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

We decided that the Plan does not have to pre-approve lower spine fusion.
You asked the Plan to pre-approve the fusion. You say that this is medically necessary. The Plan denied your request. The Plan says there was no documentation of conservative measures.
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 fusion. Our reviewer says that the requested fusion is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of a recent and adequate trial of conservative measures to include PT. There are no red flags for spinal surgery. 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 fusion have not been met. Therefore, we decided that the Plan does not have to pre-approve lower spine fusion.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital discharge day management; more than 30 minutes
(CPT Code 99239) provided to the enrollee on October 2, 2018.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your
request. The Plan says the medical records do not support this service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT code 99239 is not supported in the medical record. Specifically, Current Procedural
Terminology (CPT) code 99239 remains not supported. This service represents a hospital discharge day
management of more than 30 minutes. The documentation submitted does not indicate time spent on discharge
services. The documentation does not support the reported procedure 99239. The correct Current Procedure
Terminology (CPT) code 99238 should have been reported. This service represents a hospital discharge day
management service of 30 minutes or less. It is noted that multiple attempts were made to contact the provider
for additional information. 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 hospital discharge day
management; more than 30 minutes (CPT Code 99239) provided to the enrollee on October 2, 2018.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the outpatient surgery services provided from December 3, 2019 to December 4, 2019.You asked the Plan to waive the coinsurance for the outpatient surgery services. You say that you would like the Plan to reconsider your request.The Plan denied your request. The Plan says you received outpatient surgery services on the dates of service at issue in this appeal. The Plan states the correct coinsurance has applied per your contract with the Plan.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 Outpatient hospital services. We looked at the file, the Plan's contract and Medicare rules. The file shows you received outpatient surgery services in an outpatient hospital facility from December 3, 2019 to December 4, 2019. You have been asked to pay a 20% coinsurance for the outpatient surgery, totaling $2473.83. The outpatient surgery falls within the Outpatient hospital 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 coinsurance for the outpatient surgery services provided from December 3, 2019 to December 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 28, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says nonemergent,
non-urgent services with out-of-network 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 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 physician's services provided on October 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the non-radiological testing and specialist visit provided on September 6, 2019.
You asked the Plan to waive the cost share for the non-radiological testing and specialist visit. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received non-radiological testing and a specialist visit provided on the date of service at issue in this appeal. The Plan says that the correct cost share has applied per your contract with the Plan.
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 Medicare-covered non-radiological diagnostic services and a $50 copayment for services obtained from a specialist. We looked at the file, the Plan's contract and Medicare rules. The file shows you received non-radiological testing and an office visit provided by a specialist on September 6, 2019. You have been asked to pay a 20% coinsurance for the non-radiological testing, totaling $39.40 for CPT code 95886 and $63.37 for CPT code 95913. The non-radiological services fall within the Outpatient diagnostic tests benefit category. You have been asked to pay a $50 copayment for the specialist visit. The specialist visit falls within the Physician/Practitioner services benefit category. This means that you have been asked to pay the correct amounts 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 non-radiological testing and specialist visit provided on September 6, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the bitewings provided on January 16, 2020.You asked the Plan to pay for the bitewings. You say that your Plan's benefit book says that x-rays are covered once every 3 years. You also say that it is strange that the Plan would pay for an unnecessary full set but deny a partial set.The Plan denied your request. The Plan says that this service is not a covered benefit.The rules say a plan must disclose to its enrollees in clear, accurate terms all of the benefits offered under the Plan. Your contract with the Plan does not say in clear and accurate terms what bitewings are covered. We looked at your contract with the Plan. The contract says that complete series of intraoral x-rays including bitewing images are a covered benefit. We did not see where the contract says that only certain bitewing images are covered or that bitewing x-rays are not covered. You reasonably believed that bitewing x-rays were covered according to your plan contract.Therefore, we decided that the Plan has to pay for the bitewings provided on January 16, 2020.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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the DME provided from August 23, 2019 through September 23, 2019.
You asked the Plan to waive the coinsurance for the DME. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received the DME provided from August 23, 2019 through September 23, 2019. You are asked to pay 20% coinsurance for the DME. 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 DME provided from August 23, 2019 through September 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CardioMEMS. You asked the Plan to pre-approve CardioMEMS. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 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 CardioMEMS. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee had NYSHA Class III congestive heart failure with preserved ejection fraction (LVEF 50%) requiring hospitalization. A CardioMEMs device has been demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results. The efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure. Therefore, the requested device is still considered experimental or investigational. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CardioMEMS have not been met. Therefore, we decided that the Plan does not have to pre-approve CardioMEMS.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 26, 2019 by an out of
network (OON) provider.
You asked the Plan to pay for the OON services. You say that the enrollee has been regularly receiving care for
over 14 years. The Plan denied your request. The Plan says the services were not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at
issue. We found no exception that would require the Plan to pay for these OON services. Therefore, we decided
that the Plan does not have to pay for the medical services provided on June 26, 2019 by an out of network
(OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the resin-based composite provided on November 25, 2019.You asked the Plan to pay more for the resin-based composite. You say that your dental issues are due to extensive radiation treatments. You also say that this should be processed under your medical benefits and not dental.The Plan denied your request. The Plan says this claim was processed and paid correctly.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 Plan offers an annual maximum benefit of $600 every year for Medicare-covered dental services. The contract says that you are responsible for any amount above the coverage limit. The record shows that you met the annual maximum benefit on November 25, 2019 and your annual maximum benefit had been exhausted.Therefore, we decided that the Plan does not have to pay more for the resin-based composite provided on November 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an automatic blood pressure monitor (A4670).
You asked the Plan to pre-approve an automatic blood pressure monitor. You say that the item is necessary.
The Plan denied your request. The Plan says the item is not primarily medical in nature. Therefore, coverage
criteria has not been met.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pre-approve an automatic blood pressure monitor (A4670).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the lumbar spine fusion and outpatient
therapy provided from November 7, 2019 through November 8, 2019.
You asked the Plan to waive the copayment for the lumbar spine fusion and outpatient therapy. You say that
your copayment is $295 but the hospital says you owe $345. You say that you cannot afford the bills. The Plan
denied your request. The Plan says the copayments 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 $275
copayment for Medicare-covered surgery or other services provided to you at an in-network, outpatient
hospital, including but not limited to hospital or other facility charges and physician or surgical charges, a $35
copayment for each in-network, Medicare-covered physical therapy visit and a $35 copayment for each innetwork,
Medicare-covered occupational therapy visit.
You have been asked to pay a total of $345 for the lumbar spine fusion and outpatient therapy.
The lumbar spine fusion falls within the "Outpatient surgery, including services provided at hospital outpatient
facilities and ambulatory surgical centers" benefit category. The outpatient therapy falls within the "Outpatient
Rehabilitation Service" 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 the lumbar
spine fusion and outpatient therapy provided from November 7, 2019 through November 8, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided July 21, 2018.You asked the Plan to pay for ambulance response and treatment, no transport. You say that having been treated at the residence, the enrollee declined the ambulance transport and further costly emergency room treatment. It is reasonable that this incident be covered in full by the plan.The Plan denied your request. The Plan says this service is not covered by Medicare or the Plan.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on July 21, 2018. The ambulance benefit is a transportation benefit.When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided July 21, 2018.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an Ambulance Transport (A0429, A0425)
provided November 27, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that the copayment should be
waived. The Plan denied your request. The Plan says the correct copayment was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150
copayment for Ambulance Services.
You have been asked to pay a $150 copayment for the ambulance transport. The ambulance transport falls
within the Ambulance 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 copayment for
an Ambulance Transport (A0429, A0425) provided November 27, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on October 5, 2018.
You asked the Plan to pay for the ambulance services. You say that you were injured and not coherent enough to make any decisions. The Plan denied your request. The Plan says the ambulance benefit is a transport benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on October 5, 2018. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. When multiple ambulance providers and suppliers respond, payment is made only to the provider that transports. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on October 5, 2018.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided to the enrollee from July 5, 2019 to July 6, 2019.
You asked the Plan to pay for inpatient hospital care. You say that the claim should be paid. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required.
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 inpatient hospital care. Our physician reviewer found the review has determined that the enrollee was hemodynamically stable and appropriate for ambulance transport with monitoring to a plan facility for observation/admission level of care services after the emergency room evaluation on July 5, 2019. There was no documentation provided necessitating post-stabilization care services July 5, 2019 through July 6, 2019 at the nonPlan facility. The treating physician did not document (in the physician notes, on a form, or in an order) that the patient was not stable for transfer on any dates of service. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for inpatient hospital care provided to the enrollee from July 5, 2019 to July 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic shoes purchased on December 7, 2019 from a non-Medicare provider. You asked the Plan to pay for the diabetic shoes. You say that you did not know you had to get shoes from a Medicare approved company. The Plan denied your request. The Plan says you obtained durable medical equipment (DME) from a provider who does not participate with Medicare. The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the diabetic shoes have not been met. You obtained DME from a provider who does not participate with Medicare. There are certified providers available in your area that you can utilize for services. Therefore, we decided that the Plan does not have to pay for the diabetic shoes purchased on December 7, 2019 from a non-Medicare provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for intracardiac echocardiography (CPT 93662) provided to the enrollee on December 11, 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 this is an add-on code without the appropriate primary 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 93662 is "Intracardiac echocardiography during therapeutic/diagnostic intervention, including imaging supervision and interpretation (List separately in addition to code for primary procedure)."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 coded correctly. Our physician reviewer found per the CPT guidelines, the denied code is an add-on code. It should be billed in addition to a primary code.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 intracardiac echocardiography (CPT 93662) provided to the enrollee on December 11, 2019.