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

We decided that the Plan does not have to pre-approve a Vertiflex Superion Interspinous device for the enrollee.

You asked the Plan to pre-approve these services. You say that these services are medically necessary.The Plan denied your request. The Plan says that the clinical value and effectiveness of the Vertiflex Superion Interspinous device in the setting of lumbar stenosis have not been demonstrated in the peer-reviewed literature.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The spacer device remains experimental. More research is needed to show safety and efficacy. Also, there is no clearly documented spinal instability and hardware is not needed. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion Interspinous device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on January 10, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe laboratory services. You say that you would like reconsideration because the services were medically necessary.The Plan denied your request. The Plan says the services rendered were not urgent, emergent or approved in advance.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 foundno exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe medical services provided on January 10, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran X-ray and to waive the coinsurance for a Medicare Part B drug provided on August 18, 2020.You asked the Plan to waive the copayment foran X-ray and to waive the coinsurance for a Medicare Part B drug. You say that you paid the $20 office copayment and disagree with the additional 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 $10 copayment for X-rays. Your contract with the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs.You received an X-ray on August 18, 2020. Therefore, you are responsible to pay the $10 copayment. You received a Medicare Part B drug injection on August 18, 2020. The allowed amount is $14.82 and 20% of that is $2.96. The total amount you owe is: $12.96.  You have been asked to pay the total amount of $12.96 for an X-ray and a Medicare Part B drug. An X-ray falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. AMedicare Part B drug 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 copayment foran X-ray and to waive the coinsurance for a Medicare Part B drug provided on August 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forout of network physician services provided to the enrollee on February 5, 2020.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says the billing provider is not in network and the enrollee did not have prior authorization for out of networkcare.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 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 forout of network physician services provided to the enrollee on February 5, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forambulance transport provided to the enrollee on June 10,2020.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says the records show upon the ambulance arrival, the enrollee was complaining of lower back pain and a productive cough which the enrollee reported he had for years. The records show the enrollee was seen at hospital earlier with the same complaints and released.  The enrollee admitted to having abused alcohol and substance use.  Pt has had recent negative COVID 19 tests.The patient was hemodynamically stable with stable vital signs.There is a CPT-code modifier (-GY) for ambulance/emergency medical services response without transport.The Plan states the claim and the records provided are incomplete. 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 records provided do not support the services billed. Medicare rules for coverage of this service have not been met.Therefore, we decided that the Plan does not have to pay forambulance transport provided to the enrollee on June 10, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment foran office visit provided on July 27, 2020.You asked the Plan to waive the copayment foran office visit. You say that this was your annual wellness exam and you should not be responsible forthe charges.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. ThePlan did not provide medical records. Without medical records we cannot determine whether or the visit was for an annual wellness exam or not.Therefore, we decided that the Plan has to waive the copayment foran office visit provided on July 27, 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/orsend 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 waive the copayment forwound debridement provided on January 15, 2020.You asked the Plan to waive the copayment forwound debridement. You say that you should only owe a $20 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 $225 copayment for outpatient surgery,including services provided at hospital outpatient facilities. The record shows that you received wound debridement on January 15, 2020, at an outpatient hospital facility. Therefore, you are responsible to pay the $225 copayment. You have been asked to pay a $225 copayment for wound debridement. Wound debridement 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 paythe 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 forwound debridement provided on January 15, 2020
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray provided on February 24, 2020 by an out of network (OON) provider.
You asked the Plan to pay for an x-ray. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the referring provider is out-of-network. The Plan says 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 an x-ray provided on February 24, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay forComprehensive Genomic Profile (CGP) testing provided to the enrollee on April 15, 2020.You asked the Planto pay forthe testing. You say that this should be paid for.The Plandenied your request. The Plansaysthis should be reported with CPT 81479.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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare rules for coverage of the testing have not been met.Therefore, we decided that the Plandoes not haveto pay forComprehensive Genomic Profile (CGP) testing provided to the enrollee on April 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services coded 81401 and 81403 provided onYou asked the Plan to pay forthe laboratory services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services were billed incorrectly.The Plan must follow Medicare rules. Medicare rules say thatproviders must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT codes 81401 and 81403 are not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met.Therefore, we decided that the Plan does not have to pay forthelaboratory services coded 81401 and 81403 provided on
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an X-ray provided on July 17, 2020.
You asked the Plan to waive the copayment for an X-ray. You say that it was not your choice to have multiple
physicians review the results and you disagree with 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 basic radiological services provided in a specialist's office or freestanding radiological facility.
You have been asked to pay a $35 copayment for a specialist visit. A specialist visit falls within the outpatient
diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the
copayment for an X-ray provided on July 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 3, 2020 by an out of
network (OON) provider.
You asked the Plan to pay for these OON services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services received are not a covered benefit when
provided by an OON provider.
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 August 3, 2020
by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the Emergency Room and ancillary charges provided from July 24, 2020, to July 29, 2020.
You asked the Plan to pay for the Emergency Room and ancillary charges. You say that you are only appealing the ER and ancillary charges. The Plan denied your request. The Plan says the claim cannot be paid as 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. We find that the ER and ancillary charges cannot be paid as submitted according to Medicare guidelines. The charges must be billed separately and resubmitted. Based on this information, we decided that Medicare rules for coverage of the Emergency Room and ancillary charges have not been met. Therefore, we decided that the Plan does not have to pay for the Emergency Room and ancillary charges provided from July 24, 2020, to July 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe local anesthesia (D9215) provided on August 5, 2020.You asked the Plan to pay forthe local anesthesia. You say that you contacted the Plan prior to your appointment, and were told that a cleaning and extraction would be covered. You also say that you have no control over how the dental office and the Plan code the procedures.The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan.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 forthe local anesthesia (D9215) provided on August 5, 2020.Your complaint about possibly being charged for a service you did not receiveis not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe pulmonary rehabilitation visits you had from June 10, 2020, to June 30, 2020.You asked the Plan to waive the copayments forthe pulmonary rehabilitation visits. You say that no one ever told you that there would be a copayment for each visit.The Plan denied your request. The Plan says you were charged these copayments 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 $30 copayment for pulmonary rehabilitation visits. You have been asked to pay a $30 copayment for each of the pulmonary rehabilitation visits. 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 forthe pulmonary rehabilitation visits you had from June 10, 2020, to June 30, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe intraosseous radiofrequency ablation of the basivertebral nerve (Intracept Procedure) (22899)(C9752).You asked the Plan to pre-approvethis service. You say that this procedure is medically necessary for the enrollee.The Plan denied your request. The Plan says the service requested is 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 this service. Our reviewer says that this service is not medically necessary. Our physician reviewer found that the Intracept Procedure remains experimental for the treatment of low 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 this service have not been met.Therefore, we decided that the Plan does not have to pre-approvethe intraosseous radiofrequency ablation of the basivertebral nerve (Intracept Procedure) (22899) (C9752)
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe drug injection services rendered on August 20, 2020.You asked the Plan to waive the coinsurance forthese services. You say that you should not have to pay for injections.The Plan denied your request. The Plan says the coinsurance was applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for in-network preferred Medicare Part B covered drugs. Review of the file shows that you received injection services on August 20, 2020. You have been asked to pay a 20% coinsurance for these services. These services fall within the in-network preferred Medicare Part B covered 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 coinsurance forthe drug injection services rendered on August 20, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe portable oxygen concentrator rendered from January 24, 2020 to September 24, 2020.You asked the Plan to waive the coinsurance forthese services. You say that you have never had this equipment.The Plan denied your request. The Plan says the coinsurance was applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare-covered durable medical equipment. Review of the file shows that you received a portable oxygen concentrator from January 24, 2020 to September 24, 2020. The Plan confirmed that this equipment was ordered and delivered to your home. You have been asked to pay a 20% coinsurance for these services. These services fall within the Medicare-covered durable medical equipment 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 portable oxygen concentrator rendered from January 24, 2020 to September 24, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forhome health services provided to the enrollee from May 26, 2020, to July 14, 2020 and billed under code S9328.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says this code has a status code indicator of "I" which exclude payment on Medicare claims.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, this code is excluded for Medicare purposes. Medicare rules for coverage of this service have not been met.Therefore, we decided that the Plan does not have to pay forhome health services provided to the enrollee from May 26, 2020, to July 14, 2020 and billed under code S9328.