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

We decided that the Plan does not have to adjust the coinsurance forthe radiation therapy services provided from July 27, 2020, to October 5, 2020.You asked the Plan to adjust the coinsurance forthe out-of-network radiation therapy services. You say that you do not understand why you are billed as the provider being out-of-network.The Plan denied your request. The Plan says you were charged this coinsurance 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 50% coinsurance for out-of-network Outpatient Radiation Therapy. You have been asked to pay 50% coinsurance for the out of network radiation therapy services. The out-of-network radiation therapy services fallwithin the Outpatient Hospital Radiation Therapy benefit category. The provideris out-of-network for your Florida plan. 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 adjust the coinsurance forthe radiation therapy services provided from July 27, 2020, to October 5, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services you received on September 22, 2020.
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says these services are not covered.
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 dental services you received on September 22, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forpleural drainage provided from October 10, 2020, to October 15, 2020.You asked the Plan to waive the coinsurance forpleural drainage. You say that the procedure was necessary,and you disagree with the high 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 20% coinsurance for outpatient surgery, including services provided at hospital outpatient facilities.You received pleural drainage fromOctober 10, 2020, to October 15, 2020, at an outpatient hospital facility. Pleural drainage is considered an outpatient surgical procedure. Therefore, you are responsible to pay your share of the cost-sharing charges. The total allowed amount is $1,897.33 and 20% of that is $379.47. You have been asked to pay the total coinsurance amount of $379.47 for pleural drainage. Pleural drainage falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the coinsurance forpleural drainage provided from October 10, 2020, to October 15, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plandoes not haveto pay forthe home health services provided on August 1, 2020, reported with HIPPS code 3CHK4.You asked the Planto pay forthe home health services as billed. You say that this was medically necessary and should be paid.The Plandenied your request. The Plansaysthis was not billed with a valid HIPPS code.The Plan must follow Medicare rules. Medicare rules say that for services provided after January 1, 2020, the new PDPM provides a new set of HIPPS codes for home health services.We have reviewed the CMS master list of valid HIPPS codes, and 3CHK4 is not listed as valid for services provided in 2020 or later.Therefore, we decided that the Plandoes not haveto pay forthe home health services provided on August 1, 2020, reported with HIPPS code 3CHK4.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea speech generating device.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that a speech generating device is covered when specific criteria are met.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's natural language is severely impaired with minimal ability to verbalize novel information. She relies heavily on pointing or occasional gesturing to indicate immediate needs and wants. Auditory comprehension is moderately impaired. It is noted that the enrollee is completely dependent on family for activities of daily living. The records do not support that the enrollee's speaking needs cannot be met using natural communication methods, and that other forms of treatment have been considered and ruled out. The speech generating device is therefore not 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-approvea speech generating device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe tooth extraction rendered on May9, 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 the services are not covered.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 tooth extraction rendered on May 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forrefraction provided on November 7, 2019.You asked the Plan to pay forrefraction. You say that this exam is medically necessary and should be covered.The Plan denied your request. The Plan says the provider is not a preferred specified provider.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when provided by the specified optical provider.We looked at the file and the Plan's rules. You did not receive the refraction from the Plan specified provider. Based on this information, we decided that the Plan's rules for coverage of refraction have not been met.Therefore, we decided that the Plan does not have to pay forrefraction provided on November 7, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forlaboratory services provided on August 11, 2020.You asked the Plan to waive the copayment forlaboratory services. You say that 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 $15 copayment for laboratory tests. You have been asked to pay a $15 copayment for laboratory services. Laboratory services fall within the outpatient diagnostic tests and therapeutic services and 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 thePlan.Therefore, we decided that the Plan does not have to waive the copayment forlaboratory services provided on August 11, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forradiation therapy provided from April 6, 2020, to June 4, 2020.You asked the Plan to waive the copayment forradiation therapy. You say that you thought that you would only owe a $35 copayment for radiation services and 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 $60 copayment for each radiation therapy service. You received radiation therapy from April 6, 2020, to June 4, 2020, for a total of 37 visits. Therefore, you are responsible to pay a $60 copayment per each radiation therapy visit. The total amount you owe is: $60 (copayment) x 37 (radiation therapy services) = $2,220.You have been asked to pay the total copayment amount of $2,220 for radiation therapy. Radiation therapy falls within the outpatient diagnostic tests and therapeutic services and supplies benefitcategory. 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 forradiation therapy provided from April 6, 2020, to June 4, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve multiple power options (E2311, E2313, E2377) for a power wheelchair.
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied your request. The Plan says it is not medically necessary to control the three requested power options through the joystick.
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 accessories. Our reviewer says that the requested accessories are not considered medically reasonable and necessary in this case. Our physician reviewer found the E2377, E2311, and E2313 Expandable Controller Harness are not medically necessary. The documentation does not reveal that the enrollee requires other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.) The enrollee does not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The enrollee 's strength and function are sufficient to control any power options through their own switches. 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 accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve multiple power options (E2311, E2313, E2377) for a power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does nothave to pay forthe deluxe frames (V2020) and Anti-reflective coating (V2750) purchased August 17, 2020.You asked the Plan to pay forthe vision services. You say that you were under the impression that you were eligible for new frames and you would be reimbursed the entire $200 when submitting.The Plan denied your request. The Plan says this service exceeds the benefit frequency limitation.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The health plan contract says that the $200 vision allowance is allowed every 2 years. The records show that this service was provided September 22, 2018. This benefit was not available until after September 22, 2020.We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met.Therefore, we decided that the Plan does not have to pay forthe deluxe frames (V2020) and Anti-reflective coating (V2750) purchased August 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe consultation (D9310) provided on October 7, 2020.You asked the Plan to pay forthe dental service. You say that you were advised by a plan representative that there would no fees or charges for the consultation. You say that you were also advised that your Medicaid would be effective before your dentist appointment. You also say that after your appointment, you were advised the dentist did not take Medicaid.The Plan denied your request. The Plan says the consultation is not listed as a covered service.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, 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 consultation (D9310) provided on October 7, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing services provided on August 12, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the provided did not submit progress notes.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering physician'sintent that the tests be performed. 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 drug testing services provided on August 12,2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forGeneSighttesting provided on July 20, 2020.You asked the Plan to pay forthe GeneSight testing. You say that you would like reconsideration this testing is a Medicare covered benefit.The Plan denied your request. The Plan says the member does not meet LCD criteria for coverage.The Plan follows Medicare rules. Medicare rules say that GeneSight testing may only be ordered by licensed psychiatrists or neuropsychiatrists contemplating an alteration in neuropsychiatric medication for patients diagnosed with major depressive disorder (MDD) who are suffering with refractory moderate to severe depression after at least one prior neuropsychiatric medication failure.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 GeneSight testing. Our reviewer says that there is no documentation of this member having responded to at least one other medication for the treatment of his apparent mood disorder. Our physician reviewer found the ordering physician for this test is not boarded in psychiatry or neuropsychiatry.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 GeneSight testing have not been met.Therefore, we decided that the Plan does not have to pay forGeneSight testing provided on July 20, 2020
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe nervous system procedure (64999) provided on June 22, 2020.You asked the Plan to pay forthe nervous system procedure. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the documentation submitted does not support the service billed.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 64999 is unlisted procedure, nervous system 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 nervous system procedure. Our reviewer says that CPT code 64999 does not meet criteria for billing or reimbursement consideration. Our reviewer found documentation does not include documentation to support CPT 64999.  When reporting an unlisted procedure code, documentation should clearly indicate the service provided for the unlisted code.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 nervous system procedure have not been met.Therefore, we decided that the Plan does not have to pay forthe nervous system procedure (64999) provided on June 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe inpatient hospital services rendered from March 16, 2020 to June 26, 2020.You asked the Plan to waive the copayment forthese 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 copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $310 copayment per day, per admission for days 1-7 for inpatient hospital care. Review of the file shows that you received four days of inpatient hospital services from March 16, 2020 to March 20, 2020. You were not assessed a copayment for your date of discharge on March 20, 2020. You have been asked to pay a $310 copayment per day for these services, for a total of $1,240. These services fall within the inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. The file shows that you received four days of inpatient hospital services from June 22, 2020 to June 26, 2020. You were not assessed a copayment for your date of discharge on June 26, 2020. You have been asked to pay a $310 copayment per day for these services, for a total of$1,240. These services fall within the inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.The total amount you have been asked to pay for these services is $2,480.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 inpatient hospital services rendered from March 16, 2020 to June 26, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe urgent care visit provided on August 24, 2020.You asked the Plan to waive the copayment forthe urgent care visit. You say that you were told you would not have to pay a copayment to get the stitches in your finger removed. 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 Medicare-covered urgently needed care visits. You have been asked to pay a $40 copayment for the urgent care visit. The urgent care visit falls within the "Urgently Needed 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 forthe urgent care visit provided on August 24, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forcomprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode (93653) provided April 9, 2020.You asked the Plan to waive the coinsurance forthe outpatientsurgery visit. You say that you were never informed that the copay would have been $360 if you had the procedure done as an inpatient procedure and feel that the hospital is negligent of not informing you of that option.The Plan denied your request. The Plan says this claim was processed and the correct coinsurance was applied per the Evidence of Coverage.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 per visit for Outpatientsurgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You have been asked to pay $4,025.99 for the outpatient surgery visit. The outpatient surgery visit 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 agreedto pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the coinsurance forcomprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode (93653) provided April 9, 2020.