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

We decided that the Plan does not have to waive the copayments for the intravenous infusions provided from
September 3, 2020, to September 9, 2020.
You asked the Plan to waive the copayments for the intravenous infusions. You say that you say the hospital is
in-network. 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 $370
copayment for Medicare-covered surgery or other services provided to you at an out-of-network outpatient
hospital, including but not limited to hospital or other facility charges and physician or surgical charges. For
each date of service, you have been asked to pay the allowed amount of the claim because these amounts are
less than the $370 copayment for intravenous infusions in an outpatient hospital.
You have been asked to pay a $175.50 copayment for the intravenous infusion on each date of service.
($175.50 x 7 dates of service = $1,228.50). The intravenous infusions fall within the "Outpatient Surgery and
Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Center" benefit
category. The record shows this hospital is out-of-network. 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 intravenous infusions provided from September 3, 2020, to September 9, 2020.
Your complaint about the misundering between insurance members and the insurance company 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee has made exceptional gains while in the
current facility, and would be a great candidate to get intense, inpatient rehab in order to return home
independently. The Plan denied your request. The Plan says IRF care is not medically necessary. The Plan says
that the enrollee can safely receive the services needed in another setting.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.

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 IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
was admitted for seizure, respiratory failure and bacteremia. The enrollee's medical conditions are stable. There
are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational
therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for
physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There
is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the
intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the psychiatric diagnostic evaluations with medical services (90792-PO) provided from October 2, 2019, through December 18, 2019.
You asked the Plan to waive the copayment for psychiatric diagnostic evaluations with medical services. You say that you did not know you would have to pay a copayment. 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 $35 copayment for outpatient mental health care. You have been asked to pay a $35 copayment for psychiatric diagnostic evaluations with medical services. The services at issue fall within the outpatient mental health 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 psychiatric diagnostic evaluations with medical services (90792-PO) provided from October 2, 2019, through December 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit rendered on September 16, 2020.
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 the services are not separately payable.
The Plan must follow Medicare rules. The rules say that post-operative visits are included in the global surgical package. We looked at the file and Medicare rules. The file shows that the office visit was provided within the 10 day global surgical period of the minor surgical procedure performed on September 8, 2020. Payment for these services is included in the global surgical payment. The Plan confirmed that you have a $0 member responsibility for these services. Therefore, we decided that the Plan does not have to pay for the office visit rendered on September 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug screening (80372 and 80373).

You asked the Plan to pay for the drug screening. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says these codes are not paid under OPPS.

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 CPT codes 80372 and 80373 are not supported in the record. Specifically, CPT codes 80372 and
80373 and a status indicator of B. This means that these codes are not recognized under OPPS. Based on this
information, we decided that Medicare rules for coverage of the drug screening have not been met. Therefore,
we decided that the Plan does not have to pay for the drug screening (80372 and 80373).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on November 5, 2020.
You asked the Plan to pay for the dental service. You say that you did receive or had been told about the benefit of dental cleaning once every 6 months. You say that the provider did not advise member of benefit once every 6 months. The Plan denied your request. The Plan says cleanings are covered once every 6 months. The Plan also says that the frequency limit has been exceeded.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the frequency limit has been exceeded. The record shows that the Plan paid for periodontal maintenance that you received on June 10, 2020, less than 6 months prior. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on November 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the rest home visit (99334) provided on June 19, 2020, by an
out-of-network (OON) provider.
You asked the Plan to pay for an OON rest home visit. You say that it is the facility's responsibility to obtain
authorization. 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 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 the rest home visit (99334) provided on June 19,
2020, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture services provided on July 30, 2020.
You asked the Plan to pay for the acupuncture services. You say that the Plan should pay this claim. The Plan denied your request. The Plan says records do not document the auxiliary provider was under the supervision of a physician, PA or NP/CNS.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the services were not provided by a physician licensed to perform the service or supervised auxiliary personnel. Therefore, we decided that the Plan does not have to pay for acupuncture services provided on July 30, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the denosumab injection and its
administration.

You asked the Plan to waive the coinsurance for the injection and its administration. You say that you have
never had to pay coinsurance for this drug and its administration before. The Plan denied your request. The
Plan says the requested item/service requires a 20% coinsurance; therefore, the correct cost share amount 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 20%
coinsurance for Part B drugs.

The total cost of the drug and its administration was $1,135.49. You have been asked to pay a $227.10 in
coinsurance amounts for the injection and its administration (20% of $1,135.49 = $227.10). The injection and
its administration fall within the Part B 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
for the denosumab injection and its administration.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the recumbent bike purchased on August 20, 2020.
You asked the Plan to reimburse you for the recumbent bike. You say that even though you purchased the bike before October 1, 2020, the purchase was based on the same rationale as the Plan's. The Plan denied your request. The Plan says only purchased made from October 1, 2020, through December 31, 2020 are eligible for reimbursement.
The rules say that Medicare does not cover exercise equipment. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covered exercise equipment towards the 2020 Wellness Allowance for purchases made from October 1, 2020, through December 31, 2020. The Plan's rules for coverage of exercise equipment have not been met because the purchase was made before the start date of the benefit. Therefore, we decided that the Plan does not have to reimburse you for the recumbent bike purchased on August 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction rendered on October 8, 2020.
You asked the Plan to pay for these services. You say that you should have coverage. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we decided that the Plan does not have to pay for the eye refraction rendered on October 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the tendon sheath incision (26055) billed with
modifier 80-F2-F4.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says this service is not covered when provided by assistants at surgery, co-surgeons, or a surgical team.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Additionally, procedures billed with the assistant-at-surgery physician modifiers -80, -81, -82, or the AS modifier for physician assistants, nurse practitioners and clinical nurse specialists, are subject to the assistant-at-surgery policy.

We find that CPT code 26055 billed with modifier 80-F2-F4 is not supported in the medical record. Specifically, Medicare rules say there is a statutory payment restriction for this service when provided by assistants at surgery. 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 pay for the tendon sheath incision (26055) billed with modifier 80-F2-F4.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiovascular monitoring services provided on November 29, 2018.
You asked the Plan to pay for the cardiovascular monitoring 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 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 cardiovascular monitoring services provided on November 29, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed.
You asked the Plan to pre-approve the bed. You say that this is medically necessary. The Plan denied your request. The Plan says the request for this bed does not meet the criteria.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient: 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. Requires attachments which can only be attached to a hospital bed; AND 3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 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 bed. Our reviewer says that the requested bed is not medically reasonable or necessary. Our physician reviewer found the documentation does not clearly reveal that your condition has failed positioning of the bed in ways not feasible in an ordinary bed or why positioning of the bed in other ways is not feasible. The documentation does not support a need for an immediate or frequent change in body position or special attachments that cannot be fixed on an ordinary bed. The request for a semi-electric hospital bed is not medically necessary. 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 bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (14041, 14060) provided September 22, 2020.
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The Plan denied your request. The Plan says documentation does not support the services billed.
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 codes 14041, & 14060 are Adjacent tissue transfer or rearrangement, forehead,cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet, defect 10 sq cm or less, and Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet, defect 10.1 sq cm to 30 sq cm. We find that CPT codes 14041, & 14060 are not supported in the medical record. Specifically, the operative report does not document Adjacent tissue transfer or rearrangement was performed. Based on this information, we decided that Medicare rules for coverage of the surgical services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (14041, 14060) provided September 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1852) and the shoulder elbow wrist hand
orthosis (L3960) provided on April 28, 2020.
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the documentation submitted did not indicate
the provider discussed the need for the billed supply codes; therefore, the billed supply codes cannot be
verified.
The Plan must follow Medicare rules. Medicare rules say that for any DMEPOS item to be covered by
Medicare, the patient's medical record must contain sufficient documentation of the patient's medical condition
to substantiate the necessity for the type and quantity of items ordered and for the frequency of use or
replacement.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of these items have not been met. Specifically, the patient's medical record does not contain sufficient
documentation of their medical condition, as there was no documentation provided by the ordering physician.
Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1852) and the shoulder elbow
wrist hand orthosis (L3960) provided on April 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services (85027) performed on October 28, 2020.
You asked the Plan to waive the copayment for the lab test. You say that this lab was performed as part of your annual physical and should therefore be covered. The Plan denied your request. The Plan says there was no copayment for the physical, but a lab is a separate service that has a $5 copayment.
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 $5 copayment for laboratory tests. You have been asked to pay a $5 copayment for a lab test. You say that the lab services were provided as part of your annual physical and should be covered. However, lab tests are not included in an annual physical exam. A list of covered services can be found in your Plan's contract. If you receive services outside of those which are included, additional cost-share may apply. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for laboratory services (85027) performed on October 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit.

You asked the Plan to waive the copayment for the urgent care visit. You say that you should not be charged because they did nothing but look at your wound and refer you to the emergency room. 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 $35 copayment for each Medicare-covered urgently needed care visit.

You have been asked to pay a $35 copayment for the urgent care visit. The urgent care visit falls within the "Urgently needed services" benefit category. The medical record shows you had a physical exam at the urgent care center. 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 urgent care visit.