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

We decided that the Plan does not have to waive the copayment for an office visit provided on October 16, 2019.
You asked the Plan to waive the copayment for an office visit. You say that this was an annual wellness visit and you should not be responsible for 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 $10 copayment for primary care provider visits. The medical records show that you had an office visit on October 16, 2019. Therefore, you are responsible to pay the $10 copayment. You have been asked to pay a $10 copayment for an office visit. An office visit falls within the physician/practitioner services, including doctor's office visits 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 office visit provided on October 16, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded 80307 and G0482 provided on May 15, 2019.
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes 80307 and G0482 are not supported in the medical record. Specifically, the documentation submitted did not include a valid physician order/lab requisition or medical records (signed by the ordering physician) stating exactly what tests were to be performed for the billed date of service. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded 80307 and G0482 provided on May 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of pump with oxygenator or heat exchanger services coded 99190 provided on September 26, 2019.
You asked the Plan to pay for the assembly and operation of pump with oxygenator or heat exchanger services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not a covered benefit.
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 99190 is assembly and operation of pump with oxygenator or heat exchanger (with or without ECG and/or pressure monitoring); each hour. We find that CPT code 99190 is not supported in the medical record. Specifically, these services were provided to the enrollee while they were inpatient. Payment cannot be made to a provider or supplier other than the hospital for services provided to the enrollee while inpatient in the hospital. Based on this information, we decided that Medicare rules for coverage of the assembly and operation of pump with oxygenator or heat exchanger services have not been met. Therefore, we decided that the Plan does not have to pay for the assembly and operation of pump with oxygenator or heat exchanger services coded 99190 provided on September 26, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an abdominal lipectomy/panniculectomy.
You asked the Plan to pre-approve an abdominal lipectomy/panniculectomy. You say that this surgery would improve your quality of life. The Plan denied your request. The Plan says this procedure is cosmetic in nature.
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are coverable. The requested surgery is considered reconstructive rather than cosmetic for complicating factors such as inability to walk normally, chronic pain, ulceration created by the abdominal skin fold, or intertrigo dermatitis.
We looked at the file and Medicare rules. The documentation submitted did not include medical records that show you have a medical condition that would make this procedure reconstructive. The requested service is cosmetic in nature. Based on this information, we decided that Medicare rules for coverage of an abdominal lipectomy/panniculectomy have not been met. Therefore, we decided that the Plan does not have to pre-approve an abdominal lipectomy/panniculectomy.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 8, 2019 by the out of network provider.
You asked the Plan to pay for electrocardiogram (EKG). You say that you are appealing with medical records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and the referring physician is also out-of-network with the Plan.
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 the medical services provided on August 8, 2019 by the out of network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the laparoscopy services coded 44205 provided on June 25, 2019.
You asked the Plan to pay for the laparoscopy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed with an inappropriate modifier.
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 44205 is laparoscopy, surgical; colectomy, partial, with removal of terminal ileum with ileocolostomy. We find that CPT code 44205 is not supported in the medical record. Specifically, the documentation shows that this code was billed with modifier "RT". This modifier is inappropriate for this service since there is no indication of this service being performed bilaterally or only the right or left side. Based on this information, we decided that Medicare rules for coverage of the laparoscopy services have not been met. Therefore, we decided that the Plan does not have to pay for the laparoscopy services coded 44205 provided on June 25, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory testing provided on February 21, 2018.
You asked the Plan to pay for the laboratory testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the rendered services are a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, the laboratory testing, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory testing provided on February 21, 2018.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography angiography (CTA) of the
neck.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan
denied your request. The Plan says the 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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has a history of vascular
disease with a carotid duplex showing 40 to 60 percent stenosis. There is no documentation of an extenuating
circumstance in the records that support that a CTA is reasonable or medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a computed tomography angiography (CTA) of the neck.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on October 9, 2019.
You asked the Plan to pay for the dental service. You say that you had to switch dental providers. You say that when you found out the provider was out of network, you went to another provider and had to get another exam. You also say that since you had to switch providers, the service should be covered. The Plan denied your request. The Plan says the frequency limit has been exceeded.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage and exams are a covered service, the frequency limit has been exceeded. The records shows that the Plan has previously paid for an exam on January 10, 2019 and July 17, 2019. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on October 9, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of a lumbar interspinous process stabilization device.
You asked the Plan to pre-approve the device. The Plan denied your request. The Plan says this is 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 the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is considered experimental. More research is needed. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of a lumbar interspinous process stabilization device.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fourteen physical therapy visits for the enrollee.
You asked the Plan to pre-approve the visits. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary. The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.
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 visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition. The enrollee has had extensive prior therapy and the documentation does not reveal that the enrollee requires an additional 14 visits of therapy to instruct on a home exercise program. The records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed by a therapist, or under the
supervision of a therapist. The requested services are not part of a maintenance program. The specialized skill, knowledge and judgment of a qualified therapist are not required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. The remaining 14 therapy visits are not medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the visits have not been met. Therefore, we decided that the Plan does not have to pre-approve fourteen physical therapy visits for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the injection provided on September 3, 2019.
You asked the Plan to waive the copayment for the injection. You say that you were not informed that the injection is considered minor surgery. You say that your copayment should be $30. The Plan denied your request. The Plan says the copayment 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 outpatient hospital services. You have been asked to pay $253.82, which is less than the standard $275 copayment for the injection. The injection 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 copayment for the injection provided on September 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B injection provided on
September 17, 2019.
You asked the Plan to waive the coinsurance for the Part B injection. You say that you were told that the
injection done in the office setting is covered in full. 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% of
the cost for Part B covered prescription drugs.
You have been asked to pay $203.75 which is 20% of the allowed amount for the Part B injection. The allowed
amount is $1,018.76. ($1,018.76 x 20% = $203.75). The Part B injection falls within the "Medicare Part B
prescription drugs" benefit category. This means that you have been asked to pay the correct amount based on
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled
in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the Part B injection
provided on September 17, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laparoscopy provided on August 9, 2019.
You asked the Plan to waive the copayment for the laparoscopy. You say that you were an inpatient for 32 hours. You say that you should be charged as an inpatient instead. The Plan denied your request. The Plan says the copayment 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 $400 copayment for outpatient surgery at an outpatient hospital facility. You have been asked to pay a $400 copayment for the laparoscopy. The laparoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that this was an outpatient 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 copayment for the laparoscopy provided on August 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on August 9, 2019.
You asked the Plan to waive the copayment for a specialist visit. You say that you feel that the office visit should be included in a mammogram screening. 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 specialist visits. The medical records show that you had a specialist visit on August 9, 2019. Therefore, you are responsible to pay the $50 copayment. You have been asked to pay a $50 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 a specialist visit provided on August 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the EEG monitoring/video recording (95951) provided by the out of network provider from August 22, 2019 to August 24, 2019.
You asked the Plan to pay for these services. You say that you are requesting reconsideration of the Plan's denial. The Plan denied your request. The health plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented. 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 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 services. Therefore, we decided that the Plan does not have to pay for the EEG monitoring/video recording (95951) provided by the out of network provider from August 22, 2019 to August 24, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve Magnetic Resonance Imaging (MRI) of the Shoulder (73221).
You asked the Plan to pre-approve the MRI. You say that the MRI is medically necessary. The Plan denied your request. The Plan says that a standard X-ray would be more appropriate.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the MRI is medically necessary. Our physician reviewer found shoulder surgery is being considered. An MRI would be appropriate to help determine the need for and/or plan any surgical procedure. 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 MRI have been met. Therefore, we decided that the Plan has to pre-approve Magnetic Resonance Imaging (MRI) of the Shoulder (73221).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical supplies coded as A6216, A4217 and A6446 provided by April 4, 2018.
You asked the Plan to pay for the surgical supplies. You say that please review and reprocess for full payment promptly. The Plan denied your request. The Plan says the filing limit has been exceeded. 
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 one calendar year after the date of service. The plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. Payment to you for this service is the responsibility of the facility or hospital. The record shows that a claim for the surgical supplies was not filed until April 30, 2019. 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 for surgical supplies coded as A6216, A4217 and A6446 provided by April 4, 2018.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services.You asked the Plan to pay forthe ambulance services. You say that the ambulance was called because it was a medical emergency. You say that you do not understand why an ambulance response is not covered since you cannot know the outcome when making an emergency call. You say that you thought that your insurance would cover the service.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. Theambulance company did not provide transport services on July 23, 2019. 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 forthe ambulance services.