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

We decided that the Plan does not have to pay for a laparoscopy (49650) provided on November 13, 2019.
You asked the Plan to pay for the laparoscopy. You say that you would like reconsideration because this provider was requested by the primary surgeon due to being medically needed. The Plan denied your request. The Plan says certified surgical technicians are not recognized for payment per the Center for Medicare/Medicaid Services (CMS) guidelines.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS. In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for a laparoscopy (49650) provided on November 13, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pay for IRF care. You say that the services were medically necessary. The Plan denied your request. The Plan says coverage criteria was not 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 pay for 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 there was no medical complexity or nursing or rehabilitation needs that required an acute hospital inpatient stay with an interdisciplinary approach to the enrollee's rehabilitation care. 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 pay for acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive eye exam (92014) and refraction (92015) provided December 23, 2019.
You asked the Plan to pay for the vision services. You say that you had a routine eye exam and is now being charged $122.07. You had contacted the plan and had confirmed with a plan representative that there would be a $0 copay. The Plan denied your request. The Plan says enrollee's must receive their vision services from an in-network 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 a network provider.. We looked at the file and the Plan's rules. enrollee's must receive their vision services from an in-network
provider. 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 for comprehensive eye exam (92014) and refraction (92015) provided December 23, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital surgery services provided on November 20, 2019
You asked the Plan to pay for the hospital surgery services. 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 service 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 hospital surgery services provided on November 20, 2019
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Testosterone CYP 200mg/ml
You asked the Plan to pre-approve the drug. You say that you don't understand why the medication was denied when it was already justified. The Plan denied your request. The Plan says drug coverage is limited to Medicare Part B covered drugs.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Testosterone CYP 200mg/ml
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride provided on February 4,
2020.
You asked the Plan to pay for the topical application of fluoride. You say that you have documentation of
covered services and fluoride is included. The Plan denied your request. The Plan says your plan does not
cover this procedure.
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
topical application of fluoride provided on February 4, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided by a participating facilityon November 27, 2019.You asked the Plan to waive the copayment for an emergency room visit. You say that you were admitted to the hospital. You say that the emergency room copayment should be waived. The Plan denied your request. The Plan says the correct copayment has been applied.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $110 copayment for emergency care. You have been asked to pay a $110 copayment for an emergency room visit. Evidence was provided to show that observation services were provided. Observation services are considered outpatient; therefore, the emergency room copayment cannot be waived. An 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 copayment for an emergency room visit provided by a participating facility on November 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 11, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the office visit. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this service was not an emergency, the provider did not get prior authorization and there are in-network providers available.
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 December 11, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950) for teeth #4 and 6, retainer crown (D6740) for teeth # 4 and 6, and a pontic (D6245) for tooth # 5. You asked the Plan to pre-approve the dental services. You say that you have already received these services for the left side of your mouth. You say that now you need them for the right side if your mouth. You also say that they were denied. The Plan denied your request. The Plan says the core buildup, retainer crowns and pontic are not medically necessary. The Plan also says the enrollee is missing other teeth in the quadrant.
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 Plan covers the dental services when the services are medically necessary and reasonable. 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 dental services. Our reviewer says that the requested dental services are not medically necessary. Our physician reviewer found that the requested fixed bridge is reasonable if a retrofit to the existing partial denture is possible, though this process is always fraught with difficulty and rarely has an optimal result. Core buildups are base restorations that are placed when there is insufficient structure to retain a crown. The reviewer found that since crowns are not indicated, there is no consideration of core buildups. As the Plan limits fixed bridgework where a partial denture would also be indicated, the reviewer found that there is no medical necessity for the requested services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does not have to pre-approve core build up (D2950) for teeth # 4 and 6, retainer crown (D6740) for teeth #4 and 6, and a pontic (D6245) for tooth #5.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the lumbar-sacral brace provided on
September 17, 2019.
You asked the Plan to waive the coinsurance for the lumbar-sacral brace. You say that you were not quoted a
price for the brace. You say that the cost is less online so you shouldn't have to pay that price. The Plan denied
your request. The Plan says the coinsurance 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 20% of
the cost for in-network, Medicare-covered prosthetic devices and related supplies.
You have been asked to pay $247.68, which is 20% of the allowed amount for the lumbar-sacral brace. The
allowed amount is $1,238.42 (20% x $1,238.42 = $247.68). The lumbar-sacral brace falls within the
"Prosthetic devices and related supplies" benefit category. This means that you have been asked to pay the
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance
for the lumbar-sacral brace provided on September 17, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an Ambulance Transport (A0425, A0429) provided December 31, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that the service was an emergency and the copayment should be waived. The Plan denied your request. The Plan says the correct copayment was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 copayment for Ambulance Services. You have been asked to pay a $275 copayment for the ambulance transport. The ambulance transport falls 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 an Ambulance Transport (A0425, A0429) provided December 31, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the emergency department physician's services provided on August 18, 2019.
You asked the Plan to pay for the emergency department physician's services. The Plan denied your request. The Plan says that the medical criteria has not been met.
The Plan must follow Medicare rules. The rules say that an emergency exists based on a prudent layperson standard, not a retrospective medical review. For symptoms to be considered emergent in nature, they must be such that a prudent layperson with an average knowledge of medicine would reasonably expect the absence of immediate medical attention would result in serious jeopardy to their health. We decided that this case does meet prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine would reasonably expect the absence of immediate medical care to seriously jeopardize their health in this case. Therefore, we decided that the Plan has to pay for emergency department physician's services provided on August 18, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from September 29, 2019 to October 10, 2019.You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you should not be responsible for the copayment because this was not a scheduled inpatient hospital stay and you were not approved for the skilled nursing facility when you first requested it.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 $250 copayment per day, days 1-7 for each in-network Medicare-covered hospital admission/stay. You have been asked to pay a $250 copayment for each day, days 1-7 for the inpatient hospital stay. ($250 x 7 = $1,750). The inpatient hospital stay falls 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. 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 inpatient hospital stay provided from September 29, 2019 to October 10, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a CT Scan of the abdomen and pelvis (74176) provided on October 10, 2019.
You asked the Plan to pay for the CT Scan. You say that you would like reconsideration because this service was medically necessary and provided in good faith. The Plan denied your request. The Plan says the documentation supports one unit of 74176-26 was previously approved/paid and there is no additional documentation supporting additional studies which were billed and remain denied.
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CT Scan have not been met. Specifically, the record indicates that CPT code 74176 was already approved and paid by the plan for this date of service. There is no documentation to support that this service was rendered multiple times. Therefore, we decided that the Plan does not have to pay for a CT Scan of the abdomen and pelvis (74176) provided on October 10, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forskilled nursing services provided  December 27, 2019 by an out of network (OON) provider.You asked the Plan to pay forskilled nursing services. You say that these services were medically necessary.The Plan denied your request. The Plan says no prior authorization was obtained.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 careand 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 forskilled nursing services provided  December 27, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to reduce the copayment for the office visit provided on September 23, 2019.
You asked the Plan to reduce the copayment for the office visit. You say that you were seen by the physician's
assistant at your primary care doctor's office. You say you should only have a $25 copayment. 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 $25 copayment for Medicare-covered in-network primary
care physician services.
The Plan says you must pay a $50 copayment for the office visit. Based on the Plan contract, however, you
cannot be asked to pay more than a $25 copayment for the office visit. The record shows that a Physician
Assistant is not considered a specialty. Therefore, we decided that the Plan has to reduce the copayment for the
office visit provided on September 23, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services (90837) provided on October 1, 2019 to October 29, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the psychotherapy services. You say that the services were medically necessary. The Plan denied your request. The Plan says services were not emergent or preauthorized. There were network providers available.
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 psychotherapy services (90837) provided on October 1, 2019 to October 29, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on December 24,
2019.
You asked the Plan to waive the copayment for the office visit. You say that you should only be billed a $10
copayment. 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 $45
copayment for each specialist office visit. Covered services include consultation, diagnosis, and treatment by a
specialist.
You have been asked to pay $11.27, which is less than the standard $45 copayment for the office visit. The
office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category.
The records show that the provider is a gastroenterologist, which is considered a specialist. 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 office visit provided on December 24, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for a mammogram (77067, 77063) provided January 14, 2020.
You asked the Plan to waive the deductible for the mammogram. You say that the deductible should be waived. The Plan denied your request. The Plan says the correct cost-sharing was applied. 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 there is a $5,100 deductible for all covered services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $5,100 deductible for all covered services. This cost sharing is a contractual obligation that had not been met at the time the mammogram was received on January 14, 2020. Therefore, we decided that the Plan does not have to waive the deductible for a mammogram (77067, 77063) provided January 14, 2020.