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

We decided that the Plan does not have to waive the copayment for ophthalmological services provided on October 15, 2019.
You asked the Plan to waive the copayment for ophthalmological services. You say that you should not owe a copayment for a routine eye exam. 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 $50 copayment for vision care. The medical records show that you received diagnostic ophthalmological services on October 15, 2019. Therefore, you are responsible to pay the $50 copayment. You have been asked to pay a $50 copayment for ophthalmological services. Ophthalmological services fall within the vision 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 ophthalmological services provided on October 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the ankle foot orthoses and foot inserts.You asked the Plan to pre-approve the ankle foot orthosis (L1970), ankle foot orthosis (L1930), and foot inserts (L3000). You say that your doctor requested the orthoses.The Plan denied your request. The Plan says the records do not support the medical necessity of custom fabricated orthosis.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the ankle foot orthosis (L1970), ankle foot orthosis (L1930), and foot inserts (L3000). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a diagnosis of Achilles tendonitis. The medical records do not document failure of a trial of a prefabricated splint.  The medical records provided do not meet the requirements listed in the LCD/PIM for Medicare coverage of the ankle foot orthosis (L1970), and ankle foot orthosis (L1930). We looked at this physician's review, the file, and Medicare rules.Criteria has not been met. Based on this information, we decided that Medicare rules for coverage of the ankle foot orthosis (L1970), ankle foot orthosis (L1930), and foot inserts (L3000) have not been met.Therefore, we decided that the Plan does not have to pre-approve the ankle foot orthoses and foot inserts.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the hernia repair provided on September 23, 2019.

You asked the Plan to waive the coinsurance for the hernia repair. You say that your deductible was met and this is an in-network provider. You say that the provider should accept the insurance payment as paid in full. The Plan denied your request. The Plan says the coinsurance applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for surgery performed at an in-network outpatient hospital facility.

You have been asked to pay $1,506.52, which is 20% of the allowed amount for the hernia repair. The allowed amount is $7,532.61 (20% x $7,532.61 = $1,506.52). The hernia repair 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 coinsurance for the hernia repair provided on September 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injections provided on October 9, 2019 by an out of network
(OON) provider.
You asked the Plan to pay for injections. You say that you would like this appeal reprocessed and approved for
payment. The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says
that no prior authorization was obtained.
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 injections provided on October 9, 2019 by an out
of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoperative neuromonitoring services (IONM) provided to the enrollee on August 29, 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 the services were not authorized for the out-of-network provider. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found IONM services are not readily supported for use in lumbar spine procedures. More research is needed in this case, given the conflicting evidence to date and the overarching consensus that further study is necessary to evaluate the use of IONM in lumbar spine surgery. In that regard the Medicare definition of medical necessity would not have been satisfied. 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 intraoperative neuromonitoring services (IONM) provided to the enrollee on August 29, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extractions (D7140 x 22) and the alveloloplasty in conjunction with an extraction (D7310 x 4) provided on February 19, 2019. You asked the Plan to pay for the additional 22 surgical extractions and the 4 alveoloplasty. You say that your dentist, primary care physician, and oral surgeon says that the services were necessary for your future overall physical health since recovering from 2 mini strokes. You say that you were advised that you would be required to pay a $350 co-payment for the services and the remaining amount would be covered. You also say that the Plan requested a new claim with medical codes, but the provider would not do that. The Plan denied your request. The Plan says the services you received are dental in nature. The Plan says that 2 extractions are covered per calendar year. The Plan says that the frequency limit for extractions has been exceeded. The Plan also says that alveoloplasty in conjunction with an extraction is not a covered service.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, the frequency limit of 2 per calendar year has been exceeded. The record shows that the Plan paid for 2 extractions that you received on February 19, 2019. Therefore, we decided that the Plan does not have to pay for the surgical extractions (D7140 x 22) and the alveloloplasty in conjunction with an extraction (D7310 x 4) provided on February 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual wellness exam rendered to you on October 28,
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 you exceeded the benefit for these services.
The Plan must follow Medicare rules. Medicare rules say that an annual wellness visit is covered once every 12
months.
We looked at the file and Medicare rules. The file shows that you previously had an annual wellness visit on
January 30, 2019 for with the Plan approved and paid. Based on this information, we decided that Medicare
rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to
pay for the annual wellness exam rendered to you on October 28, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for TMVI (0484T 62) provided on May 28, 2019.
You asked the Plan to pay for the TMVI. You say that the member had a procedure and was seen by two separate providers. The Plan denied your request. The Plan says that an incorrect modifier was used to represent repeated services for the same physician.
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 We find that CPT code 0484T 62 is supported in the record. Specifically, CPT code 0484T was billed with modifier 62 by two separate physicians. Modifier 62 is appropriate when the individual skills of two surgeons are required to perform surgery on the same patient during the same operative session. In this case, co-surgeons performed surgery on the same patient. The use of modifier 62 is appropriate as billed. Based on this information, we decided that Medicare rules for coverage of the TMVI have been met. Therefore, we decided that the Plan has to pay for TMVI (0484T 62) provided on May 28, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the physician services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the physician services. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The Plan states there are equally qualified in-network Dermatologists available to you that can provide the care you are requesting.
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 the physician services to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 95999 provided on March 29, 2019. You asked the Plan to pay for CPT code 95999. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says CPT code 95999 is 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 95999 is unlisted neurological or neuromuscular diagnostic procedure. We find that CPT code 95999 is not supported in the medical record. Specifically, the record shows that train of four testing was performed and this is not the appropriate code for this service. Per Medicare guidelines, it is inappropriate to bill unlisted neurological or neuromuscular diagnostic CPT codes for train of four monitoring. There is no separate code for train of four monitoring. Based on this information, we decided that Medicare rules for coverage of CPT code 95999 have not been met. Therefore, we decided that the Plan does not have to pay for CPT code 95999 provided on March 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an intravitreal injection of a pharmacologic agent (67028) provided on March 15, 2019.
You asked the Plan to pay for the injection. 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 include documentation of intravitreal injection of a pharmacologic agent (separate procedure).
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 67028 is intravitreal injection of a pharmacologic agent (separate procedure). We asked our coder 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 injection. Our reviewer says that there is no procedural documentation of an intravitreal injection being provided to the enrollee on the date of service in question. Our reviewer found the billing of CPT code 97028 is not supported. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not have to pay for an intravitreal injection of a pharmacologic agent (67028) provided on March 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on September 11, 2019.
You asked the Plan to waive the copayment for the specialist office visit. You say that you disagree with the charges and cannot afford the bill. The Plan denied your request. The Plan says the claim was reprocessed to the Tier 1 specialist office visit 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $30 copayment for each Tier 1 Medicare-covered specialist visits. The enrollee has been asked to pay a $30 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the specialist office visit provided on September 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on April 13, 2019 and May 01, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says services from non-participating providers are not covered under the plan unless they are authorized before the services are provided.
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 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 for physician's services provided on April 13, 2019 and May 01, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the physical therapy visit provided on November 14, 2019.
You asked the Plan to reduce the copayment for the physical therapy visit. You say that Supervised Exercise Therapy has a $30 copayment and you were charged a $40 copayment. 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 $40 copayment for in-network Medicare-covered physical therapy. You have been asked to pay a $40 copayment for the physical therapy visit. The physical therapy visit falls within the "Outpatient rehabilitation services" benefit category. The medical record shows you were seen for a physical therapy evaluation.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the copayment for the physical therapy visit provided on November 14, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for ERCP (43264) provided on April 25, 2019.
You asked the Plan to pay for the ERCP. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says it is common to remove calculi/debris when placing or removing a stent, removing a foreign body or performing a sphincterotomy; therefore, this procedure should not be reported separately.
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 43264 is endoscopic retrograde cholangiopancreatography (ERCP); with removal of calculi/debris from biliary/pancreatic duct(s). We asked our coder 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 ERCP. Our reviewer says that there is no documentation that excessive amounts of sludge/debris were removed in preparation for placement of the stent. Our reviewer found removal of a small amount of sludge/debris would be considered part of the stent placement (CPT 43274). We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ERCP have not been met. Therefore, we decided that the Plan does not have to pay for ERCP (43264) provided on April 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis provided on October 21, 2019.
You asked the Plan to pay for the prophylaxis. You say that you believed that since you received no statements that payments were made in full to the clinic. You also say that when you checked out of the appointment you were informed that there was an outstanding bill. The Plan denied your request. The Plan says the benefits for this service had been satisfied and the frequency limitation had 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, prophylaxis (cleaning) is limited to one procedure per calendar year. The record shows that you received a prophylaxis on April 8, 2019 and your prophylaxis benefit was then exhausted. Therefore, we decided that the Plan does not have to pay for the prophylaxis provided on October 21, 2019.
Your complaint about not being satisfied with your dental plan 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 waive the copayment for the inpatient hospital care provided on November 22, 2019.
You asked the Plan to waive the copayment. You say that you should not be responsible for the copayment as you did not receive the services that you were scheduled for. The Plan denied your request. The Plan says that you are responsible for a $325 copayment for the inpatient hospital care provided as you received inpatient surgery to repair a laceration on your posterior oropharynx. The copayment has been applied correctly according to the structure of your benefit policy.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 copayment per day, for days 1-5 for inpatient hospital care. You have been asked to pay a $325 copayment ($325 x 1 day) 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 copayment for the inpatient hospital care provided on November 22, 2019.