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

We decided that the Plan does not have to waive the cost share for the knee arthroscopy provided on November 13, 2019.You asked the Plan to waive the cost share for the knee arthroscopy. You say that it is extremely difficult to pay this copayment. You say that the cost should be reduced.The Plan denied your request. The Plan says the cost share applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that your deductible is $1,000. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost for most of your covered services.Your contract with the Plan says that after you pay your $1,000 deductible you must pay a $350 copayment for in-network, Medicare-covered outpatient surgery.The item or service you asked the Plan to waive the cost share for falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $1,000 deductible applies to outpatient surgery. This cost sharing is a contractual obligation that had not been met at the time the knee arthroscopy was received on November 13, 2019.Therefore, $1,000 has been applied to meet your deductible. Since your $1,000 deductible was met, you have also been asked to pay a $350 copayment for the knee arthroscopy. 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 cost share for the knee arthroscopy provided on November 13, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for moderate sedation services (99152 and 99153) provided on November 14, 2019.
You asked the Plan to pay for the moderate sedation services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted did not indicate the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status.
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 99152 is moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older. The CPT Code Manual definition of code 99153 is moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List separately in addition to code for primary service). We find that CPT codes 99152 and 99153 are not supported in the record. Specifically, CPT code 99152 requires the presence of an independent trained observer. The documentation submitted does not support that an independent trained observer was present. CPT code 99153 is an add-on code. Because the primary procedure was denied, CPT code 99153 is not eligible for separate payment. Additionally, this claim was submitted with place of service code 22. Payment for this service is the responsibility of the facility.
Based on this information, we decided that Medicare rules for coverage of the moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay for moderate sedation services (99152 and 99153) provided on November 14, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for spinal surgery provided on October 28, 2019 by an out of network (OON) provider.
You asked the Plan to pay for spinal surgery. You say that no one mentioned that you had to stay in-network for these services. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that there is no network deficiency for these services and alternate network providers were found.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for spinal surgery provided on October 28, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bilateral custom foot orthotics (L3000).
You asked the Plan to pre-approve the foot orthotics. You say that bilateral custom foot orthotics are necessary as you have been experiencing pain and swelling in your feet. The Plan denied your request. The Plan says that custom foot orthotics are not a covered benefit under your contractual policy for your condition.
Medicare rules state that supportive devices for the feet (such as custom foot orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although custom foot orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of custom foot orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve bilateral custom foot orthotics (L3000).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services. You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says that the plan requires you to receive care from providers who are part of your primary care physician's (PCP) specialty network. 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 contract with the Plan also says that the plan requires the enrollee to receive care from providers who are part of the enrollee's primary care physician's (PCP) specialty network. 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. We found no exception that would require the Plan to pre-approve the requested services. Therefore, we decided the Plan does not have to pre-approve physician's services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services (C1713, 20902, 73600) provided on May 9, 2019 by an out of network (OON) provider.
You asked the Plan to pay for OON surgery. You say that you were told this provider was in-network. The Plan denied your request. The Plan says these 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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. The record shows that the Plan approved OON office visits and provided notice that other services would require additional authorization. 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 surgical services (C1713, 20902, 73600) provided on May 9, 2019 by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ER visit provided on October 30, 2019.
You asked the Plan to waive the copayment for an ER visit. You say that you ended up leaving the ER and disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $110 copayment for emergency care. You have been asked to pay a $110 copayment for an ER visit. An ER visit falls within the emergency 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 an ER visit provided on October 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lab services provided on January 9, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe OON services. The Plan denied your request. The Plan says non-emergent services by non-participating providers require prior authorization.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 lab services at issue in this appeal. The Plan did not pre-approve the services at issue. We foundno exception that would require the Plan to pay for these OON services.Therefore, we decided that the Plan does not have to pay forthe lab services provided on January 9, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Computed Tomography (CT) scan of the Abdomen and Pelvis (74177).You asked the Plan to pre-approve the CT scan. You say that the CT scan is medically necessary.The Plan denied your request. The Plan says the rules for coverage have not been met.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 CT scan. Our reviewer says that a CT scan is not medically necessary. Our physician reviewer found the enrollee is believed to have exocrine pancreatic insufficiency. This diagnosis has not been confirmed by laboratory testing or a trial of appropriate therapy. The single GI note submitted does not include a GI examination. As such, the documentation is insufficient to show that a CT scan of the abdomen and pelvis is currently medically necessary and reasonable.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 CT scan have not been met.Therefore, we decided that the Plan does not have to pre-approve a Computed Tomography (CT) scan of the Abdomen and Pelvis (74177).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lab services provided to the enrollee on October 21, 2019.You asked the Plan to pay forthe services provided. The Plan denied your request. The Plan says the documentation does not support the billed services.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 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 provided. Our physician reviewer found that the tested specimen was urine. Therefore, the billing of codes indicating that testing was performed on blood or CSF is not supported.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 provided have not been met. Therefore, we decided that the Plan does not have to pay forthe lab services provided to the enrollee on October 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling and root planings (D4341) of the
lower left, lower right, upper left, and upper right quadrants.
You asked the Plan to pre-approve the four periodontal scaling and root planings. You say that the enrollee has
bleeding and bone loss. The Plan denied your request. The Plan says there is no evidence of significant bone
loss (2.5+ mm from the cement-enamel junction) and/or radiographic root surface calculus on four or more
teeth per quadrant, as required to qualify for this procedure under this 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. The Plan covers four
periodontal scaling and root planings when the services are medically necessary and reasonable.
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 four periodontal scaling and root
planings. Our reviewer says that the service is not medically necessary. Our physician reviewer found that the
periodontal charting indicated 5mm and 6mm pockets on all remaining teeth in the mouth. The provided x-rays
are bitewing type films, and show only the posterior teeth. The reviewed x-rays do reveal some bone loss on
the molar teeth and some premolar teeth, however it does not show significant bone loss on more than three
teeth per quadrant given the current views. In this case tooth #'s 2 & 3, in the upper right quadrant, and tooth
#29, in the lower right quadrant, appear to require treatment as well as tooth #'s 13, 14, & 15, in the upper left
quadrant, and tooth #20, in the lower left quadrant. Our reviewer found that there is no one quadrant seen that
appears to have four or more areas of bone loss. Our physician reviewer also found that given the limited views
from supplied x-rays, it cannot be determined there are four or more teeth in any one quadrant that require
scaling and root planing, and therefore the requested four quadrants under code D4341 would not be medically
necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of four periodontal scaling and root planings have not been met. Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planings (D4341) of the lower left, lower right, upper left, and upper right quadrants.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services (25606, 20692) and prosthetic implant (L8699) provided on November 1, 2019 by an out of network (OON) provider.You asked the Plan to pay forOON surgical services and prosthetic implant. You say that you believed you were in-network.The Plan denied your request. The Plan says these 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 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 surgical services (25606, 20692) and prosthetic implant (L8699) provided on November 1, 2019 by an out of network (OON) provider
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve panniculectomy.
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says that the notes do not show that standard medical therapy has not worked.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 surgery. Our reviewer says that the requested surgery is considered medically reasonable and necessary in this case. Our physician reviewer found based on the documentation, you have evidence of a symptomatic abdominal pannus that has failed typical dermatologic treatment with antibiotics and cream without resolution. Your symptoms of chronic rashes have been present for a year. You have complicating factors of intertrigo dermatitis for over three months, and have been refractory to usual dermatologic therapy. The photographs are supportive of your condition. 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 surgery have been met. Therefore, we decided that the Plan has to pre-approve panniculectomy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental cleaning provided on October 16, 2019.You asked the Plan to pay for the dental cleaning. You say that you were given the provider by the Plan. You say the Plan is saying the provider is not in-network. You say you would like to be reimbursed.The Plan denied your request. The Plan says the claim was reprocessed for the non-covered service and was paid according to the allowable fee for an out-of-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 dental cleaning is covered twice a year with a 50% coinsurance.The Plan is only obligated to pay 50% of the allowed amount for the dental cleaning received from out-of-network providers. The EOC clearly states that your share of the cost may be higher. Therefore, we decided that the Plan does not have to pay for the dental cleaning provided on October 16, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from October 11, 2019 to November 9, 2019.
You asked the Plan to pay for SNF care. You say that this should be covered by Medicare. The Plan denied your request. The Plan says the enrollee did not have skilled needs for the dates at issue.
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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee did not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment from October 11, 2019 through November 09, 2019.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from October 11, 2019 to November 9, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient admission for a total knee arthroplasty.
You asked the Plan to pre-approve the inpatient admission. You say that inpatient care is medically necessary. The Plan denied your request. The Plan says insufficient records were provided to support inpatient level of care.
The Plan must follow Medicare rules. Medicare rules say that the provider, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. Insufficient medical records were provided to the plan to make a coverage determination. Based on this information, we decided that Medicare rules for coverage of the inpatient admission have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient admission for a total knee arthroplasty.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe biopsy provided on November 14, 2019.You asked the Plan to waive the coinsurance forthe biopsy. You saythat this was not surgery and that this could have been done in a doctor's office. 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, accurateterms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% of the total cost for each Medicare-covered service provided in an outpatient hospital or an ambulatory surgical center, including but not limited to hospital or facility charges, observation room/stay charges, physician charges and surgical charges. You have been asked to pay a total of $233.14 for the biopsy. The biopsy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows the biopsy is considered 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 coinsurance forthe biopsy provided on November 14, 2019.