for 2014. There is no current provider progress note, current symptoms or treatment. Without the support of the documentation, medical necessity cannot be determined. Our physician reviewer found that your condition does not meet Medicare criteria for coverage of these items.
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 a CPAP and humidifier.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not haveto pay for outpatient hospital services (36415, 80053, G0480, 85025, 81001, 70450, 99284 and 90792) provided from April 18, 2019 to April 19, 2019.You asked the Planto pay foroutpatient hospital services. You say that you would like reconsideration based on the medical records provided.The Plandenied your request. The Plansaysthe services were bundledand/or billed without a necessary modifier.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.Column One/Column Two codes shouldnot be reported together.In this case, we have confirmed that code 81001 is a Column II procedure to the Column I code 80306and cannot be paid as billed. 99284 is a Column 2 code to Column I code 90792. 90792 was appended with a modifier, but an appropriate modifier should have been used with the Column II code. Based on the claim submitted, Medicare billing criteria have not been met.Therefore, we decided that the Plandoes not haveto pay foroutpatient hospital services (36415, 80053, G0480, 85025, 81001, 70450, 99284 and 90792) provided from April 18, 2019 to April 19, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that you are appealing based on medical necessity. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found as LTACHs and acute care hospitals are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current acute care hospital until such time as no acute services are required, then be transferred/discharged to a lower level of care for any ongoing long-term care needs. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the visit provided on August 31, 2019.
You asked the Plan to waive the copayment for the visit. You say that you went to the emergency room based on bad information. You say that you should not have to pay the copayment. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $110 for each Medicare-covered emergency room visit. You have been asked to pay $110 for the ED visit. The ED 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 ED visit provided on August 31, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for acute inpatient rehabilitation services provided from August 12, 2019 through August 23, 2019.You asked the Plan to waive the copayment foracute inpatient rehabilitation 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 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you were admitted on August 12, 2019 and discharged on August 23, 2019. You were asked to pay a $275 copayment per day from August 12, 2019 through August 16, 2019, days 1-5 of your inpatient stay. There were no copayment charges from August 17, 2019, day 6 of your inpatient hospital care until your day of discharge August 23, 2019. Per your contract there is a $275 copayment per day required for days 1-5. 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 foracute inpatient rehabilitation services provided from August 12, 2019 through August 23, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transcatheter implantation of a wireless pulmonary artery pressure sensor (33289).
You asked the Plan to pre-approve this device. You say that the data is used to reduce heart failure hospitalizations. The Plan denied your request. The Plan says the requested device has not been shown to be better than conventional therapy in management of patients with heart failure.
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 this device. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found that in this circumstance therapy change based on data obtained from device has been demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results. Therefore, the efficacy of the device is uncertain at this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure. Medicare coverage criteria are not met since the device should still be considered experimental or investigational. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this device system have not been met. Therefore, we decided that the Plan does not have to pre-approve transcatheter implantation of a wireless pulmonary artery pressure sensor (33289).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a post-cataract surgery provided on June 26, 2019.
You asked the Plan to waive the copayment for a post-cataract surgery. You say that you were told that you would only owe a $300 copayment. 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 $400 copayment for each visit to an outpatient hospital facility and a $300 copayment for each visit to an ambulatory surgical center. You received a post-cataract surgery at an outpatient hospital facility on June 26, 2019. Therefore, you are responsible to pay the $400 copayment. You have been asked to pay a $400 copayment for a post-cataract surgery. A post-cataract surgery falls within the outpatient surgery, including 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 copayment for a post-cataract surgery provided on June 26, 2019.