Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for psychiatrist office visits (99213) on April 9 to May 3, 2021.

You asked the Plan to waive the copayments for psychiatrist office visits. You say that the charge at issue is not the correct copayment for a specialist visit. 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 $40 copayment for each Medicare-covered individual or group visit. 

You have been asked to pay $80, or a $40 copayment for each date of service, for psychiatrist office visits. Psychiatrist office visits fall within the "Outpatient mental health 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 copayments for psychiatrist office visits (99213) on April 9 to May 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator.
You asked the Plan to pre-approve a home ventilator. 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 follows Medicare rules. Medicare rules say that ventilators (E0465, E0466, and E0467) are covered
for specific conditions.
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 a home ventilator. Our reviewer says
that the services are not medically necessary. Our physician reviewer found based on the medical records
provided there is no documentation that you meet the coverage criteria detailed in the Local Coverage
Determination (LCD), Respiratory Assist Devices L33800. The requested device is reported to be used in a
bilevel positive airway pressure mode.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does
not have to pre-approve a home ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services you received on March 3, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not covered when provided by a chiropractor.
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 chiropractic services you received on March 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient hospital services provided from March 4, 2021, to March 25, 2021.
You asked the Plan to waive the copayment for application of multi-layer compression system (29581) and punch biopsy (11104). You say that you have never had a copayment for this type of service before. The Plan denied your request. The Plan says you were charged the copayments 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 $250 copayment for Outpatient hospital services. You have been asked to pay $250 copayment for application of multi-layer compression system (29581), punch biopsy (11104). Application of multi-layer compression system (29581) and punch biopsy (11104) falls within the Outpatient Hospital services benefit category. On March 4, March 11, and March 25, 2021 the allowed amount for the application of multi-layer compression system was less than your copayment. 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 outpatient hospital services provided from March 4, 2021, to March 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for office services provided on May 6, 2021.
You asked the Plan to waive the deductible for office services. You say that you want the Plan to pay for this
medical care. The Plan denied your request. The Plan says the deductible amount you are being charged is
correct.
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 $203 deductible which applies to office services. At the time this claim
was processed, $0 of the $203 deductible had been met. The allowed amount of this claim is $153.65, resulting
in a deductible amount of $153.65.
The item or service you asked the Plan to waive the deductible for falls within the benefit category
Physician/Practitioner Services, Including Doctor's Office Visits. The Plan has followed Medicare rules by
clearly disclosing in the contract that there is $203 deductible which applies to Physician/Practitioner Services,
Including Doctor's Office Visits. This cost sharing is a contractual obligation that had not been met at the time
office services was received on May 6, 2021. Therefore, we decided that the Plan does not have to waive the
deductible for office services provided on May 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no information showing enrollment in a clinical trial. 
 
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 to show safety and efficacy of the device. 
 
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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient office visit (99203) arthrocentesis, aspiration and/or injection (20610) provided February 22, 2021.
You asked the Plan to waive the copayment for the office visit. You say that you are disputing all charges and would appreciate further investigation regarding this matter. The Plan denied your request. The Plan says this claim was processed with the correct copayment applied per the Evidence of Coverage.
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 $25 copayment for diagnostic procedures and tests in a specialist's office. You have been asked to pay $25 copayment for the office visit. The office visit 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 the outpatient office visit (99203) arthrocentesis, aspiration and/or injection (20610) provided February 22, 2021.
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 these services are medically necessary. The Plan denied your request. The Plan says that you do not need three hours a day of therapy, your medical illnesses are stable, and you do not need a physician to monitor them three times a week.
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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do require physical therapy and occupational
therapy services but based on the medical records provided you do not require an intensive inpatient rehabilitation therapy program. There is no documentation that you require the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on October 23, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are available in-network.
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 had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services 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 the services provided by an out-of-network provider on October 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the esophagogastroduodenoscopy, flexible, 
transoral, with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy 
(43239) esophagogastroduodenoscopy, flexible, transoral, insertion of guide wire followed by dilation of 
esophagus over guide wire (43248) provided April 14, 2021. 
 
You asked the Plan to waive the copayment for the outpatient surgery services. You say that you are unhappy 
with the deductible charges and you would like them to be overturned. You had to get this test done because 
you were having difficulty swallowing. You should not have to pay this much for one test. The Plan denied 
your request. The Plan says prior to these services, the enrollee had satisfied $300.96 of the $750 yearly 
deductible therefore, the claim was processed with the correct cost share applied per the Evidence of Coverage. 
 
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 $750 deductible which applies to Outpatient surgery, including services 
provided at hospital outpatient facilities and ambulatory surgical centers.  
 
The item or service you asked the Plan to waive the copayment for falls within the benefit category Outpatient
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. The Plan 
has followed Medicare rules by clearly disclosing in the contract that there is $750 deductible which applies to 
Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. 
This cost sharing is a contractual obligation that had not been met at the time the outpatient surgery services 
was received on April 14, 2021. Therefore, we decided that the Plan does not have to waive the copayment for 
the esophagogastroduodenoscopy, flexible, transoral, with transendoscopic ultrasound-guided intramural or 
transmural fine needle aspiration/biopsy (43239) esophagogastroduodenoscopy, flexible, transoral, insertion of 
guide wire followed by dilation of esophagus over guide wire (43248) provided April 14, 2021.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the rotary wing air mileage, per statute mile (A0436), and the ambulance service, conventional air services, transport, one way (rotary wing) (A0431) provided on October 5, 2020.
You asked the Plan to pay for the air ambulance services. You say that the claim should be reprocessed according to the CMS guidelines as secondary and for the correct secondary payment. The Plan denied your request. The Plan says that the payment made by the enrollee's primary insurance exceeded the allowable amount. The Plan also says that the claim was processed correctly based on the Plan's allowed amount of $5,590.73.
The Plan must follow Medicare rules. Medicare rules say that plans must identify payers that are primary to Medicare, identify the amounts payable by the primary payer, and coordinate benefits to Medicare enrollees with the benefits of the primary payer. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the air ambulance services have been met. Specifically, the file shows that the amount that Medicare would pay if the services were not covered by the primary insurance without regard to any Medicare deductible and or coinsurance would be $8,386.51. This was the lowest payment calculation. The record shows that the Plan used the non-rural allowable amount of $5,590.73 when calculating the amount due, however, the zip code where the pick up took place is defined as rural by Medicare. The Plan is responsible for $8,386.54 less the 4% coinsurance, or $8,051.08. Therefore, we decided that the Plan has to pay for the rotary wing air mileage, per statute mile (A0436), and the ambulance service, conventional air services, transport, one way (rotary wing) (A0431) provided on October 5, 2020.
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 Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic activities provided on February 26, 2020.
You asked the Plan to pay for therapeutic activities. The Plan denied your request. The Plan says that the Plan has insufficient documentation to corroborate the services to confirm Medicare coverage has been met.
The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. The file shows that you did not submit sufficient medical documents to justify payment of the claim. Based on this information, we decided that Medicare rules for coverage of therapeutic activities have not been met. Therefore, we decided that the Plan does not have to pay for therapeutic activities provided on February 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device to 
be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a CPAP device to be provided by an OON provider. You say that the 
services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able 
to provide these services. Therefore, coverage criteria have not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a continuous positive airway pressure (CPAP) device to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the lumbar injection provided on May 3, 2021.
You asked the Plan to waive the copay for the service provided. You say that the cost is too much. The Plan denied your request. The Plan says the claim processed 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 $225 copay for outpatient surgery. The file shows that you received a lumbar epidural injection. This is considered a surgical service. You have been asked to pay a $225 copay for the service provided. The services fall 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 copay for the lumbar injection provided on May 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the special anesthesia service for patients younger than 1 or older than 70 provided on November 17, 2020, billed with code 99100.
You asked the Plan to pay for the special anesthesia services. You say that these services should be reimbursed. The Plan denied your request. The Plan says payment was approved for code 00630; however, 99100 is not separately payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Code 99100 has a status indicator of "B" in the Physician Fee Schedule. This means Medicare rules for coverage of the special anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the special anesthesia service for patients younger than 1 or older than 70 provided on November 17, 2020, billed with code 99100.that payment for this service is always bundled with payment for other services. Based on this information, we decided that
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the dialysis services (90999) provided February 22, 2021 to July 11, 2021.
You asked the Plan to waive the copayment for the dialysis services. You say that you have low income for the year. You only have social security and a pension. You make less than 29 thousand a year. There are multiple claims being billed all for the coinsurance. The Plan denied your request. The Plan says the claim was processed correctly with the correct cost share applied per the Evidence of Coverage.
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 outpatient renal dialysis services. You have been asked to pay $2,718.00 coinsurance for the dialysis services. The dialysis services fall within the Services to treat kidney disease 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 dialysis services (90999) provided February 22, 2021 to July 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography coded 70450 provided on May 6, 2021.
You asked the Plan to pay for the computed tomography. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 for the computed tomography has a bundled relationship with code 70496 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography coded 70450 provided on May 6, 2021.