Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay on January 28, 2020, to January 31, 2020.

You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you do not know why you are being charged $120 and $350. 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 $350 copayment for inpatient hospital care. 

You have been asked to pay a $350 copayment for an inpatient hospital stay. An 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 an inpatient hospital stay provided on January 28, 2020, to January 31, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for genicular nerve radiofrequency ablation procedure (64624) provided on November 3, 2020.

You asked the Plan to pay for genicular nerve radiofrequency ablation procedure. You say that please review the attached medical records for medical necessity. The Plan denied your request. The Plan says this procedure is considered investigational and not medically necessary for the treatment of chronic knee pain.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for genicular nerve radiofrequency ablation procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is an experimental/ investigational procedure that is the subject of on-going clinical trials. The enrollee is not enrolled in a clinical trial. Therefore, the procedure is not considered medically reasonable or 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 genicular nerve radiofrequency ablation procedure have not been met. Therefore, we decided that the Plan does not have to pay for genicular nerve radiofrequency ablation procedure (64624) provided on November 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on August 27, 2020.

You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you do not understand why this claim was denied. The Plan denied your request. The Plan says the treating provider opted out of Medicare effective July 16, 2015 to July 16, 2021. The Plan also says that you will not be reimbursed for charges incurred by Medicare Opt Out providers.

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 covered when they are received by a Medicare Opt Out provider. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on August 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the orthopedic surgery services (20610, J1030, 73564, 99203) provided on September 17, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the orthopedic surgery services. You say that these services were medically necessary, and the enrollee was referred to you by their in-network primary care provider. The Plan denied your request. The Plan says the referral was not authorized by the attending physician. The Plan does not cover services provided out-of-network except in specific circumstances.

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 referral provided does not specify to whom the enrollee is referred. The Plan had network providers available who could have provided 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 orthopedic surgery services (20610, J1030, 73564, 99203) provided on September 17, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-manipulative services provided from August 3, 2020, to September 2, 2020.

You asked the Plan to pay for office visits, therapy techniques, electrical stimulation and therapeutic procedures. You say that you would like the treatments be covered by the Plan. The Plan denied your request. The Plan says these services are not a covered benefit.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the non-manipulative services provided from August 3, 2020, to September 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an elevator lift.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. 

The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve an elevator lift.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that transfer to a long term care facility is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not 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 was admitted to the current acute care facility with recent COVID-19 infection, acute respiratory failure, pneumonia, and pneumothorax requiring chest tube and antibiotics. The chest tube was later successfully removed. The enrollee is currently requiring oxygen and BiPAP as needed. The enrollee appears to be stable and improving. The records do not show the enrollee needs care that cannot be provided in the current setting. Medicare coverage criteria for transfer are not met. 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services rendered on September 9, 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 procedure code 01936 was billed with an inappropriate modifier.

The Plan must follow Medicare rules. Medicare rules say that a physician reports the AA modifier and the CRNA reports the QZ modifier when both perform anesthesia services. 

We looked at the file and Medicare rules. The file shows that procedure code 01936 was billed with modifier QZ, which is not appropriate for the documented services. 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 anesthesia services rendered on September 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Superion interspinous spacer surgery.

You asked the Plan to pre-approve Superion interspinous spacer surgery. You say that this surgery is medically necessary. The Plan denied your request. The Plan says Medicare considers this surgery experimental.

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 Superion interspinous spacer surgery. Our reviewer says that Medicare coverage criteria are not met. Our physician reviewer found the spacer remains experimental. More research is needed to show safety and efficacy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Superion interspinous spacer surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve Superion interspinous spacer surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physician services provided by a participating provider on June 24, 2020.

You asked the Plan to waive the copayment for physician services. You say that you just had your lab results read and a prescription filled. 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 $10 copayment for physician/practitioner services/in-network/primary care physician. 

You have been asked to pay a $10 copayment for physician services. When services are provided like a medication refill, a copayment is applied; therefore, the correct copayment has been applied. Physician services falls within the physician/practitioner services/in-network/primary care physician 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 physician services provided by a participating provider on June 24, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the skin substitute graft (15276) provided on October 9, 2020.

You asked the Plan to pay for the skin substitute graft. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT 15726 has an MUE value of 3 and 5 units were billed.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. 

In this case, the MUE for CPT code 15276 is 3. You billed 5 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the skin substitute graft have not been met. Therefore, we decided that the Plan does not have to pay for the skin substitute graft (15276) provided on October 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the labs services provided on August 11, 2020.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says they are unable to determine how the enrollee came to the servicing provider.

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 services at issue are not supported in the records provided. The file shows that the Plan made several attempts to obtain the necessary documentation without success. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the labs services provided on August 11, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laser eye surgery (66821) provided from July 27, 2020 through July 29, 2020.

You asked the Plan to waive the copayment for laser eye surgery. You say that you were told by the physician's office that you would have to pay a lesser amount and you don't think the copayment is correct. 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 $275 copayment for outpatient surgery. 

You have been asked to pay a $275 copayment for laser eye surgery. Laser eye surgery falls within the outpatient surgery 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 laser eye surgery (66821) provided from July 27, 2020 through July 29, 2020.

Your complaint about the potential misinformation you recieved 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for out of network vision services provided on August 10, 2020, and August 24, 2020.

You asked the Plan to waive the cost share for this cost share. You say that you do not believe this bill is correct. The Plan denied your request. The Plan says you received services from an out of network vision provider. The Plan contract shows enrollees are responsible for a $45 copayment for Medicare Covered Vision Services in-network and refraction services are not covered. The Plan states enrollees are responsible for any fees over $75 for out of network vision providers.

Medicare 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. In this case you were charged the cost share appropriate for the services rendered and the type of provider they were received from. Therefore, we decided that the Plan does not have to waive the cost share for out of network vision services provided on August 10, 2020, and August 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on September 14, 2020.

You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare coverage criteria were not met.

The Plan must follow Medicare rules. Medicare has specific coverage criteria for this testing. 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 this service. Our reviewer says that Medicare coverage criteria are not met. Our physician reviewer found the guidelines noted there is a lack of evidence for using any tests other than PSA to determine the need for a referral for biopsy. The medical records show the enrollee did not have a diagnosis of prostate cancer. Therefore, the use of ConfrimMDx in this case was 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 this service have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on September 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound care supplies provided on October 9, 2020.

You asked the Plan to pay for Gauze, impregnated with other than water, normal saline, or hydrogel, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing (A6222) or Gauze, non-impregnated, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing (A6219). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the supplies are included in the payment for the procedure.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gauze, impregnated with other than water, normal saline, or hydrogel, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing (A6222) or Gauze, non-impregnated, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing (A6219) have not been met. Therefore, we decided that the Plan does not have to pay for the wound care supplies provided on October 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Vitamin D testing provided on July 7, 2020.

You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the services are not a Medicare benefit.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

The records do not show that the test was ordered to aid in the assessment of a medical condition or the identification of a disease. The test was not given to determine the nature and severity of an ailment or injury. The test at issue was requested for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for the Vitamin D testing provided on July 7, 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 provider on November 14, 2020.

You asked the Plan to waive the copayment for an emergency room visit. You say that you do not want to pay for this because no one helped you with anything. 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 $90 copayment for emergency care. 

You have been asked to pay a $90 copayment for an emergency room visit. The correct copayment has been applied to the emergency room visit that was provided. 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 provider on November 14, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that inpatient skilled nursing facility care is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for coverage of inpatient skilled nursing facility care.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 SNF care. Our reviewer says that inpatient skilled nursing facility care is not medically necessary. Our physician reviewer found that the documentation does not support that skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse is required to safely and effectively provide medically necessary and reasonable treatment only in a skilled nursing facility. The patient does not have complex wound care or other skilled nursing needs that require a skilled nursing facility stay. The patient's wound care does not need daily dressing changes or a SNF level of care. The patient's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment only in a skilled nursing facility. Skilled services are not needed on a daily basis or as practical matter in a skilled nursing facility setting.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to waive the copayment for an ultrasound of arterial inflow provided on November 2, 2020.

You asked the Plan to waive the copayment for an ultrasound of arterial inflow. You say that you disagree with the charges because you should not owe a copayment for ultrasounds. The Plan denied your request. The Plan says that 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. Your contract with the Plan says that enrollees must pay a $0 copayment for mammograms and ultrasounds. 

The Plan says you must pay a $100 copayment for an ultrasound of arterial inflow. Based on the Plan contract, however, you cannot be asked to pay more than a $0 copayment for an ultrasound of arterial inflow. Therefore, we decided that the Plan has to waive the copayment for an ultrasound of arterial inflow provided on November 2, 2020.