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

We decided that the Plan does not have to waive the copayment foran observation stay provided from October 24, 2019 to October 25, 2019.You asked the Plan to waive the copayment foran observation stay. You say that you thought that you were admitted inpatient and 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 $400 copayment for outpatientsurgery, including services provided at hospital outpatient facilities.The medical records show that you had an observation stay provided from October 24, 2019 to October 25, 2019. Therefore, you are responsible to pay the $400 copayment.  You have been asked to pay a $400 copayment for an observation stay. An observation stay falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have beenasked 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 foran observation stay provided from October 24, 2019 to October 25, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided from September 4,
2019 to November 22, 2019.
You asked the Plan to pay for home infusion therapy. You say that this was incorrectly denied. The Plan denied
your request. The Plan says this code is not payable under Medicare rules.
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 S9328 is not supported in the medical record. Specifically, this code has a status
indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this
information, we decided that Medicare rules for coverage of home infusion therapy have not been met.
Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) provided from
September 4, 2019 to November 22, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the arthrotomy services coded 27033 provided on January 2, 2020.
You asked the Plan to pay for the arthrotomy 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 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. In this case, the CPT Code Manual definition of code 27033 is arthrotomy, hip, including exploration or removal of loose or foreign body. We find that CPT code 27033 is not supported in the medical record. Specifically, the documentation submitted does not indicate that arthrotomy, hip, including exploration or removal of loose or foreign body was performed; therefore, the billed service cannot be verified. Based on this information, we decided that Medicare rules for coverage of the arthrotomy services have not been met. Therefore, we decided that the Plan does not have to pay for the arthrotomy services coded 27033 provided on January 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. 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 LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee does not appear to require services at the proposed LTACH that are not already available at the current acute care hospital. If additional acute care is needed, they could be administered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary. Transfer to a lower level of care now or in the near future appears most appropriate based on the provided documentation. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forcatheter placement (36227, 36228) provided on February 3, 2020.You asked the Plan to pay forcatheter placement. You say that these codes were appropriately billed with the primary code 61524.The Plan denied your request. The Plan says these codes were not billed with an appropriate primary code.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 36227 and 36228 is not supported in the medical record. Specifically, these codes are add-on codes that must be billed with an appropriate primary code, namely 36222, 36223, or 36224. An appropriate primary code was not billed on this claim. Based on this information, we decided that Medicare rules for coverage of catheter placement have not been met.Therefore, we decided that the Plan does not have to pay forcatheter placement (36227, 36228) provided on February 3, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided on February 18, 2020 and February 25, 2020.
You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you were informed that you would owe 20% but it appears the plan did not pay anything and you believe you should owe $0 according to the 2020 benefit for outpatient hospital services. 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 Medicare Part B prescription drugs. You received Medicare Part B drugs from February 18, 2020 to February 25, 2020. The total allowed amount is $1,485.40 and 20% of that is $297.08. You have been asked to pay the total coinsurance amount of $297.08 for Medicare Part B drugs. Medicare Part B drugs fall 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 Medicare Part B drugs provided on February 18, 2020 and February 25, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for Prednisone provided on March 12, 2020.
You asked the Plan to pay for the self-administered drug. The Plan denied your request. The Plan says the self-administered drug is not covered under your Medicare Part B benefit.
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 pay for Prednisone provided on March 12, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost forthe CT scan provided on March 19, 2020.You asked the Plan to reduce the cost forthe CT scan. You say that you are wondering why doctor visits with copayments don't go toward your deductible. You say that the website estimated a copayment of $150.The Plan denied your request. The Plan says the cost shareapplied correctly.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 your in-network deductible is $300. This is the amount you have to pay out-of-pocket before we will pay our share for your covered in-network medical services. Until you have paid the in-network deductible amount, you must pay the full cost of your covered in-network services. Your contract with the Plan also says thatafter your yearly deductible is metyou must pay $150 per day, per in-network provider, for Medicare-covered diagnosticradiology services.The item or service you asked the Plan to waive the deductible for falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your$300in-network deductible applies to diagnostic radiology. This cost sharing is a contractual obligation that had not been met at the time the CT scanwas received on March 19, 2020.Therefore,$300 has been applied to meet your in-network deductible.  Since your $300 deductible has been met, you have also been asked to pay $70.51, which is less than the standard $150 copayment for the CT scan. 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 forthe CT scan provided on March 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve removal of torus mandibularis, teeth 1 and 8 (D7473)
provided February 27, 2020.
You asked the Plan to pre-approve the dental services. You say that you are disabled and on a fixed income.
You have asked for a copy of your dental coverage with no avail. You needed these procedures to help your
dental treatments. The Plan denied your request. The Plan says this service is not covered under the plan
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. The health plan contract
specifically says that any services not listed are not covered.
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 pre-approve
removal of torus mandibularis, teeth 1 and 8 (D7473) provided February 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive procedure provided on May 4, 2020.
You asked the Plan to pay for the preventive dental procedure. You say that the Plan has to pay the part that corresponds to the Plan. You also say that due to continuous Plan negligence's to your treatments and health are further delayed and continue to affect you. The Plan denied your request. The Plan says this service 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 the preventive procedure provided on May 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay fordrug testing provided on August 7, 2019.You asked the Plan to pay fordrug test. You say that you have submitted a valid physician laboratory requisition form.The Plan denied your request. The Plan says the denial of payment for this service is correct, because the documentation submitted does not include a valid physician order, lab requisition, or medical records to support the code billed.The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a valid physician order or clear intent to order the specific lab service billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug test have not been met.Therefore, we decided that the Plan does not have to pay fordrug testing provided on August 7, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Image Guided Radiation Therapy (IGRT).
You asked the Plan to pre-approve IGRT. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IGRT. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found generally, 3D radiation is necessary when the 2D radiation plan results in unacceptable normal tissue dose exposure and toxicity risks (uncommon with palliative treatment). It usually implies the need to spare normal tissues in a manner that cannot be achieved with 2D radiation. The documentation does not support the need for 3D radiation. The documentation supports that it would be within accepted standards of care to use 2D radiation. Therefore, the enrollee does not meet criteria for the requested services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IGRT have not been met. Therefore, we decided that the Plan does not have to pre-approve Image Guided Radiation Therapy (IGRT).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on December 5, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the documentation
submitted did not include a physician order/lab requisition or medical records stating exactly what tests are to
be performed.
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 a valid physician order or lab
requisition stating exactly which testing was to 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 for the drug testing services provided on December 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on June 4, 2019.You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the servicesat 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 subsequent nursing facility care provided on June 4, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ER visits provided on February 24, 2020
and February 25, 2020. You asked the Plan to waive the copayment for ER visits. You say that you disagree with the charges because you feel that you were improperly informed to go to the ER. 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 $90 copayment for emergency care.
You had an ER visit on February 24, 2020. Therefore, you are responsible to pay the allowed amount of
$62.23, which is less than the $90 copayment.
You had an ER visit on February 25, 2020. Therefore, you are responsible to pay the $90 copayment.
The total amount you owe is: $152.23.
You have been asked to pay the total copayment amount of $152.23 for ER visits. ER visits fall 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 copayment for an ER visits provided on
February 24, 2020 and February 25, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the breast ultrasounds and diagnostic mammography
provided on February 17, 2020.
You asked the Plan to pay for the ultrasounds and mammography. The Plan denied your request. The Plan says
Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to
the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for the breast ultrasounds and diagnostic mammography
provided on February 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for needle electromyography (95886) provided on March 4, 2019.You asked the Plan to pay for needle electromyography. You say that this code is supported.The Plan denied your request. The Plan says this code is not documented in the records.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 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).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 needle electromyography. Our reviewer says that this code is not supported. Our physician reviewer found the documentation is insufficient to verify that CPT code 95886 was performed.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of needle electromyography have not been met.Therefore, we decided that the Plan does not have to pay for needle electromyography (95886) provided on March 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for oral/facial photography (D0350x4) oral hygiene instruction
(D1330) and gingival irrigation (D4921) provided March 12, 2020.
You asked the Plan to pay for the dental services. You say that you went for a teeth cleaning and was told you
would have to pay $177 and paid exactly what they quoted you in full. You cannot afford these undisclosed
and hidden charges coming after the fact. The Plan denied your request. The Plan says these services are not
covered under the plan 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 oral/facial
photography (D0350x4) oral hygiene instruction (D1330) and gingival irrigation (D4921) provided March 12,
2020.
Your complaint about the provider quoting you one price and then billing another is not a valid appeal for
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does
not permit us to make a decision about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient detoxification treatment.
You asked the Plan to pre-approve the inpatient detoxification services. You say that the services are medically
necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that inpatient detoxification services are covered when
reasonable and 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 inpatient detoxification services.
Our reviewer says that the requested inpatient services are not medically necessary. Our physician reviewer
found the admission of this patient does not meet criteria for acute inpatient mental health treatment as she was
not shown to be a danger to herself or others, auditory or visual hallucinations. She is noted to be cooperative
and compliant with treatment while not showing any aggressive behaviors or any behaviors on withdrawal
causing an acute threat to safety.
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 inpatient detoxification services have not been met. Therefore, we decided
that the Plan does not have to pre-approve inpatient detoxification treatment.