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

 We decided that the Plan does not have to waive the copayment for an electrocardiogram (EKG) provided on October 1, 2021.  

You asked the Plan to waive the copayment for the EKG. You say that the EKG should be part of the semi-annual cardiology visit. 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 $30 copayment for non-radiological diagnostic services.   

Please note that the testing performed is a separate charge from the specialist office visit copayment. Therefore, you have been asked to pay $16.13, which is less than the $30 copayment for the EKG.  

The EKG falls 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 an electrocardiogram (EKG) provided on October 1, 2021.
Appeal type: Lab
Decision: Favorable

 We decided that the Plan has to pay for the lab services (88120) provided on May 10, 2021.  You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says that the diagnosis code does not substantiate this service.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has not provided documentation supporting that code 88120 is not substantiated by the billed diagnosis code. Without supporting documentation, the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the lab services (88120) provided on May 10, 2021.   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: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the x-ray of the ankle you had on July 15, 2021.  You asked the Plan to waive the copayment for the x-ray. You say that you do not want to pay the copayment to have this doctor read your x-ray. The Plan denied your request. The Plan says you were charged this copayment 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 $35 copayment for basic radiology services.   You have been asked to pay a $35 copayment for the x-ray. The records do confirm that you had x-rays of the left foot and ankle on this date of service. 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 x-ray of the ankle you had on July 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection rendered on August 9, 2021.

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 the services are not covered.

The Plan must follow Medicare rules. Medicare rules say that for code 62320 to be covered, certain documentation requirements must be met. 

The medical records in this case do not meet Medicare's documentation requirements. Specifically, the record is not signed and there is no notation of the percent of pain relief achieved either before or after the injection. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of procedure code 62320 have not been met. Therefore, we decided that the Plan does not have to pay for the injection rendered on August 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from November 5, 2020, to November 7, 2020.  You asked the Plan to waive the copayment for the inpatient hospital services. You say that you used up your 6 days for inpatient care earlier in the year. 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 $275 per day for days 1-6 and $0 per day after day 6 for each inpatient stay, subject to an annual maximum of $1,925.    The file shows you were in the hospital from November 5, 2020, to November 7, 2020. This is considered a new benefit period since you surpassed 60 consecutive days without hospitalization. You have been asked to pay $275 per day for only the first day of inpatient hospital services. Please note that the applied copayment for the first 6 days applies to each benefit period. The inpatient hospital services fall within the Inpatient Hospital Care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 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 inpatient hospital services provided from November 5, 2020, to November 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Rifton Tram frame and accessories for the enrollee.  You asked the Plan to pre-approve these items. You say that the enrollee needs this to walk safely. The Plan denied your request. The Plan says that this device is not primarily medical in nature.  The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a Rifton Tram frame and accessories for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the outpatient office visit (99214) individual psychotherapy (90833) provided March 11, 2020.  

You asked the Plan to pay for the outpatient visit. You say that the enrollee had established a relationship with the provider and did not want to change in the middle of her treatment. A referral was obtained but the claims denied for timely filing. The Plan denied your request. The Plan says the limit for filing has expired.  

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 outpatient visit was not filed until August 3, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99214) individual psychotherapy (90833) provided March 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the bone replacement graft (D7953), and removal of impacted tooth (D7241) provided on September 8, 2021, by an out-of-network dentist.  You asked the Plan to pay for the dental services. You say that the coverage documents state extractions, including surgical are covered for out of network providers. You say that there is no code mentioned in those documents. You also say that no pre-authorization would have been filed as this is the surgical complexity could not be pre-determined in this case. The Plan denied your request. The Plan says the claim was processed correctly.    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 bone replacement graft and removal of an impacted tooth are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the bone replacement graft (D7953), and removal of impacted tooth (D7241) provided on September 8, 2021, by an out-of-network dentist.
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.      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 you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a lower level of 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: SNF
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for skilled nursing facility services provided from June 8, 2021, to June 29, 2021.  You asked the Plan to waive the copayment for the skilled nursing facility services. You say that the services should be covered as it is not your fault that the home health services were not set up in time. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.  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 $184 copayment for days 21-40 for Skilled nursing facility (SNF) care.   You have been asked to pay a $184 copayment for day 21 of skilled nursing facility services. 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 skilled nursing facility services provided from June 8, 2021, to June 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient hospital services rendered from August 8, 2020 to August 11, 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 the submitted records do not support the billing of DRG 871 and principal diagnosis A41.9.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.    In this case, you billed the inpatient services provided with DRG 871 and principal diagnosis A41.9 (sepsis, unspecified organism). 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 these services. Our reviewer says that the submitted records do not support the billing of DRG 871 and principal diagnosis A41.9. Our physician reviewer found the enrollee was treated in the hospital for pneumonia and altered mental status with pain medication and antibiotics. The white blood cell count went down from 14 to 10 with treatment. Creatinine returned to normal with fluids and her vitals were stable. The records do not support the billing of DRG 871 and diagnosis A41.9, as the enrollee did not have clear signs of sepsis via symptoms clinical examination, or lab testing. There was no evidence of organ failure.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services rendered from August 8, 2020 to August 11, 2020.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.  You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to insufficient evidence of efficacy.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental. More research is needed.       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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for a regadenoson injection provided on September 10, 2021.  

You asked the Plan to waive the coinsurance for the injection. You say that you were only made aware of the $100 copayment and you do not feel responsible for the coinsurance. The Plan denied your request. The Plan says the correct coinsurance 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 20% coinsurance for Part B drugs, including injectable drugs.   

You have been asked to pay $45.26, which is 20% of the allowed amount for the injection ($226.29 allowed amount x 20% coinsurance = $45.26). The injection falls 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 a regadenoson injection provided on September 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by a participating provider on September 27, 2021.  You asked the Plan to pay for a limited oral evaluation. You say that you moved to Texas. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says the benefit limit for a limited oral evaluation has already been exhausted.  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 one limited oral evaluation per plan year.   We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a limited oral evaluation have already been met. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by a participating provider on September 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the two-dimensional (2D) oral/facial photographic image (D0350) provided on November 29, 2021.  You asked the Plan to pay for the 2D oral/facial photographic image. You say that you would like to know if you can see another provider, or an explanation to why you were sent to them and later told the provider is not in-network. The Plan denied your request. The Plan says this service is not covered under your benefit plan.    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 two-dimensional (2D) oral/facial photographic image (D0350) provided on November 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on October 8, 2021.  You asked the Plan to pay for the dental service. You say that this was not a regular dentist visit. You say that you were referred to a specialist to diagnose a new problem. You say that you did not think that the 6 month rule applied to a specialist visit. You also say that you feel you should only have to pay the $50 specialist copay. The Plan denied your request. The Plan says 1 limited oral evaluation is covered per calendar year. The Plan also says that the frequency limit 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.  Though the Plan offers a dental benefit in excess of Medicare coverage and the service is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a limited oral evaluation that you received on September 30, 2021. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on October 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for mechanical traction (97012) electrical stimulation (G0283) provided August 9, 2021.  You asked the Plan to pay for the chiropractic service. You say that this claim did not process with a PR reason code which it should have done per Medicare guidelines. The Plan denied your request. The Plan says these services are not covered under the Plan benefits.  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 service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for mechanical traction (97012) electrical stimulation (G0283) provided August 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the post stabilization care provided from April 29, 2021, to May 4, 2021.  You asked the Plan to pay for post-stabilization care. You say that the enrollee was not stable for transfer and the Plan was notified of this in a timely manner. The Plan denied your request. The Plan says the enrollee was stable with normal vital signs upon admission and could have been transferred to a contracted facility.  The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required.   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 post-stabilization care. Our reviewer says that the enrollee could have been transferred to a contracted facility at the time of hospital admission. Our physician reviewer found while the treating physician did state that the enrollee was not stable for transfer at the time of admission on April 30, 2021, the documentation suggested that the enrollee was stable for transfer to a contracted facility as of 12:19 AM on April 30, 2021. The enrollee was reported to have improved significantly after initial resuscitation treatments in the emergency department and was hemodynamically stable for transfer via ambulance at that 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 post-stabilization care have not been met. Therefore, we decided that the Plan does not have to pay for the post stabilization care provided from April 29, 2021, to May 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on September 27, 2021, to October 7, 2021.  You asked the Plan to pay for dental services. You say that you were unaware your dentist was not in-network. The Plan denied your request. The Plan says when services obtained out-of-network, the Plan only pays up to a certain amount.  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 have been provided by an out-of-network provider. When you use an out-of-network provider, your share of the costs for your covered services may be higher. Therefore, we decided that the Plan does not have to pay for dental services provided by an out-of-network provider on September 27, 2021, to October 7, 2021.