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

We decided that the Plan does not have to waive the copayment for the laryngoscopy provided on July 16, 2019.
You asked the Plan to waive the copayment for the laryngoscopy. You say that medical benefits should not have been paid to the provider. 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 $310 copayment for Medicare-covered outpatient surgery at in in-network outpatient hospital. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $310 copayment for the laryngoscopy.
You have been asked to pay a $187.71 copayment for the laryngoscopy. The laryngoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical center" 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 laryngoscopy provided on July 16, 2019.
Your complaint that you are still sick and getting sicker from the same problem 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 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 the documentation does not support that the enrollee's nursing, medical and rehabilitation needs require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee is medically stable and does not have complex medical issues that require acute rehab nursing care, or monitoring by an inpatient rehabilitation physician three times per week. While the enrollee is expected to benefit from continuing physical therapy (PT) and occupational therapy (OT), there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to 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 pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on February 20, 2020.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 there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 pay for the drug testing rendered on February 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral exam (D0150) and intraoral -
periapical each additional x-rays (D0230) provided February 4, 2020 to February 7, 2020.
You asked the Plan to pay for the dental services. You say that when you had these procedures you were
advised by the dental office that all of these procedures are covered and you are not responsible for paying
anything. The Plan denied your request. The Plan says the benefit frequency limitation has been exceeded.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The plan contract says that
comprehensive oral exams are covered every 3 years and only 1 set of periapical x-rays are covered per year.
The records show that the plan paid for a comprehensive oral exam on October 11, 2018 and an intraoral x-ray
on February 4, 2020.
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
comprehensive oral exam (D0150) and intraoral - periapical each additional x-rays (D0230) provided February
4, 2020 to February 7, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ground mileage provided on September 27, 2019.
You asked the Plan to pay for the ground mileage. You say that an enrollee does not start hospice care until the initial assessment and plan of care is developed. You also say that true proof was not provided from the hospice that the enrollee had started care on September 27, 2019. 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 ground mileage provided on September 27, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for an injection provided on January 29, 2020.
You asked the Plan to reduce the coinsurance for an injections. You say that you were told that you would only owe $78. The Plan denied your request. The Plan says the correct coinsurance 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 10% coinsurance up to a quarterly maximum of $300 for Medicare Part B prescription drugs/network. You have been asked to pay a 10% coinsurance of the allowed amount up to a quarterly maximum of $300 for an injection. The total coinsurance amount is higher than your maximum amount of $300; therefore, the total coinsurance has been applied. An injection falls within the Medicare Part B prescription drugs/network 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 reduce the coinsurance for an injection provided on January 29, 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 require services at the LTACH that are not already available and being received at the current acute care facility. There are no services available at the proposed LTACH that the patient requires that are not available at the current acute care facility or a skilled nursing facility. Therefore, this request for LTACH services is not sufficiently supported and will be considered not medically necessary, based on the provided records.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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on March 16, 2020.
You asked the Plan to waive the copayment for the emergency room visit. You say that you were not held for observation. You say you were admitted as an inpatient and should be charged the inpatient copayment. 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 $50 copayment for each Medicare-covered emergency room visit. You have been asked to pay a $50 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. The medical record shows your hospitalization status was observation.
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 emergency room visit provided on March 16, 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 requested LTACH care is medically reasonable and necessary. The Plan denied your request. The Plan says the requested LTACH care is not considered medically reasonable and necessary in this case.
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 was admitted to the acute care hospital on 6/19/20 with profound hypoglycemia. Intubation was required. The enrollee was found to have a urinary tract infection. The enrollee has now been extubated, but failed a swallowing study, and is receiving nutrition through an NG tube. Her mental status has improved over the course of her hospital stay. Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. The member is receiving acute hospital care, and acute care services have not been denied. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where she is currently receiving care. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the over-the-counter (OTC) items purchased October 7, 2018 to December 10, 2018.
You asked the Plan to pay for the OTC items. You say that you obtained a copy of your receipt around June of 2019 but misplaced it, however as soon as you located it you resubmitted. The Plan denied your request. The Plan says claim submitted after filing limit. Submissions under the Flex Benefit must be received with 90 days of the service or purchase date.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service. The record shows that a claim for the OTC items was not filed until December 16, 2019. This means that more than 90 days the date of service or purchase had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the over-the-counter (OTC) items purchased October 7, 2018 to December 10, 2018.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for Emergency Room Services provided February 3, 2020. You asked the Plan to pay for the Emergency Room Services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim was submitted incorrectly. 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 the Emergency Room services are not supported in the record. Specifically, the claim was submitted as an inpatient claim. The Emergency Room services must be submitted as a separate outpatient claim. Based on this information, we decided that Medicare rules for coverage of the Emergency Room Services have not been met. Therefore, we decided that the Plan does not have to pay for Emergency Room Services provided February 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory tests provided on January 10, 2020.
You asked the Plan to waive the copayment for the laboratory tests. You say that you made an appointment with the doctor but were seen by the physician assistant. You say that the copayment should be paid. 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 $10 copayment for in-network, Medicare-covered lab services. You have been asked to pay a $10 copayment for the laboratory tests. The laboratory tests 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 the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the laboratory tests provided on January 10, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for needle electromyography (95885), electromyography (95955), neuromuscular junction testing (95937) and nerve conduction studies (95908) provided on October 16, 2019.
You asked the Plan to pay for the neuromonitoring services. 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 services 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 95885 is needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited (List separately in addition to code for primary procedure). The CPT Code Manual definition of code 95995 is electromyography (EEG) during nonins (e.g., carotid surgery). The CPT Code Manual definition of code 95937 is neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method. The CPT Code Manual definition of code 95908 is nerve conduction studies; 3-4 studies. 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 neuromonitoring services. Our reviewer says that CPT codes 95885, 95955, 95937 and 95908 do not meet criteria for billing or reimbursement consideration. Our reviewer found these services are not documented in the record and are unable to be verified.
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 neuromonitoring services have not been met. Therefore, we decided that the Plan does not have to pay for needle electromyography (95885), electromyography (95955), neuromuscular junction testing (95937) and nerve conduction studies (95908) provided on October 16, 2019.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the definitive drug testing panel provided on April 16, 2019.You asked the Plan to pay for the definitive drug testing panel. You say that this was medically necessary testing that was ordered by the treating physician to ensure compliance with the enrollee's drug treatment regimen.The Plan denied your request. The Plan says that the records do not support that 8-14 drug classes were tested in this case to support payment of G0481.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 G0481 is Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 8-14 drug class(es), including metabolite(s) if performed.We find that CPT code G0481 is supported in the medical record. Specifically, the documentation includes an order which supports that the physician intended between 8 and 14 drug classes to be tested. The laboratory report reflects that no fewer than 8 drug classes were tested. Based on this information, we decided that Medicare rules for coverage of the definitive drug testing panel have been met.Therefore, we decided that the Plan has to pay for the definitive drug testing panel provided on April 16, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the oxygen equipment provided on December 19, 2019.You asked the Plan to waive the coinsurance for the oxygen equipment. You say that you do not agree with paying for the durable medical equipment because the contract changed. 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 in-network Medicare-covered item. You have been asked to pay $17.77 which is 20% of the allowed amount for the oxygen equipment. The allowed amount is $88.81. ($88.81 x 20% = $17.77). The oxygen equipment falls within the "Durable medical equipment and related supplies (DME)" 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 oxygen equipment provided on December 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ophthalmic biometry provided on February 24, 2020.
You asked the Plan to waive the copayment for the ophthalmic biometry. You say that insurance didn't pay toward the claim. You say that this is incorrect. 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 $40 copayment for each specialist visit. Covered services include consultation, diagnosis, and treatment by a specialist. You have been asked to pay $34.82, which is less than the standard $40 copayment for the ophthalmic biometry. The ophthalmic biometry falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.
Therefore, we decided that the Plan does not have to waive the copayment for the ophthalmic biometry provided on February 24, 2020.