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

We decided that the Plan does not have to waive the copayment for arthrocentesis provided on November 21, 2019.
You asked the Plan to waive the copayment for arthrocentesis. You say that you feel that the hospital is overcharging. 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, including services provided at hospital outpatient facilities and ambulatory surgical centers. You have been asked to pay the allowed amount of $204.56, which is less than the $250 copayment for arthrocentesis. Arthrocentesis falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for arthrocentesis provided on November 21, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe assembly and operation of a pump with oxygenator or heat exchanger (99190) provided on December 2, 2019.You asked the Plan to pay forthe assembly and operation of a pump with oxygenator or heat exchanger. You say that this was a necessary service.The Plan denied yourrequest. The Plan says payment for this service is included in the DRG. The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule. The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of "C" on Addendum B of the 2019 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission.Therefore, we decided that the Plan does not have to pay forthe assembly and operation of a pump with oxygenator or heat exchanger (99190) provided on December 2, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a guided tissue regeneration (D4266) and a bone replacement graft for ridge preservation (D7953).You asked the Plan to pre-approve the guided tissue regeneration and bone replacement graft. You say that you need these services because you are in a lot of pain and are not able to chew with that part of your mouth.The Plan denied your request. The Plan says these services are not covered benefits.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 guided tissue regeneration (D4266) and a bone replacement graft for ridge preservation (D7953).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on October 28, 2019.You asked the Plan to pay for the pump operation and assembly. You say that you would like reconsideration because it takes 30 minutes to set up the machine and the perfusionist is required to be in the operation throughout the duration of the procedure. The Plan denied your request. The Plan says payment for this service is the responsibility of the facility to any vendor.The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pump operation and assembly have not been met. Specifically, payment for this service is included in the DRG payment to the facility. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on October 28, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation system to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the high frequency chest wall oscillation system. You say that the requested item is necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide this item. Therefore, coverage criteria has not been met.
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 a high frequency chest wall oscillation system to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for oxygen concentrator (CPT Code E1390) provided to the enrollee on October 23, 2019.You asked the Plan to pay forthe DME. You say that the claim should be paid.The Plan denied your request. The Plan says the Medicare rules have not been met.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based onthis information, we decided that Medicare rules for coverage of the DME have not been met. There is no clinical documentation of medical necessity identified and oxygen saturation levels are from 2009.Therefore, we decided that the Plan does not have to pay foroxygen concentrator (CPT Code E1390) provided to the enrollee on October 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe nursing facility care (99308) provided on May 15, 2019 by an out of network (OON) provider.You asked the Plan to pay fornursing facility care. You say that this service was medically necessary.The Plan denied your request. The Plan says this service was not authorized.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 forthe nursing facility care (99308) provided on May 15, 2019 by an out of network (OON) provider
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient care provided April 17, 2019 to
April 22, 2019.
You asked the Plan to waive the copayment for the inpatient care. You say that the copayment should be
waived. The Plan denied your request. The Plan says the correct copayment was 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). Your contract with the Plan clearly says that you must pay a $300
per day copayment for days 1 through 5 of an inpatient hospital admission.
You have been asked to pay a $1500 for 5 days of inpatient hospital care. 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 care provided April 17, 2019 to April 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full amount for the immediate surgical extractions (D7140) of teeth # 7 and 8, the complex surgical extraction (D7210) for tooth # 9, and the addition of 2 gold crown teeth to your denture (D9999) provided on October 1, 2019 by out of network provider.You asked the Plan to pay the full amount for the dental services. You say that you went through a lot of trouble trying to find an in network dentist and were unsuccessful. You say that you were unaware that there would be a financial responsibility for the extractions. You say that you cannot afford the dental services without plan coverage. You also say that the dental rider was active at the time that you received the services.The Plan denied your request. The Plan says the $100 deductible must be met before coverage for services begins. The Plan says that the provider in this case is not a network provider and therefore is subject to higher cost sharing amounts. The Plan says there is a 50% coinsurance for surgical extractions that you receive out of network. The Plan also says that you were notified prior to receiving the gold teeth that they would not be 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 and extractions are a covered service, there is a higher cost share when you receive them out of network. The record shows that the$100 deductible had not been met prior to receiving these service. The deductible and coinsurance amounts area contractual obligation you agreed to when you enrolled in the Plan's dental coverage.Additionally, the addition of gold teeth to an existing denture is not covered because it is considered cosmetic in nature.Therefore, we decided that the Plan does not have to pay the full amount for the immediate surgical extractions (D7140) of teeth # 7 and 8, the complex surgical extraction(D7210) for tooth # 9, and the addition of 2 gold crown teeth to your denture (D9999) provided on October 1, 2019 by out of network provider
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a bilobectomy (32482) and the removal all remaining lung following previous removal of a portion of lung (32488) provided on May 29, 2019.
You asked the Plan to pay for a bilobectomy and the removal all remaining lung following previous removal of a portion of lung. You say that these codes should be paid. The Plan denied your request. The Plan says these codes are not supported in the records.
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 32482 is removal of lung, other than pneumonectomy; 2 lobes (bilobectomy), and 32488 is removal of lung, other than pneumonectomy; with all remaining lung following previous removal of a portion of lung (completion pneumonectomy). 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 a bilobectomy and the removal all remaining lung following previous removal of a portion of lung. Our reviewer says that these codes are not supported. Our physician reviewer found the enrollee's past surgical history did not include prior partial pneumonectomy. The record does not support the billed codes. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a bilobectomy and the removal all remaining lung following previous removal of a portion of lung have not been met. Therefore, we decided that the Plan does not have to pay for a bilobectomy (32482) and the removal all remaining lung following previous removal of a portion of lung (32488) provided on May 29, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the clinical crown lengthening - hard tissue (D4249) provided on November 14, 2019.
You asked the Plan to pay for the clinical crown lengthening. You say that this service was absolutely necessary. You also say that this was not a cosmetic or superfluous procedure. The Plan denied your request. The Plan says this service is not covered by your 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 for the clinical crown lengthening - hard tissue (D4249) provided on November 14, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea tier exception for the Budesonide 1mg/2ml inhalation solution medication (J7626).You asked the Plan to pre-approvea tier exception. You say that you are requesting a reconsideration of the Plan's denial.The Plan denied your request. The Plan says that the drug requested is covered under the Medicare Part B (medical) benefit. Tier exceptions are only possible for certain Part D drugs. A tier exception cannot be granted for the Part B medication.The Plan must follow Medicare rules. Medicare rules say that tiered cost-sharing means a process of grouping Part D drugs into different cost sharing levels within a Part D sponsor's formulary. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a tier exception have not been met. Specifically, the record indicates that the drug at issue is being covered by the Plan under Medicare Part B. Part B drugs are not eligible for tier exceptions.Therefore, we decided that the Plan does not have to pre-approvea tier exception for the Budesonide 1mg/2ml inhalation solution medication (J7626).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for tubing used with positive airway pressure device (CPT Code A7037) provided to the enrollee on October 25, 2019.
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. The Plan says the medical records do not support this service.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. Healthcare Common Procedure
Coding System (HCPCS) code A7037 NU KX (1 Unit) remains not supported. The documentation submitted did not include an itemized shipping/billing invoice to corroborate with the proof of delivery. Therefore, the billed supply code cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information. Therefore, we decided that the Plan does not have to pay for tubing used with positive airway pressure device (CPT Code A7037) provided to the enrollee on October 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of home oxygen equipment.You asked the Plan to pre-approvecontinuation of home oxygen equipment. You say that you need oxygen and do not want to lose your oxygen machine.The Plan denied your request. The Plan says your records show your oxygen saturation level was above 90% and there are no primary care physician records within the last 12 months pertaining to your home oxygen use.The Plan must follow Medicare rules. The rules say that for patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90%, there is a rebuttable presumption of non-coverage for home oxygen.  We looked at the fileand Medicare rules. Based on this information, we decided that Medicare rules for coverage of continuation of home oxygen equipment have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinuation of home oxygen equipment.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an immunization provided on September 16, 2019.
You asked the Plan to pay for the immunization. You say that you have been to this clinic before and the services have been covered. The Plan denied your request. The Plan says you must receive your care from a network provider. In most cases, care you receive from an out-of-network provider will not be covered. If you need medical care that Medicare requires the Plan to cover and the providers in-network cannot provide this care, you can get this care from an out-of-network provider. You, or your PCP must obtain authorization from the Plan prior to seeking care.
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 services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for an immunization provided on September 16, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on August 1, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on August 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the specialist office visits provided on November 7, 2019 and November 18, 2019.
You asked the Plan to waive the copayments for the specialist office visits. You say that you say you were told there would be no charge for these visits due to being follow-up visits from surgery on October 22, 2019. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for specialist visits. You have been asked to pay a $50 copayment for each of the specialist office visits. The specialist office visits fall within the "Physician/Practitioner services, including doctor's office visits" benefit category. Please note, there is no provision in the contract which indicates a copayment would be waived if performed as a follow-up to a surgical procedure.
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 specialist office visits provided on November 7, 2019 and November 18, 2019.
Appeal type: Surgery
Decision: Partially Favorable

You asked the Plan to waive the cost-sharing for outpatient services. You say that you submitted these bills, but they have not been paid. The Plan says that the cost-sharing amounts you are being charged are correct.
We decided that the Plan has to waive the cost-sharing for the injection with code J1100 and contrast materials with code Q9967. 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 forward to us information regarding their decision to charge you these cost-sharing amounts. The Plan claims that you are being charged $0.02 cents as cost-sharing for code J1100 and $0.36 as cost-sharing for code Q9967. The Plan has not provided documentation showing the allowed amounts of these charges. Without this information, we cannot determine whether these amounts are the appropriate coinsurance amounts for these codes. Therefore, the Plan has not shown that these cost-sharing amounts are correct or justified according to the Plan contract. Therefore, we decided that the Plan has to waive the cost-sharing for injection code J1100 and contrast materials code Q9967.
We also decided that the Plan does not have to waive the cost-sharing for injection with code J3490 and surgery services.
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 injections of Medicare Part B drugs and $20 copayment for surgery services provided by a specialist. The allowed amount of the injection is $540.75, resulting in a coinsurance amount of $108.15. Your total cost-sharing obligation is therefore $128.15. Therefore, we decided that the Plan does not have to waive the cost-sharing for outpatient services. Therefore, we decided that the Plan has to reduce your total cost-sharing obligation for this claim from $128.53 to $128.15.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered to the enrollee on July 17, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 81479-59 is not supported.
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service. The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural service. Specifically, the code was billed as part of an oncology panel. Based on this information, we decided that Medicare rules for coverage of services billed with a -59 modifier have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered to the enrollee on July 17, 2019.