Persius/hicric huggingface dataset:
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 requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.
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 does not have any complex wound care needs as well as nursing, complex medical or surgical needs. The LTACH will amount to over treatment and futile care and will increase risk of complications. The enrollee can be safely managed in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an EGD provided on August 27, 2021.
You asked the Plan to waive the copayment for an EGD. You say that you have never paid more than a $50
copayment for colonoscopies in the past. The Plan denied your request. The Plan says the claims were
processed correctly, and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $350
copayment for outpatient surgery, including services provided at hospital outpatient facilities.
You received an EGD at an outpatient hospital facility on August 27, 2021. An EGD is considered an
outpatient surgical procedure. Therefore, you are responsible to pay the $350 copayment.
You have been asked to pay a $350 copayment for an EGD. An EGD falls within the outpatient surgery,
including services provided at hospital outpatient facilities and ambulatory surgical centers 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 EGD provided on August 27, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81407, 81408, 81479) provided March 24,
2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan
denied your request. The Plan says the claim cannot be paid as billed.
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or
proprietary laboratory analysis code. If no code accurately describes the procedure performed, the laboratory
may report procedure code 81479.
We looked at the file and Medicare rules. Multiple codes were billed for a single genetic panel. Based on this
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we
decided that the Plan does not have to pay for lab services (81407, 81408, 81479) provided March 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network services provided to the enrollee on June 24, 2021.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.

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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for out of network services provided to the enrollee on June 24, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for genetic testing provided on May 27, 2021.
You asked the Plan to waive the coinsurance for the genetic testing. You say that your organization is the only lab that performs this test, this claims should be paid as in-network. The Plan denied your request. The Plan says the claim was paid at the in-network rate. However, the member's appropriate cost sharing was subtracted from the amount you were paid.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay 20% coinsurance for genetic testing. The enrollee has been asked to pay 20% coinsurance for the genetic testing. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for genetic testing provided on May 27, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pathology services provided on April 6, 2021.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the claim was processed correctly.
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 codes 88333 and 88334 were billed with code 88173 on the date of service at issue. Codes 88333 and 88334 may be eligible for payment when billed with this code combination. The claim provided does not show that the modifier billed is suitable 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 pathology services provided on April 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does
not meet criteria.
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 that the enrollee requires that are not available at the health care setting
being offered by the health 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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network chiropractic services provided to from
June 21, 2021, to July 7, 2021.
You asked the Plan to pay for out of network services. You say that you were unaware that you needed a referral for these services. The Plan denied your request. The Plan says the contract is clear that all out of network service require prior authorization.
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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for out of network chiropractic services provided to from June 21, 2021, to July 7, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient mental health care provided
from June 14, 2021, to August 25, 2021.
You asked the Plan to waive the copayments for outpatient mental health care. You say that you want to know
why the copayment was returned and disagree with the charges. The Plan denied your request. The Plan says
the claims were processed correctly, and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $40
copayment for outpatient mental health care.
You received outpatient mental health care on June 14, 2021. Therefore, you are responsible to pay the $40
copayment.
You received outpatient mental health care on July 7, 2021. Therefore, you are responsible to pay the allowed
amount of $37.85, which is less than the $40 copayment.
You received outpatient mental health care on August 25, 2021. Therefore, you are responsible to pay the $40
copayment.
The total amount you owe is: $117.85.
You have been asked to pay the total copayment amount of $117.85 for outpatient mental health care.
Outpatient mental health care falls 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 outpatient mental health care provided from June 14, 2021, to
August 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for wound care services provided from
April 13, 2021, through July 20, 2021.
You asked the Plan to waive the copayment for wound care. You say that this is a continuation of care. You say you are not going to surgery on these visits. 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 $150 copayment for surgery at an outpatient hospital or ambulatory surgical center.
The services you received are considered surgical services. You have been asked to pay a $150 copayment for each visit for wound care. Wound care fall within the Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 wound care services provided from April 13, 2021, through July 20, 2021
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from January 29, 2021, to February 27, 2021.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says Skilled Nursing Facility (SNF) care beyond 100 days per benefit period is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.
The file shows that the enrollee received 100 days of SNF care during the benefit period from August 11, 2020, to January 28, 2021. The Plan has covered 100 days of SNF care. Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from January 29, 2021, to
February 27, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the esophagogastroduodenoscopy (EGD) you had on June 10, 2021.
You asked the Plan to waive the copayment for the EGD. You say that you were told that since you were having this at the same time as a screening colonoscopy that there would be no copayment. You said that you would not have had it done if you had not been told there was a $0 copayment. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that they looked at the phone records and they should you were only advised there was a $0 copayment for the colonoscopy. There was no mention of a $0 copayment for the EGD.
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 $250 copayment for outpatient surgery.
You have been asked to pay a $250 copayment for the EGD. The EGD falls within the outpatient surgery benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the esophagogastroduodenoscopy (EGD) you had on June 10, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for physical therapy (PT) services on June 2,
2021, June 8, 2021, and June 15, 2021.
You asked the Plan to waive the copayments for the PT services. You say that you did not have PT on these
days. The Plan denied your request. The Plan says you were charged these copayments correctly. The Plan says
that they have confirmed with the provider that you received PT on each of these dates.
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
copayment per visit for physical therapy.
You have been asked to pay a $20 copayment per visit for the PT 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 copayments for physical therapy (PT) services on June 2, 2021, June 8, 2021, and June 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on August 30, 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 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 37221 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services rendered on August 30, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the leuprolide acetate injection you
received on August 3, 2021.
You asked the Plan to waive the coinsurance for the leuprolide acetate injection. You say that you do not recall
anything in the Evidence of Coverage about being responsible for 20% for this drug. The Plan denied your
request. The Plan says you were charged this coinsurance 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 20%
coinsurance for Medicare Part B drugs.
You have been asked to pay 20% coinsurance for the leuprolide acetate injection. The leuprolide acetate
injection falls within the Medicare Part B 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 the leuprolide acetate injection you received on August 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established
patient (D0150) and intraoral - complete series of radiographic images (D0210) provided August 6, 2021.
You asked the Plan to pay for the comprehensive oral exam and intraoral x-rays. You say that you went to the
dentist for a covered dental cleaning. The Plan denied your request. The Plan says you have exceeded the
frequency limit for the comprehensive oral exam and the intraoral x-rays are not covered under your benefits.
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 the
comprehensive oral exam once every three years.
We looked at the file and Medicare rules. In this case the Plan provided documentation showing that a
comprehensive oral exam was previously covered on December 23, 2020. Based on this information, we
decided that the Plan's frequency limit for coverage of the comprehensive oral exam has been exceeded.
Though the Plan provide dental benefits in excess of Medicare coverage, intraoral x-rays are not among those
covered services. Therefore, we decided that the Plan does not have to pay for the comprehensive oral
evaluation - new or established patient (D0150) and intraoral - complete series of radiographic images (D0210)
provided August 6, 2021.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pay for the drug test provided on June 10, 2021.
You asked the Plan to pay for the drug test. You say that you are sending supporting medical records to prove
the necessity. You say that the claim should be reviewed, and payment released. The Plan denied your request.
The Plan says that procedure code 80307 has been overturned. The denial for procedure code G0483 has been
upheld as the documentation does not support 22 or more drug classes.
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, the CPT Code Manual definition of
code G0483 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs
and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to
gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia,
eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other
universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and
variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control
material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all
sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if
performed.
We asked our coder 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 drug test. Our reviewer says that the documentation was
reviewed and does meet criteria for coverage. Our reviewer found that the laboratory report documents 30
definitive drug classes, and therefore, should be covered.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the drug test have been met. Therefore, we decided that the Plan has to pay for
the drug test provided on June 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.