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

 
We decided that the Plan does not have to waive the copayment for an eye examination provided on August 3, 
2020. 
 
You asked the Plan to waive the copayment for eye exam. You say that you have no idea why this expense 
would be your responsibility. The Plan denied your request. The Plan says the copayment amount you are 
being charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $35 
copayment for in-network eye exam.  
 
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. Therefore, we 
decided that the Plan does not have to waive the copayment for an eye examination provided on August 3, 
2020.  
 
If the provider is billing you for charges beyond any applicable cost-sharing amounts, please contact the Plan 
directly.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient hospital care provided April 9, 2020, to April 12, 2020. 
 
You asked the Plan to pay for the inpatient hospital care. You say that the services provided were medically 
necessary for the enrollee. The Plan denied your request. The Plan says that the inpatient care provided after 
April 11, 2020, was unauthorized post-stabilization care. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 inpatient hospital care. Our reviewer 
says that the services provided were medically necessary for the enrollee. Our physician reviewer found there 
was still a medical need for inpatient care, and the care provided was appropriate for the enrollee's condition. 
 
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 inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the inpatient hospital care provided April 9, 2020, to April 12, 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 pay for the extraction of erupted tooth (D7210) provided, by a 
provider that has opted out of Medicare. 
 
You asked the Plan to pay for the extraction of erupted tooth. You say that you were not aware you are not 
allowed to use providers who are opted out of Medicare. The Plan denied your request. The Plan says the 
provider has opted out of Medicare and is not eligible for payment. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
extraction of erupted tooth (D7210) provided on March 19, 2020, by a provider that has opted out of Medicare.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan has to pre-approve joint surgery for the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there is inadequate evidence that the enrollee has received supervised conservative 
management. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the surgery. Our reviewer says that the 
requested surgery is considered medically reasonable and necessary in this case. Our physician reviewer found 
the enrollee presents with significant right shoulder pain and instability. He had an initial dislocation event 
followed by 5 subsequent episodes, one requiring closed reduction in the emergency room. Functional 
limitations are noted in overhead activities. Clinical exam findings are consistent with imaging evidence of 
anterior instability with Bankart lesion and small Hill-Sachs lesion, full thickness anterior supraspinatus tear, 
and significant tendinopathy of the intra-articular portion of the biceps tendon with degenerative appearance of 
the biceps anchor. There is reported imaging evidence of degenerative anterior labrum. He has failed 
reasonable and/or comprehensive conservative treatment. Surgery has been recommended to include right 
shoulder arthroscopy with labral repair, rotator cuff repair, debridement, possible acromioplasty, and biceps 
tenodesis. Partial certification has been granted from right shoulder arthroscopy with rotator cuff repair, 
possible acromioplasty, and capsular repair. Under consideration is a request for CPT codes 29823 (extensive 
debridement) and 29828 (biceps tenodesis). Current evidence based medical literature would support the 
inclusion of these codes for treatment of this enrollee? extensive shoulder pathology and as indicated upon 
arthroscopic evaluation of the shoulder. Therefore, this request for shoulder joint surgery (CPT codes 29823 
and 29828) is medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the surgery have been met. Therefore, we decided that the Plan has to pre-
approve joint surgery for the enrollee.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transection or avulsion procedures on the extracranial nerves, 
peripheral nerves, and autonomic nervous system (64772) provided February 20, 2020. 
 
You asked the Plan to pay for the surgical procedure. You say that you are asking for reconsideration for the 
non-payment you received for the services provided. The Plan denied your request. The Plan says resubmit the 
claim with the appropriate ASA code. 
 
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 64772 is the extracranial nerves, peripheral nerves, and 
autonomic nervous system 
 
We find that CPT code 64772 is not supported in the medical record. Specifically, the denied procedure does 
not meet the separately reportable conditions for an epidural or peripheral nerve block injection as the primary 
specialty of the provider is an Anesthesiologist. The procedure code 64772 should be billed with an anesthesia 
services procedure codes when billed by an anesthesia practitioner who may be a physician, a certified 
registered nurse anesthetist(CRNA) with or without medical direction, or an anesthesia assistant (AA) with 
medical direction. Based on this information, we decided that Medicare rules for coverage of the surgical 
procedure have not been met. Therefore, we decided that the Plan does not have to pay for transection or 
avulsion procedures on the extracranial nerves, peripheral nerves, and autonomic nervous system (64772) 
provided February 20, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for laboratory tests provided on June 17, 2020. 
 
You asked the Plan to waive the deductible for laboratory tests. You say that you disagree with the out-of-
network charges because you thought that the provider was in-network. 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 $250 deductible for out-of-network outpatient diagnostic tests and 
therapeutic services and supplies.  
 
You received laboratory tests on June 17, 2020, from an out-of-network provider. The record shows that you 
had paid $0 toward the $250 deductible prior to receiving the services. Therefore, you are responsible to pay 
the allowed amount of $36.66.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient 
diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $250 deductible for outpatient diagnostic tests and therapeutic services 
and supplies. This cost sharing is a contractual obligation that had not been met at the time laboratory tests was 
received on June 17, 2020. Therefore, we decided that the Plan does not have to waive the deductible for 
laboratory tests provided on June 17, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay foran arthroscopy (29823) performed May 11, 2020.You asked the Plan to pay forthe arthroscopy. You say that the services were medically necessary.The Plan denied your request. The Plan says the documentation does not support the services billed.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 29823 is Arthroscopy, shoulder, surgical; debridement, extensive for reimbursement consideration.We find that CPT code 29823 is not supported in the medical record. Specifically, the documentation does not support extensive debridement. Extensive debridement includes chondroplasty of the humeral head or glenoid and associated osteophytes, or multiple soft structures such as labrum, subscapularis and supraspinatus. In this case, the operative report supports only limited debridement. Based on this information, we decided that Medicare rules for coverage of the arthroscopy have not been met.Therefore, we decided that the Plan does not have to pay foran arthroscopy (29823) performed May 11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on July 4, 2020
and billed under codes 99291 and 99292.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says CPT code 99291 CR 25 (1 Unit) remains not supported. The documentation submitted
did not support a critical care visit of 30-74 minutes was performed. The documentation does not include the
time spent with the enrollee. The Plan also states that CPT code 99292 CR 25 (2 Units) remains not supported.
The documentation submitted also did not support a critical care visit of an additional 30 minutes of critical
care time in addition to the first 30-74 minutes of a critical care evaluation and management service (CPT code
99291) for this date of service. Medicare billing criteria are not met.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code and the medical record documentation must
support the services billed. In this case, the documentation provided does not include the time spent providing
the services billed, as is required. Medicare rules for coverage of these services have not been met. Therefore,
we decided that the Plan does not have to pay for physician services provided to the enrollee on July 4, 2020
and billed under codes 99291 and 99292.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the physician's services.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 physician's services provided.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forpathology services provided on August 12, 2020 by an out of network (OON) provider.You asked the Plan to pay forpathology 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 the referring provider is also out-of-network.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 forpathology services provided on August 12, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services provided on August 14, 2020 by
an out of network (OON) provider.
You asked the Plan to pay for outpatient hospital 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 the member's primary care physician did not refer these services.
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 outpatient hospital services provided on August
14, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay forknee orthoses billed with HCPCS codes L1843-LT and L1843-RT provided on April 13, 2020.You asked the Plan to pay forthe knee orthoses. You say that the records provided support the items in dispute.The Plan denied your request. The Plan says that the documentation submitted did not include an itemized shipping/billing invoice to indicate the specific supplies or proof of delivery. The Plan says that, because of this, the billed supplies cannot be verified.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does contain a valid proof of delivery for the supplies provided in this case. The date of service matches the date the enrollee signed acknowledging receipt of the orthoses in dispute. The Plan has not substantiated their denial reason.Therefore, we decided that the Plan has to pay forknee orthoses billed with HCPCS codes L1843-LT and L1843-RT provided on April 13, 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe echocardiography provided on July 13, 2020.You asked the Plan to waive the coinsurance forthe echocardiography. You say that you feel that you owe nothing. You say that you are disputing the charge.The Plan denied your request. The Plan says the coinsurance applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare-covered diagnostic procedures and tests. You have beenasked to pay $96.64, which is 20% of the allowed amount for the echocardiography. The allowed amount is $483.21 (20% x $483.21 = $96.64). The echocardiography 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 coinsurance forthe echocardiography provided on July 13, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a colonoscopy provided.

You asked the Plan to waive the copayment fora colonoscopy. You say that you feel that the colonoscopy should be considered preventative.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.

You received a colonoscopy. The record shows that you have a personal history of polyps. Therefore, the colonoscopy is considered diagnostic, not preventative, and you are responsible to pay the $250 copayment. 

You have been asked to pay a $250 copayment for a colonoscopy. A colonoscopy 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 fora colonoscopy provided.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forskin substitute graft services provided to the enrollee on July 16, 2020.You asked the Plan to pay forthe services. You say that this should be paid for.The Plan denied your request. The Plan says the denied code is not supported by the medical records submitted.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 15275 is "Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia,hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area."We asked our coding 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found the documentation did not include any provider documentation to verify the code.We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay forskin substitute graft services provided to the enrollee on July 16, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approveComputed Tomography (CT) of the Chest, Abdomen, and Pelvis (74177).You asked the Plan to pre-approvethe CT scan. You say that the CT scan is medically necessary.The Plan denied your request. The Plan says that coverage criteria has not been met.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the CT scan. Our reviewer says that the requested CT scan is medically necessary. Our physician reviewer found CT of the abdomen and pelvis in this case is to asses an ileofemoral DVT more than surveillance of the esophageal cancer. Due to location near the pelvic veins imaging with CT in addition to ultrasound is appropriate.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 CT scan have been met.Therefore, we decided that the Plan has to pre-approveComputed Tomography (CT) of the Chest, Abdomen, and Pelvis (74177).