Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic exercises provided on January 27, 2021.
You asked the Plan to pay for the therapeutic exercises. You say that plans are required to pay non-contracted
providers at the preferred provider rate if services are not available from preferred providers. You say that the
in-network benefits should be honored, and the claim processed for payment. The Plan denied your request.
The Plan says an appropriate modifier was not billed with this code edit.
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 97110
has a bundled relationship with code 92526 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 therapeutic exercises provided on January 27, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the GeneSight testing rendered on January 19, 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 that the services were not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that pharmacogenetic testing is covered when specific criteria are met. 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 services were medically necessary. Our physician reviewer found the enrollee has a diagnosis of recurrent moderate major depressive disorder, adjustment insomnia, and hypersomnia. She has a diagnosis for which pharmacologic therapy is reasonable and necessary, and the drug or drugs that the clinician is considering using must be reasonable and necessary for the treatment of these diagnoses. The submitted records support that the criteria for coverage are met and the testing was reasonable and medically necessary for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pay for the GeneSight testing rendered on January 19, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a non-invasive home ventilator.
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary for treatment of chronic obstructive pulmonary disease (COPD) and chronic respiratory failure (CHF). The Plan denied your request. The Plan says the request for a home mechanical ventilator set in average volume-assured pressure support (AVAPS) mode that could be delivered by bilevel positive airway pressure (BiPAP) is not covered.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 ventilator. Our reviewer says that the requested ventilator is not medically reasonable or necessary. Our physician reviewer found you have restrictive lung disease related to severe obesity, obstructive sleep apnea (OSA), and heart failure with preserved ejection fraction (HFpEF). You also likely have obesity-hypoventilation syndrome (OHS). The
medical records indicate that you did well on BiPAP in the past. There is no documented failure of BiPAP. There is no documentation of carbon dioxide (C02) retention. Medicare does not cover a home ventilator for the treatment of OHS or OSA. 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 ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a non-invasive home ventilator.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for supervision of a nursing facility patient (99380) provided on March 29, 2021.
You asked the Plan to pay for nursing facility visit. You say that your provider performed medically necessary services in good faith. The Plan denied your request. The Plan says the denial of payment for this service is correct, because payment for this service is always bundled and no separate payment is made.
The Plan must follow Medicare rules. Medicare rules say that payment for code 99380 is always bundled and it is not separately payable. We looked at the file and Medicare rules. Payment for this code is always bundled so it is not separately payable. Based on this information, we decided that Medicare rules for coverage of nursing facility visit have not been met. Therefore, we decided that the Plan does not have to pay for supervision of a nursing facility patient (99380) provided on March 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the occlusal guard (D9944) provided on June 14, 2021.
You asked the Plan to pay for the occlusal guard (D9944). You say that your dentist recommended the occlusal guard to wear because you clench your teeth when you sleep. You say that this is not for cosmetic purposes and should be covered. The Plan denied your request. The Plan says the service is not a covered benefit.
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 occlusal guard (D9944) provided on June 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the chest x-ray and the computed tomography (CT) scan of the abdomen and pelvis you had on January 27, 2021.
You asked the Plan to waive the copayments for the x-ray and the CT scan. You say that you should only be charged one copayment because these tests were done at the same time. The Plan denied your request. The Plan says you were charged these 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 a $45 copayment for x-rays and a $200 copayment for complex radiology (including CT scans). You have been asked to pay a $45 copayment for the x-ray and a $200 copayment for the CT scan. The chest x-ray and the CT scans are in different benefit categories in your Evidence of Coverage. The x-ray is a basic radiology service and the CT scan is a complex radiology service. Because these services were in different benefit categories, separate cost sharing can apply. The 'per provider, per date of service' language in your contract applies only to services within the same benefit category. For example, had you received two x-rays on this date, only one copayment would apply. However, because these services were different, that is not the case here. 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 the chest x-ray and the computed tomography (CT) scan of the abdomen and pelvis you had on January 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for additional supplies provided on February 11, 2021.
You asked the Plan to pay for additional supplies (99072). You say that the Plan should pay this claim. The Plan denied your request. The Plan says this procedure is always bundled into payment for other services.
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 additional supplies (99072) has a bundled relationship with code 99199 and cannot be paid as billed. This code has a status code of B, bundled service. 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 additional supplies provided on February 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the outpatient services provided on May 19, 2021.
You asked the Plan to reduce the copayment for injection(s), of diagnostic or therapeutic substance (62323). You say that you thought the copayment was $275. The Plan denied your request. The Plan says you were charged the correct copayment.
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 outpatient surgery in an outpatient hospital facility. You have been asked to pay a $350 copayment for injection(s), of diagnostic or therapeutic substance (62323). Injection(s), of diagnostic or therapeutic substance (62323) falls within the outpatient surgery in an outpatient hospital facility 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 copayment for the outpatient services provided on May 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the injections provided on January 28, 2021, February 23, 2021 and April 5, 2021.
You asked the Plan to reduce the copayment for the injections. You say that you paid a $125 copayment three times instead of $75. You say that this is wrong for copayments at the ambulatory surgery center and you are appealing the charges. The Plan denied your request. The Plan says the copayments 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 $125 copayment for Medicare-covered outpatient hospital services.
You have been asked to pay a $125 copayment each injection. The total amount you owe is $375 ($125/injection x 3 injections = $375). The injections fall within the "Outpatient hospital services" benefit category. The records show the injections were billed by the hospital. 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 copayment for the injections provided on January 28, 2021, February 23, 2021 and April 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the evaluation and management services provided on March 10, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the OON services. You say that the service was provided with no adequate time frame to obtain authorization. The Plan denied your request. The Plan says authorization is required for out-of-network providers.
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 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 evaluation and management services provided on March 10, 2020 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the services (99205) provided on April 8, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that this code is not
payable.
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 argues that code 99205 is a column 2 code to column 1 codes 77263,
77470, and 77334. However, a code pair check shows that there are no edits between these codes. As such,
code 99205 is payable in this case. The Plan has not provided documentation to substantiate its denial.
Therefore, we decided that the Plan has to pay for the services (99205) provided on April 8, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement services provided on May 26, 2021, by an
OON provider.
You asked the Plan to pay for the debridement services. You say that the enrollee has no control over which
physician they see when they are in the nursing facility. The Plan denied your request. The Plan says no prior
authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The
records provided for review do not show that the services at issue were urgent or emergent. Therefore, we
decided that the Plan does not have to pay for the debridement services provided on May 26, 2021, by an OON
provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided on December 1,
2020, to December 2, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that enrollee's working diagnosis with
inherent potential complications, the severity of illness at the time of evaluation and an estimate of the risk to
decompensate based on the clinical features of the case. The Plan denied your request. The Plan says the
enrollee tolerated the procedure without complications. The Plan says that inpatient hospital care was not
medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
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 acute inpatient hospital care. Our reviewer
says that the documentation does not support that the criteria for inpatient payment were met in this case. Our
physician reviewer found the review has determined that there were no complications noted during the
procedure. The record did not show that at the time of inpatient admission the admitting physician reasonably
expected that the enrollee's necessary hospital care (including earlier emergency department and/or observation
care) would span two midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the
Plan does not have to pay for the acute inpatient hospital care provided on December 1, 2020, to December 2,
2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency ambulance transportation services (A0429) provided on June 19, 2021.
You asked the Plan to waive the copayment for the ambulance services. You say that you feel your copays are higher than they should be. The Plan denied your request. The Plan says this claim was processed correctly, and your copayment was assessed in accordance with your contract.
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 $300 copayment for ambulance services. You have been asked to pay a $300 copayment for the ambulance 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 the emergency ambulance transportation services (A0429) provided on June 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and services provided from June 7, 2021, to June 16, 2021.
You asked the Plan to waive the copayment for the inpatient care. You say that your previous copay for a hospital stay in January was waived, and you feel this cost-share should be waived as well. The Plan denied your request. The Plan says the January copayment for hospital services was waived because your care was provided to treat a COVID-related diagnosis. At that time, the Plan was choosing to waive copays for COVID-related claims. However, that waiver period has since ended, and the copayment applies in this case.
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 $200 copayment for each of the first five days of an inpatient hospital stay. There is a $0 copayment after day five.
You have been asked to pay a $1,000 copayment for the 10-day inpatient hospital stay. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital admission and services provided from June 7, 2021, to June 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device (HFCWOD) for the enrollee.
You asked the Plan to pre-approve a HFCWOD. You say that this is medically necessary. The Plan denied your request. The Plan says there is no information showing that this is necessary for complications due to bronchiectasis, cystic fibrosis, or a neuromuscular disease.
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. 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 HFCWOD. Our reviewer says that the requested device is not medically reasonable or necessary.
Our physician reviewer found in this case, the enrollee has dementia and aspiration pneumonia causing respiratory failure. The record does not indicate that the enrollee has an enumerated condition for which coverage is available under the coverage criteria. The elements of the coverage criteria are not satisfied. 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 HFCWOD have not been met. Therefore, we decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device (HFCWOD) for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (76937) provided on March 9, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the add-on code was not billed with an appropriate primary code.

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 76937 is an add-on code that has not been billed with the required primary procedure code. This code cannot be paid as billed. 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 services (76937) provided on March 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the esophagogastroduodenoscopy (EGD) you had at an ambulatory surgery center on May 14, 2021.
You asked the Plan to waive the copayment for the EGD. You say that you cannot afford this copayment. 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 $275 copayment for outpatient surgery at an ambulatory surgery center. You have been asked to pay a $275 copayment for the EGD. The EGD falls within the outpatient surgery at an ambulatory surgery 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 esophagogastroduodenoscopy (EGD) you had at an ambulatory surgery center on May 14, 2021.