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

We decided that the Plan does not have to waive the copayment for laboratory tests provided on July 24, 2020.
You asked the Plan to waive the copayment for laboratory tests. You say that you feel that the Plan should cover the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for laboratory services for outpatient hospital services. You have been asked to pay a $35 copayment for laboratory tests. Laboratory tests fall within the outpatient hospital 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 laboratory tests provided on July 24, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan has to waive the copayment for a hearing test provided on October 5, 2020.
You asked the Plan to waive the copayment for a hearing test. You say that this was a routine hearing test and you have never paid for one in the past. The Plan denied your request. The Plan says that the claims were processed correctly and you are being charged the correct amount.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not provide medical records. Without medical records we cannot determine whether the hearing test was routine or not. Therefore, we decided that the Plan has to waive the copayment for a hearing test provided on October 5, 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the Botox injection of chemical for destruction of facial and neck nerve muscles (64615, J0585) provided on September 10, 2020.
You asked the Plan to waive the cost share for the Botox injection of chemical for destruction of facial and neck nerve muscles. You say that you believed the services provided were fully covered. The Plan denied your request. The Plan says the cost share applied correctly in this case.
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 and a 20% coinsurance for specialist visit for Medicare-covered services and Medicare Part B drugs, respectively. You have been asked to pay a total cost share of $294.00 ($50 specialist copayment + $244 Medicare Part B drug coinsurance). The services provided fall within the specialist visit for Medicare-covered services and Medicare Part B drugs 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 share for the Botox injection of chemical for destruction of facial and neck nerve muscles (64615, J0585) provided on September 10, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve CT, abdomen and pelvis (CPT Code 74178), CT thorax (71260) and PET with CT for attenuation correction and anatomical localization imaging; skull base to mid-thigh (78815).
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says that the services are not necessary. 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 services. Our physician reviewer found patient with rapidly changing condition with metastatic cancer. Patient has no steady state. Has had repeat CT ordered and denied due to recent CT having been performed. Patient has changed clinically since last CT. Feel the scan is medically reasonable and indicated. 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 services have been met. Therefore, we decided that the Plan has to pre-approve CT, abdomen and pelvis (CPT Code 74178), CT thorax (71260) and PET with CT for attenuation correction and anatomical localization imaging; skull base to mid-thigh (78815).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay fordental services provided on November 30, 2018.You asked the Plan to pay forthe dental services. You say that you were told not to file a claim until you had fully paid off your balance at the dental office.The Plan denied your request. The Plan says the claim was not submitted within the required timeframe.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.The record shows that a claim for the dental services was not filed until June 30, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay fordental services provided on November 30, 2018.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the total cost share of the ultrasound of breast (76641) and denosumab injections (J0897) provided December 4, 2019, to June 10, 2020.
You asked the Plan to waive the total cost share of the ultrasound of breast and denosumab injections. You say that you believed you would not be charged for the services provided. The Plan denied your request. The Plan says the cost share applied correctly in this case.
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 an ultrasound received at an outpatient hospital setting and a 20% coinsurance for Medicare Part B drugs. You have been asked to pay a total cost share of $832.92 for the ultrasound of breast and denosumab injections ($25 copayment + $412.48 coinsurance + $ 395.44 coinsurance). The services provided fall within the Medicare Part B drugs and ultrasound 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 total cost share of the ultrasound of breast (76641) and denosumab injections (J0897) provided December 4, 2019, to June 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the shower chair (CPT Code E0240).
You asked the Plan to pre-approve the shower chair. You say that you are unable to safely perform basic hygiene without assistance from the shower chair. The Plan denied your request. The Plan says this is not covered by Medicare because it is considered to be a comfort or convenience item.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve the shower chair (CPT Code E0240).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveradiofrequency ablation services.You asked the Plan to pre-approveradiofrequency ablation 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 radiofrequency ablation services. 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 left knee pain from osteoarthritis. The enrollee had prior genicular nerves radiofrequency ablation 2 years ago. The requested diagnostic genicular nerve blocks before performing repeat radiofrequency ablation is considered experimental/investigational as a therapy for osteoarthritis of the knee. It is the subject of on-going clinical trials. Therefore, the enrollee does 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 radiofrequency ablation services have not been met.Therefore, we decided that the Plan does not have to pre-approveradiofrequency ablation services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe knee replacement provided on December 17, 2019.You asked the Plan to waive the coinsurance forthe knee replacement. You say that you had to schedule a knee revision. You say that you don't wish to pay the balance.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 40% coinsurance for Medicare-covered surgery or other services provided to you at an out-of-network outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges.You have been asked to pay $574.11, which is 40% of the allowed amount for the knee replacement. The allowed amount is $1,435.27 (40% x $1,435.27 = $574.11). The knee replacement falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The record show that the knee replacement was performed. 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 knee replacement provided on December 17, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) stay provided.

You asked the Plan to pay for the SNF stay. You say that the SNF stay was medically necessary for the enrollee.The Plan denied your request. The Plan says rules for SNF care have not been met.

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 pay for the SNF stay. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing or 
skilled therapy service needs. In addition, the beneficiary does not require skilled nursing or therapy services on a daily basis and does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 the SNF stay have not been met.Therefore, we decided that the Plan does not have to pay forthe skilled nursing facility (SNF) stay provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral evaluation (D0120) provided on September 16, 2020.
You asked the Plan to pay for the dental service. You say that your appointment was not pleasant. You say that
you were not able to get the services done that you wanted. You also say that you should not be responsible for
the exam. The Plan denied your request. The Plan says 1 exam per calendar year is covered. The Plan says that
the frequency limit for this service has been exceeded.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the oral
evaluation (D0120) provided on September 16, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve injection(s), anesthetic agent and/or steroid, transforaminal
epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, single level (CPT Code 64483).
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your
request. The Plan says that the service is not 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 service. Our physician reviewer found the patient has chronic lumbar radiculopathy and has
had prior epidural steroid injections with good effect. The LCD criteria are met and the procedure is medically
necessary and reasonable. 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 service have been met. Therefore, we decided
that the Plan has to pre-approve injection(s), anesthetic agent and/or steroid, transforaminal epidural, with
imaging guidance (fluoroscopy or CT); lumbar or sacral, single level (CPT Code 64483).
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe Intracept procedure for the enrollee.You asked the Plan to pre-approvethe procedure. You say that this is medically necessary.The Plan denied your request. The Plan says this is not an accepted standard of medical practice for the diagnosis of treatment of back pain.The Plan must follow Medicare rules.Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Intracept procedure remains experimental for the treatment of back pain. More research is needed to show safety and efficacy.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 procedure have not been met.Therefore, we decided that the Plan does not have to pre-approvethe Intracept procedure for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe office visit and x-ray provided on August 4, 2020.You asked the Plan to waive the copayment forthe office visit and x-ray. You say that you shouldn't have gotten another x-ray or charged for another office visit. You say that you are appealing both copayments.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 $45 copayment for a specialty physician and a $45 copayment for each Medicare-covered x-ray..You have been asked to pay a total of $82.91 for the office visit and x-ray. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The x-ray falls within the ""Outpatient diagnostic tests and therapeutic services and supplies"benefit category. The records show that the services were provided. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe office visit and x-ray provided on August 4, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic ultrasound provided by a
participating provider on July 24, 2020.
You asked the Plan to waive the copayment for a diagnostic ultrasound. You say that you never had to pay for
this before. 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). The enrollee's contract with the Plan clearly says that enrollees
must pay a $110 copayment for outpatient diagnostic tests/radiological diagnostic services/in-network.
The enrollee has been asked to pay $108.62 which is less than your copayment amount of $110 for a diagnostic
ultrasound. A diagnostic ultrasound falls within the outpatient diagnostic tests/radiological diagnostic
services/in-network benefit category. This means that the enrollee has been asked to pay the correct amount
based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay
upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a
diagnostic ultrasound provided by a participating provider on July 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on February 28, 2020 by an out of
network (OON) provider.
You asked the Plan to pay for the lab services. You say that these services were medically necessary. The Plan
denied your request. The Plan says unauthorized, non-plan care is not covered.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could 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 lab services provided on February 28, 2020 by an out of
network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the colectomy services coded 44144 provided on February 3,
2020.
You asked the Plan to pay for the colectomy 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 44144 is colectomy, partial; with resection, with
colostomy or ileostomy and creation of mucofistula.
We find that CPT code 44144 is not supported in the medical record. Specifically, the operative report did not
include documentation of a partial colectomy, with resection, including colostomy or ileostomy and creation of
mucofistula; therefore, this code cannot be verified. Based on this information, we decided that Medicare rules
for coverage of the colectomy services have not been met. Therefore, we decided that the Plan does not have to
pay for the colectomy services coded 44144 provided on February 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for chiropractic service on July 8, 2020.
You asked the Plan to waive the copayment for chiropractic service. You say that copayments were waived
since July 1, 2020. The Plan denied your request. The Plan says you were charged this copayment 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 chiropractic services.
You have been asked to pay a $20 copayment for chiropractic services. The chiropractic service falls within the
chiropractic 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 chiropractic service
on July 8, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergency transportation in a stretcher van provided on May 20, 2020.
You asked the Plan to pay for the stretcher van services. You say that you were advised that this was the only form of transportation that would work. You say that you were forced to receive the services which are now being denied. The Plan denied your request. The Plan says the services in dispute are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for stretcher van transport services. The services you have asked the Plan to pay for are stretcher van transport services. Therefore, we decided that the Plan does not have to pay for non-emergency transportation in a stretcher van provided on May 20, 2020.