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

We decided that the Plan does not have to waive the copayment forthe repositioning of a pacemaker provided by "the provider" on September 11, 2019.You asked the Plan to waive the copayment forthe repositioning of a pacemaker. You say that the copayment should be included in the original surgery 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 $250 copayment for outpatient surgery services provided in an ambulatory surgical center or outpatient hospital facility. You have been asked to pay a $250 copayment for therepositioning of a pacemaker. The repositioning of a pacemaker falls within the outpatient surgery, including services provided at hospital facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correctamount 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 repositioning of a pacemaker provided by "the provider" on September 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for arthrocentesis (20611).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 the documentation submitted did not include documentation of Arthrocentesis, aspiration and/or injection, major joint or bursa with ultrasound guidance with permanent recording and reporting for two major joints or bursas.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 ofcode 20611 is arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting.We asked our 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 arthrocentesis. Our reviewer says that CPT Code 20611 LT (2 units) does not meet billing or reimbursement criteria. Our reviewer found the medical records indicate an injection was performed in the acromioclavicular joint and an injection performed in the glenohumeral joint.  Per Current Procedural Terminology reference, an injection in the acrimioclavicualr joint would be coded with CPT code 20606. 2 units of CPT code 20611 was submitted for reimbursement consideration but cannot be validated by the medical documentation submitted. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of arthrocentesis have not been met. Therefore, we decided that the Plan does not have to pay for arthrocentesis (20611).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray coded 73140 provided on November 14, 2019.
You asked the Plan to pay for the x-ray. 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 separately payable.
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, we have confirmed that code 93140 for the x-ray has a bundled relationship with code 73130 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray coded 73140 provided on November 14, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Divalproex tablets.
You asked the Plan to pre-approve self-administered drugs. You say that you are appealing with medical records. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Divalproex tablets.
Benefits for 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 waive the cost share for the arthrocentesis and gel-one injection provided on August 29, 2019.You asked the Plan to waive the cost share for the arthrocentesis and gel-one injection. You say that you have never had to pay that much for the injection. You say that you are being over billed.The Plan denied your request. The Plan says the cost share 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 $50 copayment for specialist visits and 15% coinsurance for Part B drugs that are administered by a provider.You have been asked to pay a total of $446 for the arthrocentesis and gel-one injection.The arthrocentesis falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The gel-one 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 cost share forthe arthrocentesis and gel-one injection provided on August 29, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued Skilled Nursing Facility (SNF) care after February 2, 2020.You asked the Plan to pre-approvecontinued SNF care. You say that you have not fully recovered and do not have anywhere to go.The Plan denied your request. The Plan says the denial of authorization for continued SNF care after February 2, 2020 is correct.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, knowledge,and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a Skilled Nursing Facility (SNF) setting.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued SNF care have not been met.Therefore,we decided that the Plan does not have to pre-approvecontinued Skilled Nursing Facility (SNF) care after February 2, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forEmergency Room Services (99283, 93971) provided on June 27, 2019.You asked the Plan to waive the copayment forthe Emergency Room services. You say that you disagree with the copayment.The Plan denied your request. The Plan says the correct copayment has been applied.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 $90 copayment for Emergency Care. You have been asked to pay a $90 copayment for the Emergency Room services. The Emergency Room services fall 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 forEmergency Room Services (99283, 93971) provided on June 27, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic radiology services provided on August 7, 2019.
You asked the Plan to pay for the diagnostic radiology services. The Plan denied your request. The Plan says the Plan requires utilization of network providers, when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for diagnostic radiology services provided on August 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 26, 2019 by an out of network provider.
You asked the Plan to pay for the follow up evaluation (99213). You say that you called the provider prior to your appointment and were told they accept your insurance. The Plan denied your request. The Plan says the claim on file has been processed and denied correctly according to your benefits.
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 the medical services provided on September 26, 2019 by an out of network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient services provided from September 27, 2019 through November 4, 2019.
You asked the Plan to waive the copayments for outpatient services. You say that these services are related to your original surgeries. You say that you should not be responsible for payment. 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 $400 copayment for Medicare-covered outpatient hospital surgery services, a $20 copayment for all other Medicare- covered outpatient hospital services and a $30 copayment for Medicare-covered visits with a specialist.
You have been asked to pay a total of $1,104.49 for outpatient services.
Date of Service
Service
Allowed Amount
Standard Copayment
Member Liability
September 27, 2019
Aspiration
$316.46
$400
$316.46
October 4, 2019
Office Visit
$60.92
$30
$30
October 4, 2019
Skin Debridement
$316.46
$400
$316.46
October 10, 2019
Office Visit
$60.92
$30
$30
October 10, 2019
Skin Debridement
$316.46
$400
$316.46
October 21, 2019
Clinic Visit
$116.73
$20
20
October 21, 2019
Office Visit
$50.45
$30
$30
November 4, 2019
Office Visit
$25.11
$30
$25.11
November 4, 2019
Clinic Visit
$116.73
$20
$20
TOTAL:
$1,104.49
The outpatient services fall within the "Outpatient hospital services" and "Physician/Practitioner services, including doctor's office visits" 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 outpatient services provided from September 27, 2019 through November 4, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the endoscopy provided on June 17, 2019.
You asked the Plan to waive the copayment for the endoscopy. You submitted your bill for review. You say that you thought the Plan was going to cover the test. 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 each Medicare-covered outpatient surgery or procedure at an outpatient hospital facility or ambulatory surgical center. You have been asked to pay a $150 copayment for the endoscopy. The endoscopy 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 endoscopy provided on June 17, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the laboratory services provided on March 28, 2019.You asked the Plan to waive the deductible for the laboratory services. You say that the laboratory services were a part of your routine physical. 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. Your contract with the Plan says that there is a $300 annual deductible that applies towards laboratory services. The laboratory work you asked the Plan to waive the deductible for falls within the "Outpatient diagnostic tests and therapeutic supplies and services" benefit category. The record shows diagnostic tests are considered separate services.The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $300 annual deductible that applies towards laboratory services. The allowed amount of the laboratory services is $24.98. Therefore, $24.98 was applied to your $300annual deductible.This cost sharing is a contractual obligation that had not been met at the time the laboratory services were received on March 28, 2019. Therefore, we decided that the Plan does not have to waive the deductible for the laboratory services provided on March 28, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

Plan denied your request. The Plan says the Medicare rules have not been met.
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 DME have not been met. We reviewed your records and they show you have shoulder and back pain. You need a power wheelchair to help you with your activities of daily living. Furthermore, the cup holder is a convenience item and does not serve a medical purpose. Therefore, we decided that the Plan does not have to pre-approve power wheelchair, group 2 standard, captains chair, patient weight capacity up to and including 300 pounds (CPT Code K0823) and a cup holder, for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for bilateral knee orthoses (L1833) and suspension sleeves (L2397) provided to the enrollee on September 6, 2019.
You asked the Plan to pay for the orthoses and sleeves. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the documentation indicates services are not necessary for treatment of the enrollee's condition.
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 the orthoses and sleeves. Our reviewer says that the enrollee does not meet criteria for the orthoses and sleeves ordered. Our physician reviewer found the documentation in the case file does not support that the requested knee orthoses with sleeves were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is no documentation of recent injury to, or recent surgical procedure on, either of the enrollee's knees, and there is insufficient credible objective documentation of joint laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered. 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 orthoses and sleeves have not been met. Therefore, we decided that the Plan does not have to pay for bilateral knee orthoses (L1833) and suspension sleeves (L2397) provided to the enrollee on September 6, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on
October 9, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that you should not be
responsible for the copay because it was an emergency. The Plan denied your request. The Plan says that the
benefit 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 $250
copayment for Ambulance services.
You have been asked to pay a $250 copayment for the ambulance transport. The ambulance transport 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
the ambulance transport provided on October 9, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy provided on June 10, 2019.
You asked the Plan to waive the copayment for the colonoscopy. You say that this was your 5-year screening colonoscopy and there should not be a 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). Your contract with the Plan clearly says that you must pay a $250 copayment per day for outpatient procedures and services, including but not limited to diagnostic and therapeutic endoscopy, and outpatient surgery performed in an outpatient hospital or ambulatory surgical center. You have been asked to pay a $250 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows the colonoscopy was performed because of symptoms of diarrhea abdominal cramping and urgency. Therefore, the colonoscopy is diagnostic in nature.
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 colonoscopy provided on June 10, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular diagnostic infectious disease testing provided on August 13, 2019.
You asked the Plan to pay for the molecular diagnostic infectious disease testing. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for molecular diagnostic infectious disease testing provided on August 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on September 12, 2019.

You asked the Plan to waive the copayment for the specialist office visit. You say that you had a routine eye exam and should not be charged a 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). Your contract with the Plan clearly says that you must pay a $25 copayment for each physician specialist visit for Medicare-covered services. 

You have been asked to pay a $25 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows a diagnosis of cataracts, which makes the office visit medical in nature.

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 specialist office visit provided on September 12, 2019.