Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for the CPAP supplies provided from April 3, 2020, to October 3, 2020.
You asked the Plan to reduce the coinsurance for the CPAP supplies. You say that you should pay the same $24.24 amount throughout the entire 13-month rental agreement. 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 20% coinsurance for durable medical equipment (DME) and related supplies. You have been asked to pay 20% of the allowed amount for the CPAP supplies. The CPAP supplies falls within the "Durable medical equipment (DME) and related supplies" benefit category. See chart below.
Date of Service
Service
Allowed Amount
Coinsurance
Member Liability
April 3, 2020
CPAP supplies
$172.41
20%
$34.48
April 3, 2020
CPAP supplies
$106.54
20%
$21.31
May 3, 2020
CPAP supplies
$121.17
20%
$24.24
June 3, 2020
CPAP supplies
$121.17
20%
$24.24
July 3, 2020
CPAP supplies
$121.17
20%
$24.24
August 3, 2020
CPAP supplies
$121.17
20%
$24.24
September 3, 2020
CPAP supplies
$145.41
20%
$29.08
October 3, 2020
CPAP supplies
$184.85
20%
$36.97
Date of Service
Service
Allowed Amount
Coinsurance
Member Liability
Total
$218.80
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 coinsurance for the CPAP supplies provided from April 3, 2020, to October 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for topical application of fluoride varnish (D1206) received on January 17, 2020.
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for topical application of fluoride varnish (D1206) received on January 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay forthe lab testing provided on September 2, 2020 by an out of network (OON) provider.You asked the Planto pay forthe lab testing. You say that you were having symptoms while you were in THE STATE. You called your doctor who recommended getting this lab test done due to your use of warfarin. You feel that this shouldbe covered.The Plandenied your request. The Plansaysit was confirmed with your physician's office that you were not referred to this laboratory for testing. There are no records provided, despite requeststo the facility to support that the testing was urgently needed out of area care.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. There is insufficient evidence to support that the testing was emergent or urgently needed. 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 Plandoes not haveto pay forthe lab testing provided on September 2, 2020 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasonic guidance rendered on August 24, 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 procedure code 76942 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 76942 is ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation. We find that CPT code 76942 is not supported in the medical record. Specifically, the operative report does not include documentation of imaging supervision and interpretation of ultrasonic guidance for needle placement. 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 ultrasonic guidance rendered on August 24, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forthe testing services rendered on June 24, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure codes 95907, 95886, and 95999 are not supported.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 95907 is nerve conduction studies; 1-2 studies. The definition of code 95886 is needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List separately in addition to code for primary procedure). The definition of code 95999 is unlisted neurological or neuromuscular diagnostic procedure.We find that CPT codes 95907, 95886, and 95999 are not supported in the medical record. Specifically, there is no documentation of 1-2 nerve conduction studies to support code 95907. There is no documentation of needle electromyography to support code 95886. The file shows that Train of Four testing was performed and 95999 is not the most appropriate code for these services. 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 forthe testing services rendered on June 24, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the co payment for the breast ultrasound rendered.

You asked the Plan to waive the copayment for these services. You say that you disagree with the charges.The Plan denied your request. The Plan says the copayment was applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a freestanding facility. 

Review of the file shows that you received a diagnostic breast ultrasound. Per the contract with the Plan, thereis a $150 co payment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a freestanding facility. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. However, the Medicare allowed amount for these services was $79.41. Given that the allowed amount was less than the $150 copayment, you have been asked to pay $79.41 for these services.

The file shows that the Plan did not assess a copayment for your screening mammogram. The amount you are being asked to pay is for the separate breast ultrasound that was performed.

Therefore, we decided that the Plan does not have to waive the copayment for the breast ultrasound rendered.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.The Plan must followMedicare 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 thePlan was correct in denying the request to pre-approve IRF care. Our reviewer says that the enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does notrequire an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for osteomyelitis and lumbar spine surgery. 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, in 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.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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe humidifier provided on September 23, 2020.You asked the Plan to waive the coinsurance forthe humidifier. You say that you cannot afford this amount. You say you should only have to pay for the CPAP device and not for the supplies. 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 20% coinsurance for covered items and related supplies. You have been asked to pay $54.80 which is 20% of the allowed amount for the humidifier. The allowed amount is $274. ($274 x 20% = $54.80). The humidifier falls within the "Durable medical equipment (DME) and related supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance forthe humidifier provided on September 23, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services provided to the enrollee on May 6, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says these services are not covered.The Plan must follow Medicare rules. Medicare rules say that the routine physical checkup exclusion applies to (a) examinations performed without relationship to treatment or diagnosis for a specific illness, symptom, complaint, or injury; and (b) examinations required by third parties such as insurance companies, business establishments, or Government agencies. We looked at the file and Medicare rules. The services in question were performed as requested by parole/jail officials. Services required by third parties are not covered by Medicare. 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 forthe services provided to the enrollee on May 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services provided on April 23, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the claim was submitted after the timely filing limit.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than onecalendar year after the date of service.The record shows that a claim for the services was not filed until September 3, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay forthe services provided on April 23, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveTramadol.You asked the Plan to pre-approveTramadol. You say that the enrollee has been on Tramadol with great pain control.The Plan denied your request. The Plan says the enrollee's medical plan does not cover outpatient prescription drugs.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveTramadol.Benefits for Tramadolmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay forthe skilled nursing services provided from July 1, 2020, to July 31, 2020.You asked the Plan to pay forthe skilled nursing services. You say that the services were medically necessary.The Plan denied your request. The Plan says that the enrollee's skilled nursing benefit has been exceeded.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not provide records showing the enrollee has exhausted their 100-day Skilled Nursing Facility (SNF)care benefit. A response to our request for information was not received. Without this information, we cannot determine that the Plan's coverage rules support the denial of payment SNF services.The Plan has not provided evidence that the benefit has been exceeded.Therefore, we decided that the Plan has to pay forthe skilled nursing services provided from July 1, 2020, to July 31, 2020.If the Plan does not agree with our decision,theycan 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 openthe case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe preventive procedure, core buildup, including any pins when required, and endodontic therapy provided on October 7, 2020.You asked the Plan to pay forthe preventive procedure, core buildup, and endodontic therapy. You say that you would like half of the root canal service to be covered by the Plan.The Plan denied your request. The Plan says these services are not covered.The Plan also says that participating providers are receiving a separate monthly stipend for unspecified preventive procedures, and no additional payment can be made for it on this claim.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe preventive procedure, core buildup, including any pins when required, and endodontic therapy provided on October 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on August 21, 2020 by an out of network (OON) provider.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without 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 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 forthe medical services provided on August 21, 2020 by an out of network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forarthrocentesis provided from June 15, 2020, to September 24, 2020.You asked the Plan to waive the copayments forarthrocentesis. You say that you should only owe a $20 copayment and have never been charged this much in the past.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 $225 copayment for outpatient surgery, including services provided at hospital outpatient facilities.You received arthrocentesis at an outpatient hospital facility, from June 15, 2020, to September 24, 2020, for a total of 5 visits. Arthrocentesis is considered an outpatient surgical procedure. Therefore, you are responsible to pay a $225 copayment per each visit. The total amount you owe is: $225 (copayment) x 5 (outpatient surgery services) = $1,125.00. You have been asked to pay the total copayment amount of $1,125.00 for arthrocentesis. Arthrocentesis 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 copayments forarthrocentesis provided from June 15, 2020, to September 24, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forSNF services provided on March 1 to March 26, 2020.You asked the Plan to waive the copayment forSNF services. You say that you call upon the Plan to fulfill its obligations to pay the enrollee's claim.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). The enrollee's contract with the Plan clearly says that enrollees must pay a $178 copayment for each day of days 21-100 for each SNF stay within a benefit period. Because the enrollee was near the annual out-of-pocket maximum for 2020, the enrollee has been asked to pay a total of $75.80 for SNF serviceson days 21-30 of a SNF stay. SNF services fall within the "Skilled nursing facility (SNF) care" benefit category. This means that the enrollee has been asked to pay less than or equal to 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 forSNF services provided on March 1 to March 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on September 8, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not approved in advance.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has topay 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 couldhave provided 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 services.Therefore, we decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on September 8, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe assistant surgeon services provided on July 17, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says assistant surgeon services are not payable for these procedures.The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are notcovered. In this case, you billed assistant surgery services for CPT codes 27062 and 27095. The Medicare Fee Schedule Database contains a surgical indicator of 1 for these procedures. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the services have not been met.Therefore, we decided that the Plan does not have to pay forthe assistant surgeon services provided onJuly 17, 2020