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

We decided that the Plan does not have to pay for the tissue transfer services provided on June 22, 2020.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says an
appropriate modifier was not billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate code.
We looked at the file and the rules. We find that CPT code 14040 was billed with code 14041. CPT code 14040
may be eligible for payment when billed with this code pair. However, the claim does not show that a suitable
modifier was billed for separate payment. Based on this information, we decided that Medicare rules for
coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay
for the tissue transfer services provided on June 22, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the aquatic therapy visits provided from May 27, 2021, to June 3, 2021.
You asked the Plan to waive the copayments for the aquatic therapy visits. You say that you are appealing these claims. The Plan denied your request. The Plan says you have been asked to pay 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 $25 copayment for each physical and speech therapy session.
You have been asked to pay a $25 copayment for the aquatic therapy visits on each date of service. The aquatic therapy visits fall within the "Outpatient rehabilitation services" 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 the aquatic therapy visits provided from May 27, 2021, to June 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the implantation of an auricular stimulator (64555, L8679).
You asked the Plan to pre-approve the implantation of an auricular stimulator. You say that this is a covered services. The Plan denied your request. The Plan says auricular peripheral nerve stimulation is non-covered.
The Plan must follow Medicare rules. Medicare rules say that auricular peripheral nerve stimulation will be denied as non-covered. This service is not a covered Medicare benefit because acupuncture for auricular stimulation does not meet the definition of reasonable and necessary under Section 1862(a)(1) of the Act. Devices used for the procedure auricular peripheral nerve stimulation or electro-acupuncture are considered a non-covered service. We looked at the file and Medicare rules. The requested services are non-covered. Based on this information, we decided that Medicare rules for coverage of the implantation of an auricular stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve the implantation of an auricular stimulator (64555, L8679).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the magnetic resonance imaging (MRI) of the upper extremity you had on June 26, 2021.
You asked the Plan to reduce the copayment for the MRI. You say that this MRI resulted in a $230.10 copayment for you. You stated that in the Plan portal, the cost estimator showed the cost to be $230 with $162 billed to you. You do not understand the difference between the portal estimator and the actual cost. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that the cost estimator is an estimate and is not exact. The Plan said that because the allowed amount for this MRI ($230.10) is less than your copayment obligation, you are responsible for the full allowed 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 $275 copayment for diagnostic radiology services.
You have been asked to pay a $275 copayment for the MRI. The MRI falls within the diagnostic radiology services 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 magnetic resonance imaging (MRI) of the upper extremity you had on June 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on January 2, 2021.
You asked the Plan to pay for the services provided. You say that the medical records support the billed code. The Plan denied your request. The Plan says the claim denied correctly.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. The claim shows 2 units of this code were billed, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the physician services provided on January 2, 2021.
Appeal type: Testing
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 June 18, 2021.
You asked the Plan to waive the copayment for the EGD. You did not provide an explanation for your appeal request. 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 $200 copayment for outpatient surgery and services provided at an ambulatory surgery center. You have been asked to pay a $200 copayment for the EGD. The EGD falls within the outpatient surgery and services provided 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 June 18, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to hold you harmless for a limited oral evaluation (D0140) provided on July 9,
2021.
You asked the Plan to hold you harmless for a limited oral evaluation. You say that you had pain in your gums
for a couple of days. You also say the provider would not extract your tooth without examining you. The Plan
paid for two x-rays but not the exam. You are requesting reconsideration of payment. The Plan denied your
request. The Plan says that the services provided are not covered on your 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.
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 been met. Therefore, we decided that the Plan has to hold you
harmless for a limited oral evaluation (D0140) provided on July 9, 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 you need IRF care for your recovery. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. You can safely receive the services you need in an alternate setting.
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 that the complexity of your nursing, medical and rehabilitation needs does not require
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services to evaluate and repair your teeth after an accident.
You asked the Plan to pre-approve dental care. You say that these services are necessary to restore your teeth. The Plan denied your request. The Plan says dental care is not covered by Original Medicare, with few exceptions. Dental services relating to accidental injury to sound and natural teeth are not covered, including the cost to repair or replace teeth (natural or dentures). Your Plan also does not offer additional benefits for dental care.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve dental services to evaluate and repair your teeth after an accident.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee clearly exceeds the Medicare criteria for appropriate LTACH admission. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.
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 is receiving appropriate care at the present acute care hospital. There are no services available at the LTACH which the enrollee requires that are not available at the health care setting being offered by the Plan.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services (90832) provided on April 26, 2021.
You asked the Plan to pay for the psychotherapy services. You say that you would like reconsideration because these services were medically necessary. The Plan denied your request. The Plan says there is no documented contact with the member's primary care physician.
The Plan must follow Medicare rules. Medicare rules say that when services are rendered by a Clinical Psychologist, if the patient consents, you must attempt to consult their attending or primary care physician about the provided services and document the consent or declination date to consultations and date of the consultations in the patient's medical record.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the psychotherapy services have not been met. Specifically, the record does not include any documentation of a consultation with the member's physician about the provided services. Additionally, there is no referring physician listed on the claim. Therefore, we decided that the Plan does not have to pay for the psychotherapy services (90832) provided on April 26, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve vestibular rehabilitation physical therapy to be rendered by the out-of-network (OON) provider.
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested service.
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 service at issue in this appeal. We found no exception that would require the Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve vestibular rehabilitation physical therapy to be rendered by the out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy with polyp 
removal you had at an outpatient hospital on July 2, 2021. 
 
You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that you had not had a 
colonoscopy in 15 years so you don't think you should have to pay 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 diagnostic colonoscopies at an outpatient hospital.  
 
You have been asked to pay a $275 copayment for the diagnostic colonoscopy. The billing records show that 
this colonoscopy was ordered because of fecal abnormalities.  In addition, you were found to have a polyp, 
diverticulosis, and hemorrhoidal skin tags. This was not billed as a screening colonoscopy.  Only screening 
colonoscopies have a $0 copayment. Because this was a diagnostic colonoscopy, 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 diagnostic colonoscopy with polyp removal you had at an outpatient hospital on 
July 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for long term acute care hospital (LTACH) services.
You asked the Plan to pay for the LTACH services. You say that the enrollee is ready to be discharged from the current facility and requires ongoing care at an LTACH. The Plan denied your request. The Plan says the criteria for admission to an LTACH are not met; there are no issues for which an LTACH may offer a therapeutic advantage. The Plan will continue to cover medically necessary acute and critical care at the current facility until the enrollee's condition is stable for transfer to a lower level of care or until the clinical circumstances change such that an LTACH may be considered.
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 pay for 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 there is no documentation provided indicating medical necessity for LTACH services. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being
offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 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 pay for long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the simple extraction (D7140) provided on May 17, 2021.
You asked the Plan to pay for the simple extraction. You say that you feel that having the tooth extracted was the best option for you. You also say that you believe this service should be covered due to health reasons. The Plan denied your request. The Plan says this service is not covered by your dental 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 simple extraction (D7140) provided on May 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on June 23, 2021.
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you did not know that your plan had changed this year and you were only allowed to have one cleaning instead of two. The Plan denied your request. The Plan says your benefits for these services have been satisfied and the frequency limitations have been exceeded. The Plan also says that you did not contact the Plan prior to the date of service to verify benefits and provider eligibility.
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, periodic oral evaluation (D0120) and prophylaxis (D1110) are each limited to one procedure code per calendar year. The record shows that you received a periodic oral evaluation (D0120) and prophylaxis (D1110) on March 26, 2021 and your periodic oral evaluation (D0120) and prophylaxis (D1110) benefits have been exhausted. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on June 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the office visits you had with a urologist on May 27, 2021, June 24, 2021, June 25, 2021, July 13, 2021, and August 12, 2021, the office visit you had with a vascular surgeon on August 12, 2021, and the urinary supplies you received on June 25, 2021, and July 13, 2021.
You asked the Plan to waive the cost sharing for the specialist visits and the medical supplies. You say that these copayments should be waived because these items and services were needed due to an error. 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 $32 copayment for visits with a specialist and 20% coinsurance for durable medical equipment and supplies.
You have been asked to pay a $32 copayment for the specialist visits and 20% coinsurance for the medical supplies. These cost sharing amounts apply regardless of the reason for the items and services. This means that you have been asked to pay the correct amounts 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 cost sharing for the office visits you had with a urologist on May 27, 2021, June 24, 2021, June 25, 2021, July 13, 2021, and August 12, 2021, the office visit you had with a vascular surgeon on August 12, 2021, and the urinary supplies you received on June 25, 2021, and July 13, 2021.