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

We decided that the Plan does not have to waive the cost share for the Medicare Part B drugs provided on November 19, 2019.
You asked the Plan to waive the cost share for the provided drugs. You say that this is a huge financial burden. The Plan denied your request. The Plan says the copay applies per your plan 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). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a 20% coinsurance for the provided drugs. The drugs fall 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 for the Medicare Part B drugs provided on November 19, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the injection provided on March 4, 2020.
You asked the Plan to waive the copayment for the injection. You say that you do not know why you are being charged. You say that anytime you see a specialist, the facility charge is paid for by the insurance. 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 $325 copayment for each Medicare-covered in-network outpatient hospital facility visit. For this date of service, you have been asked to pay less than the allowed amount of the claim because this amount is less than the $325 copayment for the injection.
You have been asked to pay an $85 copayment for the injection. The injection falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows you were billed by an outpatient hospital.
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 injection provided on March 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cervical fusion and inpatient hospital services.
You asked the Plan to pre-approve cervical fusion and inpatient hospital services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
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 cervical fusion and inpatient hospital services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found you have cervical pain and upper extremity pain. There is no clear correlation between MRI imaging and physical exam. The imaging does not show severe instability or stenosis. Therefore, you do not meet criteria for the requested 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 cervical fusion and inpatient hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve cervical fusion and inpatient hospital services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost shares for the medical services provided on February 
26, 2020. 
 
You asked the Plan to waive the cost shares for the services provided. The Plan denied your request. The Plan 
says the cost share was applied based on your plan 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).  
 
The file shows that you received a transthoracic echocardiography and fluoroscopy. The total cost of the 
services was $722.17. You were charged $500, which was applied to your deductible amount. Once the 
deductible was met, you were charged a $160 copay for the diagnostic services. The services fall within the 
outpatient diagnostic tests 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 shares for the medical 
services provided on February 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the injection provided on August 20, 2019. 
 
You asked the Plan to waive the cost share for the services provided. You say that you were told you would 
only be responsible for one charge. The Plan denied your request. The Plan says the Part B coinsurance applies 
per your Evidence of Coverage. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a 20% coinsurance for the Ferumoxytol injection you received. The 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 
for the injection provided on August 20, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on October 8, 2019. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services are not 
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, the codes at issue are not payable on the Physician Fee Schedule but have a PC/TC indicator of "9" 
meaning that the concept of professional/technical components does not apply. These services are paid in the 
Clinical Laboratory Fee Schedule and only have a fee for the global service, and no breakdown for PC/TC of 
the service. This means that payment cannot be made for these codes when billed with the modifier -26. Based 
on this information, we decided that Medicare rules for coverage the codes in question have not been met. 
Therefore, we decided that the Plan does not have to pay for the lab services provided on October 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on November 6, 2019.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be reported with one unit of CPT 81479 and the appropriate DEX Z-Code. We looked at the file and Medicare rules. The requested Guardant360 testing was billed with multiple CPT codes. Per the applicable article, this testing must be reported with CPT 81479 and the appropriate DEX Z-Code. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on November 6, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug test services provided on March 11, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the drug test services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services provided are not a covered benefit. 
 
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 drug test services provided on March 11, 2020 
by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the diagnostic mammogram provided on May 1, 2020.
You asked the Plan to waive the copay for the service provided. You say that you never had to pay for a mammogram before. The Plan denied your request. The Plan says the claim was processed correctly according to your 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 $40 copay for each basic imaging service. You have been asked to pay a $40 copay for the provided mammogram. The mammogram falls within the outpatient diagnostic tests 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 copay for the diagnostic mammogram provided on May 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesiology services provided on October 29, 2019 by an
out of network (OON) provider.
You asked the Plan to pay for anesthesiology services. You say that you would like this claim reprocessed and
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The
Plan says that these services are not considered an emergency service.
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 anesthesiology services provided on October 29,
2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CardioMEMS. 
 
You asked the Plan to pre-approve CardioMEMS. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
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 CardioMEMS. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has congestive heart failure with preserved left ventricle ejection fraction (LVEF 
greater than 55%) requiring hospitalization. Therapy change based on data obtained from a CardioMEMS 
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 CardioMEMS device is uncertain at this time according to leading 
authorities and not recommended in current guidelines for the treatment of heart failure. Therefore, this device 
is still considered experimental and 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 CardioMEMS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve CardioMEMS.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost shares for the medical services provided from January 
3, 2020 to March 12, 2020. 
 
You asked the Plan to waive the cost shares for the services provided. You say that you were told the provider 
was Medicare certified. The Plan denied your request. The Plan says the deductible was applied correctly. 
 
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 until you have paid the deductible amount, you must pay the full cost for most 
of your covered services. 
 
The service you asked the Plan to waive the cost shares for falls within the physician services benefit category. 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible. This 
cost sharing is a contractual obligation that had not been met at the time the services were received. Therefore, 
we decided that the Plan does not have to waive the cost shares for the medical services provided from January 
3, 2020 to March 12, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a duplex scan provided on February 18, 2020. 
 
You asked the Plan to pay for the duplex scan. 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 
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 a duplex scan provided on February 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost shares for the medical services provided on February 27, 2019.
You asked the Plan to waive the cost shares for the services provided. You say that it would have been easier to deal with the charges in 2019. The Plan denied your request. The Plan says the clap processed correctly per your 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).
You have been asked to pay a 20% coinsurance for the Part B drugs and a $50 copay for the urgent care visit. The services fall within the Medicare Part B prescription drugs and urgently needed services benefit categories. 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 shares for the medical services provided on February 27, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on March 1, 2020.
You asked the Plan to waive the copayment for the emergency room visit. You say that you cannot afford 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). Your contract with the Plan clearly says that you must pay a $90 copayment for each emergency room visit. You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the "Emergency Care" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency room visit provided on March 1, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a laparoscopic procedure provided on 
January 6, 2020. 
 
You asked the Plan to waive the coinsurance for a laparoscopic procedure. You say that you are a senior citizen 
and cannot afford 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 20% 
coinsurance for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
You received a laparoscopic procedure on January 6, 2020. A laparoscopic procedure is considered an 
outpatient surgical procedure. Therefore, you are responsible to pay your share of the cost-sharing charges. The 
total allowed amount is $5,332.15 and 20% of that is $1,066.43.  
 
You have been asked to pay the total coinsurance amount of $1,066.43 for a laparoscopic procedure. A 
laparoscopic procedure 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 coinsurance 
for a laparoscopic procedure provided on January 6, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional non-emergent ambulance transportation.
You asked the Plan to pre-approve additional transportation. You say that the enrollee is bedbound and needs continuous supervision due to her medical history. The Plan denied your request.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. The file shows that 90 transportation trips were requested. The Plan has agreed to pre-approve 72 trips. In this case, there is insufficient information to show that additional trips are necessary to meet the enrollee's needs. Oxygen and routine supplies were also requested. We looked at the file, and Medicare rules. These are considered part of the general ambulance service and payment for them is included in the payment rate for the transport. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve additional non-emergent ambulance transportation services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the osteotomy services coded 21198 provided on November 
19, 2019. 
 
You asked the Plan to pay for the osteotomy services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 21198 is osteotomy, mandible, segmental. 
 
We find that CPT code 21198 is not supported in the medical record. Specifically, the operative report did not 
include documentation of osteotomy, mandible, segmental; therefore, this code cannot be verified. Based on 
this information, we decided that Medicare rules for coverage of the osteotomy services have not been met. 
Therefore, we decided that the Plan does not have to pay for the osteotomy services coded 21198 provided on 
November 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded 80307 and G0483 provided on July 8,
2019.
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the services billed are not supported by the documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT codes 80307 and G0483 are not supported in the medical record. Specifically, the
documentation submitted did not include a valid physician order/lab requisition form or medical records signed
by the ordering physician. In addition, the custom profile is not dated. Based on this information, we decided
that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan
does not have to pay for the drug testing coded 80307 and G0483 provided on July 8, 2019.