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

We decided that the Plan does not have to waive the copayment for therapeutic phlebotomy provided on December 4, 2020.
You asked the Plan to waive the copayment for therapeutic phlebotomy. You say that you disagree with the denial of 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 $370 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities. You received therapeutic phlebotomy on December 4, 2020, at an outpatient hospital facility. Therefore, you are responsible to pay $94.41, which is less than the $370 copayment. You have been asked to pay $94.41 for therapeutic phlebotomy. Therapeutic phlebotomy falls within the
outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for therapeutic phlebotomy provided on December 4, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the complete ultrasound study of arm and leg arteries provided on March 24, 2021.
You asked the Plan to waive the copayment for the complete ultrasound study of arm and leg arteries. You say that you should only owe a $20 copayment for non-radiological procedures and tests. 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 $110 copayment for ultrasounds. You have been asked to pay a $110 copayment the complete ultrasound study of arm and leg arteries. The complete ultrasound study of arm and leg arteries 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 the complete ultrasound study of arm and leg arteries provided on March 24, 2021.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the services (93308, 93325) provided on March 16, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that this is a column two code and is not payable.
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 argues that codes 93308 and 93325 are column two codes to column one code 33361. The records provided do not show that code 33361 was billed on the date of service in question. Without supporting documentation, the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the services (93308, 93325) provided on March 16, 2021.
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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit (99285) provided on September 26, 2020.
You asked the Plan to pay for the evaluation and management service. You say that the services that were provided were not related to the enrollee's hospice diagnosis. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it
is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the emergency department visit (99285) provided on September 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an intraoral periapical radiographic image (D0230) provided on April 28, 2021.
You asked the Plan to pay for an intraoral periapical radiographic image. You say that the service should be covered. The Plan denied your request. The Plan says the service is a covered benefit, but you have exceeded the frequency limit of one every calendar year.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of an intraoral periapical radiographic image have not been met. Specifically, the record shows that you had exceeded the frequency limit for this service. Therefore, we decided that the Plan does not have to pay for an intraoral periapical radiographic image (D0230) provided on April 28, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy with an out-of-network provider.
You asked the Plan to pre-approve out-of-network physical therapy. You say that you have been going to this provider for a number of years and did not know it wasn't in-network. You say that you want to continue seeing this provider. The Plan denied your request. The Plan says in-network providers are available.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve physical therapy with an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the screening (D0190) provided on March 30, 2021.
You asked the Plan to pay for the screening. You say that you need a bridge in your upper jaw, and you need a dental cleaning of tartar which was denied. The Plan denied your request. The Plan says this service is not covered.
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 screening (D0190) provided on March 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve positron emission tomography (PET) of the brain.
You asked the Plan to pre-approve PET of the brain. You say that the requested PET scan is medically necessary. The Plan denied your request. The Plan says the records do not show that the enrollee meets the criteria for the requested PET scan. The Plan says that the records do not show that the enrollee noted a problem with thinking and reasoning processes that has declined for at least 6 months.
The Plan must follow Medicare rules. Medicare rules say that PET 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 PET of the brain. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the case file does not contain documentation of a comprehensive clinical evaluation, and a physical and mental status examination, aided by cognitive scales or neuropsychological testing. It is not documented that the enrollee has had cognitive decline of at least 6 months. It has not been demonstrated that the enrollee meets diagnostic criteria for both Alzheimer's disease and fronto-temporal dementia.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of PET of the brain have not been met. Therefore, we decided that the Plan does not have to pre-approve positron emission tomography (PET) of the brain.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the infectious agent detections by nucleic acid (U0003 and U0005) provided on January 12, 2021.
You asked the Plan to pay for the infectious agent detections. You say that you would like this claim to be reprocessed for payment. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the infectious agent detections by nucleic acid (U0003 and U0005) provided on January 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a removal of torus mandibularis (D7473), first 15 minutes of deep sedation/general anesthesia (D9222), and each subsequent 15-minute increment of deep sedation/general anesthesia (D9223).
You asked the Plan to pre-approve the removal of torus mandibularis and deep sedation/general anesthesia services. You say that without this procedure you cannot have the partial dentures done that you need. The Plan denied your request. The Plan says these services are not covered.
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 pre-approve a removal of torus mandibularis (D7473), first 15 minutes of deep sedation/general anesthesia (D9222), and each subsequent 15-minute increment of deep sedation/general anesthesia (D9223).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for fluoroscopic guidance and does not have to waive the coinsurance for Medicare Part B drugs provided from August 27, 2020, to September 9, 2020.
You asked the Plan to waive the copayments for fluoroscopic guidance and to waive the coinsurance for Medicare Part B drugs. You say that you cannot afford the charges and the injections help you to be able to walk. 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 $160 copayment for radiological diagnostic services. Your contract with the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs. You received fluoroscopic guidance and Medicare Part B drugs from August 27, 2020, to September 9, 2020. Therefore, you are responsible to pay your share of the cost-sharing charges. Please see the chart below.
Date of Service
Service
Allowed Amount
Amount You Owe
9/9/2020
77002
$104.55
$104.55
8/27.2020
77002
$104.55
$104.55
9/3/2020
77002
$104.55
$104.55
9/3/2020
J7332
$1,007.20
$201.44
The total amount you owe is: $515.09. You have been asked to pay the total amount of $515.09 for fluoroscopic guidance and Medicare Part B drugs. Fluoroscopic guidance falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. Medicare Part B 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 copayments for fluoroscopic guidance and does not have to waive the coinsurance for Medicare Part B drugs provided from August 27, 2020, to September 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an orthopedic surgeon.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says the primary care provider (PCP) is in disagreement with this request.
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 referral. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found detailed documentation is not evident regarding any significant orthopedic findings that would require specialized care from an orthopedic surgeon. There is no evidence that she has been recently examined by her primary care physician and/or that initial conservative management has been attempted. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. 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 referral have not been met. Therefore, we decided that the Plan does not have to pre-approve a referral to an orthopedic surgeon
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for pathology tests provided on February 16, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for pathology tests. You say that your lab performed all the tests that were ordered by the referring physician. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that there are in-network providers available for 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 had network providers available who could have provided 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 pathology tests provided on February 16, 2021 by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid for Coronavirus (U0003 and U0005) provided on January 5, 2021.
You asked the Plan to pay for the infectious agent detection. You say that you would like this claim to be reprocessed for payment. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the infectious agent detection by nucleic acid for Coronavirus (U0003 and U0005) provided on January 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from January 22, 2021, through January 25, 2021.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you do not agree with the charges. The Plan denied your request. The Plan says the copayment 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 $325 copayment for days 1 to 6 for inpatient hospital care. You have been asked to pay a $325 copayment for days 1 to 6 for inpatient hospital care. The services at issue fall within the inpatient hospital 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 inpatient hospital care from January 22, 2021, through January 25, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the injections, medical surgical supplies and implantable mesh provided on November 16, 2018.
You asked the Plan to waive the coinsurance for the injections, medical surgical supplies and implantable mesh. You say that you paid your $195 copayment and were not explained why you had to pay the additional bill. 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 each Medicare-covered Part B drug and 20% coinsurance for each Medicare-covered medical supply.
You have been asked to pay a total of $549.56 for the injections, medical surgical supplies and implantable mesh.
Service
Allowed Amount
Coinsurance
Member Liability
Dexamethasone Sodium Phosphate Injection
$18.75
20%
$3.75
Lidocaine Injection
$18.75
20%
$3.75
Ondansetron Hydrochloride Injection
$18.75
20%
$3.75
Propofol Injection
$43.13
20%
$8.63
Fentanyl Citrate Injection
$22.50
20%
$4.50
Medical Surgical Supplies
$2197.91
20%
$439.58
Implantable Mesh
$428
20%
$85.60
TOTAL:
$549.56
The injections fall within the "Medicare Part B Prescription Drugs" benefit category. The medical surgical supplies and implantable mesh fall 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 for the injections, medical surgical supplies and implantable mesh provided on November 16, 2018.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the thyroidectomy procedure you had on March 29, 2021 and the physical therapy (PT) evaluation you had on March 31, 2021.
You asked the Plan to waive the copayments for the thyroidectomy and PT evaluation. You say that you paid your copay before being admitted for surgery. 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 $125 copayment for surgery services in an outpatient hospital facility and a $35 copayment for PT services. You have been asked to pay a $125 copayment for the thyroidectomy and a $35 copayment for the PT
evaluation. Records show that you only paid $120 when you had surgery, but your total copayment obligation is $160 ($125 for the surgery and $35 for the PT evaluation.) This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the thyroidectomy procedure you had on March 29, 2021 and the physical therapy (PT) evaluation you had on March 31, 2021.