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

We decided that the Plan does not have to waive the copayments for the office visit, the influenza testing, and the emergency room visit provided from March 13, 2020 to March 14, 2020.
You asked the Plan to waive the copayments for the office visit, the influenza testing, and the emergency room visit. You say that you believe these claims should be fully covered under the Plan's guidelines. 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 $5 copayment for each in-network Medicare-covered visit with a PCP, and a $20 copayment per day, per provider, for in-network Medicare-covered lab services, and a $90 copayment for each in- and out-of-service area Medicare-covered emergency room visit. You have been asked to pay a $5 copayment for the office visit, a $16.55 copayment for the influenza testing, which is less than the standard amount, and a $90 copayment for the emergency room visit. ($5 + $16.55 + $90 = $111.55). The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The influenza testing falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The emergency room visit falls within the "Emergency care" benefit category.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the office visit, the influenza testing, and the emergency room visit provided from March 13, 2020 to March 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe chiropractic manipulative treatment (98942) rendered by the out of network (OON) provider on November 8, 2019.You asked the Plan to pay forthis service. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says the service was 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 thePlan 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 canprovide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service.Therefore, we decided that the Plan does not have to pay forthe chiropractic manipulative treatment (98942) rendered by the out of network (OON) provider on November 8, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare 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 the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found records do not indicate that there are significant, or complex medical/nursing issues
that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other
medication management, wound care, and daily therapy can be provided at a SNF. In this case, you are
anywhere from stand-by assist (SBA) to maximum assist for functional transfers and activities of daily living
(ADL's) and a less intensive, longer duration of therapy will allow for measurable gains to be attained within a
reasonable, and predicted period. An IRF intensity is not warranted.
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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 21, 2019 by an
out of network (OON) provider.
You asked the Plan to pay for endovenous ablation therapy (36478). You say that you would like
reconsideration because the services were medically necessary and rendered in good faith. The Plan denied
your request. The Plan says these services were rendered by a non-participating 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 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 February 21,
2019 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on August 9,
2019.
You asked the Plan to waive the copayment for ambulance services. You say that you cannot afford 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 $200
copayment for ambulance services.
You have been asked to pay a $200 copayment for ambulance services. Ambulance services fall 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 ambulance services
provided on August 9, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 24, 2020 by a
non-plan provider.
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 the services were rendered by a non-plan 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 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 February 24,
2020 by a non-plan provider.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to reduce the copayment for the diagnostic sleep study provided on February 5,
2020.
You asked the Plan to reduce the copayment for the diagnostic sleep study. You say that you should be charged
a $95 copayment for the sleep study. The Plan denied your request. The Plan says that 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. Your
contract with the Plan says that enrollees must pay a $95 copayment for all other diagnostic procedures and
tests.
The Plan says you must pay a $175 copayment for the diagnostic sleep study. Based on the Plan contract,
however, you cannot be asked to pay more than a $95 copayment for the diagnostic sleep study. The record
shows that the diagnostic sleep study is not considered a radiological service. Therefore, we decided that the
Plan has to reduce the copayment for a diagnostic sleep study provided on February 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation and extraction provided on January 15,
2020.
You asked the Plan to pay for the consultation and extraction. You say that you were informed the services
were covered under the plan. You say that you don't have the income to pay for the services. The Plan denied
your request. The Plan says the services are not covered benefits.
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 the
consultation and extraction provided on January 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost share for the Part B injection and its administration
provided on January 7, 2020.
You asked the Plan to reduce the cost share for the Part B injection and its administration. You say that you had
this same services done in October 2018 and were only charged $159.58. 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 each Medicare-covered Part B drug and a $160 copayment for Medicare-covered surgery or
other services provided to you at an outpatient hospital, including but not limited to hospital or other facility
charges and physician or surgical charges.
You have been asked to pay a total of $2,116.73 for the Part B injection and its administration. The Part B
injection falls within the "Medicare Part B Prescription Drugs" benefit category. The administration of the drug
falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and
Ambulatory Surgical Centers" benefit category. See chart below.
Date of Service Service Allowed Amount Coinsurance/
Copayment
Member Liability
January 7, 2020 Part B injection $9,788 20% $1,957.60
January 7, 2020 Administration of
the drug
$159.13 $160 $159.13
Total $2,116.73
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 cost share for the Part B injection and its administration provided on
January 7, 2020.
Our decision is only about the 2020 services. If you have any questions about prior years billing, please contact
the plan directly.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on March 2,
2020.
You asked the Plan to pay for the services. You say that the services were conducted in good faith, as ordered
by the referring physician who deemed the services to be medically necessary. The Plan denied your request.
The Plan says Medicare rules say there must be a particular reason why this type of drug testing is needed for
care.
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 the
enrollee's medication list included Hydromorphone, Morphine, and Tizanidine.
In this case, the case file contains a Laboratory Request order form and the results of the testing. There are
insufficient medical records in the case file. The documentation does not support that there was a specific
substance or metabolite that was inadequately detected by a presumptive UDT screen. The definitive urine drug
testing (UDT) was not reasonable and 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 services have not been met. Therefore, we decided that the Plan does not
have to pay for drug testing services provided to the enrollee on March 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0482 provided on October 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 code G0482 is 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. 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 G0482 provided on October 15, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zolpidem Tabs 10mg.
You asked the Plan to pre-approve Zolpidem Tabs 10mg. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.
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-approve Zolpidem Tabs 10mg.
Benefits for Zolpidem Tabs 10mg may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe removal of an implanted spinal neurostimulator provided on May 3,2019.You asked the Plan to waive the copayment forthe removal of an implanted spinal neurostimulator. You say that you disagree with the charges and feel the Plan should cover it.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 $275 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You have been asked to pay a $275 copayment for the removal of an implanted spinal neurostimulator. The removal of an implanted spinal neurostimulator 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 forthe removal of an implanted spinal neurostimulator provided on May 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213) provided on February 3, 2020.
You asked the Plan to pay for the office visit. You say that you would like reconsideration because these
lesions were not previously examined and required further assessment. The Plan denied your request. The Plan
says the modifier is not supported to show that the code 99213 was separately identifiable as being distinct
from code 17110.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
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 office visit. Our reviewer says that the documentation
does not support that a significant, separately identifiable evaluation and management service by the same
physician or other qualified health care professional was rendered on the same day of the procedure or other
service. 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 office visit have not been met. Therefore, we decided that the Plan does not
have to pay for the office visit (99213) provided on February 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory work provided on February 24, 2020.
You asked the Plan to waive the copayment for the laboratory work. You say that your laboratory bills have never been this high. 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 laboratory services at an in-network outpatient hospital. You have been asked to pay a $40 copayment for the laboratory work. The laboratory work falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows you were billed by the outpatient hospital.
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 laboratory work provided on February 24, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve2 additional home health visits (G0299).You asked the Plan to pre-approvethe additional home health visits. You say that the additional visits are medically necessary.The Plan denied your request. The Plan says the enrollee's needs can be met by the 2 visits already approved.The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.We asked our physician reviewer to carefully review the case file and applythe relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the additional home health visits. Our reviewer says that the 2 additional visits beyond the 2 already approved are not medically necessary. Our physician reviewer found the records do not show that the 2 additional skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration.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 additional home health visits have not been met.Therefore, we decided that the Plan does not have to pre-approve2 additional home health visits (G0299).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment fora specialist visit provided on February 12, 2020.You asked the Plan to reduce the copayment fora specialist visit. You say that the provider is your primary care physician and you disagree with the charges.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 copayment for each specialistoffice visit.The record shows that you had an office visit with a provider that is listed as a specialist on February 12, 2020.  Therefore, you are responsible to pay the $30 copayment. You have been asked to pay a $30 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 contractualobligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to reduce the copayment fora specialist visit provided on February 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral x-rays and adjunctive procedure provided on January 14, 2020.You asked the Plan to pay for the intraoral x-rays and adjunctive procedure. You say that you had a biopsy for a potentially cancerous lesion. You say that you should be reimbursed.The Plan denied your request. The Plan says the services are not covered benefits.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth.These are dental services that are not covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pay for the intraoral x-rays and adjunctive procedure provided on January 14, 2020.