Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for limited oral exam (D0140) provided on December 6, 2019.You asked the Plan to pay for the dental services. You say that you are not able to afford the financial responsibility.The Plan denied your request. The Plan says enrollee's must receive their dental services from an in network provider.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 when rendered by an out of network dental provider.Therefore, we decided that the Plan does not have to pay for limited oral exam (D0140) provided on December 6, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forCPT code G0483 provided on September 25, 2019.You asked the Plan to pay forCPT code G0483. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not supported.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 G0483 is Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed.We find that CPT code G0483 is not supported in the medical record. Specifically, the record does not contain evidence that definitive testing on 22 or more drug classes was performed. Based on this information, we decided that Medicare rules for coverage of CPT code G0483 have not been met.Therefore, we decided that the Plan does not have to pay forCPT code G0483 provided on September 25, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for neurosurgery services (CPT 92585) provided to the enrollee on November 4, 2019.You asked the Plan to pay forthe services. You say that this should be paid for.The Plan denied your request. The Plan says Current Procedural Terminology (CPT) code 92585-26 (1 unit) remains not supported.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 92585 is "Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; comprehensive."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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found to report a comprehensive auditory evoked response exam (CPT 92585, Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; comprehensive), the documentation should include measurement of middle latency and late cortical responses, and evaluation of brainstem response. The documentation does not support that a comprehensive auditory evoked response examination was performed in this case.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 not been met.Therefore, we decided that the Plan does not have to pay for neurosurgery services (CPT 92585) provided to the enrollee on November 4, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (HCPCS G0483) provided to the enrollee on December 13, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Healthcare Common Procedure Coding System (HCPCS) G0483 (1 Unit) remains not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. Medicare rules say that a physician order must be present for labs to be covered. We find that HCPCS code G0483 is not supported in the medical record. Specifically, the documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were to be performed. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing services (HCPCS G0483) provided to the enrollee on December 13, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe skilled nursing facility (SNF) services rendered from July 1, 2019 to August 31, 2019.You asked the Plan to waive the copayments forthese services. You say that you disagree 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 $0 copayment per day for days 1-20 anda $172 copayment per day for days 21-100 for in-network SNF care. Review of the file shows that you received SNF services from July 1, 2019 to August 31, 2019. You were not assessed a copayment for your date of discharge on August 31, 2019. You have been asked to pay a $172 copayment per day for the services rendered from July 1, 2019 to July 31, 2019 for a total of $3,612. These services fall within the in-network SNF 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. The file shows that you received SNF services from August 1, 2019 to August 31, 2019. Per your contract with the Plan, there is a $0 copayment per day for days 1-20 and a $172 copayment per day for days 21-100 for in-network SNF care. However, you have been asked to pay $295.83 for these services. These services fall within the in-network SNF care benefit category. This meansthat 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 skilled nursing facility (SNF) services rendered from July 1, 2019 to August 31, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided by a participating provider on December 30, 2019 and January 3, 2020.You asked the Plan to waive the copayment for physical therapy. You say that follow up appointments should not have a copayment. The Plan denied your request. The Plan says the correct copayments have 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). Your contract with the Plan clearly says that you must pay a $30 copayment for outpatient rehabilitation services/in-network. You have been asked to pay a $30 copayment for physical therapy. The total amount you are being asked to pay is $60 ($30 x 2 visits = $60). Physical therapy falls within the outpatient rehabilitation services/in-network 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 physical therapy provided by a participating provider on December 30, 2019 and January 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copaymentfor the inpatient hospital care provided April 6, 2019 to April 8, 2019.You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial.The Plan denied your request. The Plan says that the copayment was applied correctly to the inpatient hospital care provided.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 per day,for days 1-5for each inpatient hospital admission. You have been asked to pay a $740 copayment ($370 x2 days) for 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 copaymentfor the inpatient hospital care provided April 6, 2019 to April 8, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided on August 21, 2018.You asked the Plan to waive the copayment for a CT scan. You say that you cannot afford 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 $205 copayment for diagnostic tests including CT scans. You have been asked to pay a $205 copayment for a CT scan. A CT scan 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 a CT scan provided on August 21, 2018.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the enrollee from October 26, 2019 to November 13, 2019.
You asked the Plan to pay for the services. You say that this office is authorized to pursue a claim for Medicare coverage of these services. The Plan denied your request. The Plan says medical necessity cannot be established for continued stay at the skilled nursing facility beginning 10/26/2019 through and including 11/13/2019.
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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there were no identifiable skilled nursing service needs. There were no identifiable skilled therapy service needs. The enrollee did not require skilled nursing or therapy services on a daily basis. The enrollee did 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 services have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the enrollee from October 26, 2019 to November 13, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the occupational therapy visits provided from November 7, 2019 to November 8, 2019.
You asked the Plan to waive the copayments for the occupational therapy visits. You say that you should not be charged for the therapy. 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 $30 copayment per therapy type, per provider, per day for in-network rehabilitation services. You have been asked to pay a $30 copayment for each of the occupational therapy visits. The occupational therapy visits fall within the "Outpatient rehabilitation 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 copayments for the occupational therapy visits provided from November 7, 2019 to November 8, 2019.
Your complaint that you did not want any occupational therapy services is 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ankle foot orthosis (L1940KX-LT-59, L1940KX-RT), soft interface for molded plastic -below knee section (L2820KX-LT-59, L2820KX-RT), lacer molded to patient model (L2330KX-LT-59, L2330KX-RT), and molded inner boot (L2280KX-LT-59, L2280KX-RT) provided from June 26, 2019 to July 31, 2019 by the provider.You asked the Plan to waive the copayment forthe ankle foot orthosis, soft interface for molded plastic -below knee section, lacer molded to patient model, and molded inner boot. You say that you were under the impression you would not be responsible for any charges.The Plan denied your request. The Plan says based on Medicare billing criteria, the claims were billed 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 DME. You have been asked to pay $689.42 for the ankle foot orthosis, soft interface for molded plastic, below knee section, lacer molded to patient model, and molded inner boot. 20% coinsurance for the DME equals $689.42. 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 ankle foot orthosis (L1940KX-LT-59, L1940KX-RT), soft interface for molded plastic -below knee section (L2820KX-LT-59, L2820KX-RT), lacer molded to patient model (L2330KX-LT-59, L2330KX-RT), and molded inner boot (L2280KX-LT-59, L2280KX-RT) provided from June 26, 2019 to July 31, 2019 by the provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe inpatient hospital stay provided from January 9, 2020 to January 15, 2020.You asked the Plan to waive the copayment forthe inpatient stay. You say that this was very expensive and you have never had to pay bills that were this expensive on your previous insurance. 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 $150 copayment per day for days 1 through 5 for inpatient hospital care. You have been asked to pay a $150 copayment for each day, days 1 to 5 of the inpatient stay. ($150 x 5 = $750). The inpatient stay falls 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 forthe inpatient hospital stay provided from January 9, 2020 to January 15, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT scan of the abdomen for the enrollee.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says CT scan of the abdomen is not medically indicated for a inguinal hernia.
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 scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found the enrollee has a negative abdominal physical exam with no sign of bowel obstruction, gangrene, or abnormal bowel sounds. The CT of the pelvis which has been approved will be sufficient to diagnose the problem or rule out left inguinal hernia. There is no clinical indication offered for CT of the abdomen to be appropriate. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the scan have not been met. Therefore, we decided that the Plan does not have to pre-approve CT scan of the abdomen for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe Botox injection provided on September 30, 2019.You asked the Plan to waive the coinsurance forthe injection. The Plan denied your request. The Plan says that coinsurance is a financial obligation and cannot be waived.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles andcoinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for each Medicare-covered Part B drug. You have been asked to pay a 20% coinsurance for the injection. The injection falls within the Medicare-covered Part B drugbenefit 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 doesnot have to waive the coinsurance forthe Botox injection provided on September 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan doesnot have to pay forexcision of benign lesion (D7410) and consultation, other than requesting dentist (D9310) provided October 23, 2019.You asked the Plan to pay forthe dental services. You say that the provider had called to confirm that the services would be covered and you were assured it would be.The Plan denied your request. The Plan says the 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. Services not listed as a covered serice is not covered by the plan.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or servicesare not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forexcision of benign lesion (D7410) and consultation, other than requesting dentist (D9310) provided October 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fornurse practitioner services provided on December 29, 2019.You asked the Plan to pay forout of network services. You say that you have gone to this clinic before and not gotten a bill.The Plan denied your request. The Plan says you did not have prior authorization for out of network 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 provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide theservices at issue in this appeal. The Plan did not pre-approve the service 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 fornurse practitioner services provided on December 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the rest home visits provided on December 13, 2019 to December 19, 2019 by an out of network (OON) provider.You asked the Plan to pay for the rest home visits. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services rendered are not a covered benefit.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 rest home visits provided on December 13, 2019 to December 19, 2019 by an out of network (OON) provider.