Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for manual therapy techniques (97140)
rendered on August 23, 2021.
You asked the Plan to waive the copayment for manual therapy techniques. You say that you have been going
to this provider for four years and this is the first time you have heard about a copayment. You also say that
you were there in April and May of this year and was not charged a copayment and you were not notified of a
copayment. You also say that they just started charging this copayment in August and you did not know until
you received the bill for $80.00. The Plan denied your request. The Plan says you were 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 $10
copayment for Medicare-covered physical therapy visits.
You have been asked to pay a $10 copayment for manual therapy techniques. Manual therapy techniques 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 copayment
for manual therapy techniques (97140) rendered on August 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services (82310, 83970, 84100) provided on April 7, 2021.  You asked the Plan to pay for laboratory services. You say that you do not have a contractual agreement to include these services in the dialysis rate. The Plan denied your request. The Plan says these services are not separately payable.  The Plan must follow Medicare rules. Medicare rules say that all laboratory services furnished to individuals for the treatment of end-stage renal disease (ESRD) are included in the ESRD Prospective Payment System (PPS) as Part B services and are not paid separately.  We looked at the file and Medicare rules. The laboratory services at issue were provided for the treatment of ESRD. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (82310, 83970, 84100) provided on April 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311,
E2313, E2377).
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied
your request. The Plan says upper limb strength and function are therefore adequate for the enrollee to be able
to control the power options using their own switches which are included in the allowance of these power
options.
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 accessories. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the enrollee does not require non-proportional input devices (e.g., sip and puff, head array,
etc.). The enrollee does not require a separate display (i.e., for alternate control devices), other electronic
devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an
attendant control. The enrollee's upper extremity strength supports that the enrollee can control any power
options through their own switches.
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 accessories have not been met. Therefore, we decided that the Plan does not
have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for cardiovascular procedures (93799) provided on June 10, 2021, and June 11, 2021.
You asked the Plan to waive the copayment for the cardiovascular procedures. You say that the services should be covered as you were not made aware of the copayment. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $285 copayment for Outpatient hospital services.
You have been asked to pay a $460 copayment for two cardiovascular procedures, you were billed $230 for each procedure, which is less than the $285 stated in the Plan's contract. Cardiovascular procedures fall within the Outpatient hospital 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 copayment for cardiovascular procedures (93799) provided on June 10, 2021, and June 11, 2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from July 28, 2021 to July 30, 2021.  You asked the Plan to waive the copayment for an inpatient hospital stay. You say that the enrollee should not have been admitted into the hospital The Plan denied your request. The Plan says the correct copayment has been 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $305 copayment for Inpatient hospital care per day for days 1-5 per hospital. The enrollee was billed a $610 copayment ($305 x 2 days) which is the correct amount billed for the copayment.    The enrollee has been asked to pay a $610 copayment for the inpatient hospital stay. Inpatient hospital stay falls within the Inpatient hospital care benefit category. 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 copayment for an inpatient hospital stay from July 28, 2021 to July 30, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (G0480, 84228, 82542) provided on 
August 29, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for laboratory services. You say that you were not aware of the requirement of 
obtaining a prior authorization, specifically for this member's plan type at the time of rendering services. The 
Plan denied your request. The Plan says this provider is a non-participating provider, and the referring provider 
also is a non-participating provider. The Plan also says that these services were not authorized.

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 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 laboratory services (G0480, 84228, 82542) 
provided on August 29, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids provided on August 17, 2021.
You asked the Plan to reimburse you for the hearing aids. You say that could not afford other providers hearing aids, and that the only provider that adjusted to your budget for hearing aids was this provider. The Plan denied your request. The Plan says there was no referral, no authorization and there are available contracted providers in your municipality.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case.
We looked at the file and the Plan's rules. The file shows that the Plan requires authorization for out-of-network covered services and you did not obtain authorization to purchase the hearing aids.
Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids provided on August 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the observation services provided on November 5, 2020, by 
an OON provider.

You asked the Plan to pay for the observation services provided by an OON provider. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says prior 
authorization was not obtained to provide 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. Medicare rules also say that for Medicare to consider coverage 
and payment for any item or service, the information submitted by the supplier or provider must confirm that 
Medicare coverage criteria have been met.

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 items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. The records provided were insufficient to determine if the services provided were 
emergent or urgent. 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 the observation services provided on November 5, 
2020, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary or rest home visit (99336) provided on April 12, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for a domiciliary or rest home visit. You say that authorization was not obtained prior to seeing this patient since it is the nursing facilities responsibility to get authorizations for their patients. The Plan denied your request. The Plan says this provider is out-of-network with the Plan and authorization was not obtained prior to the services being rendered.
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 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 a domiciliary or rest home visit (99336) provided on April 12, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the facet joint injections.
You asked the Plan to pre-approve the facet joint injections. You say that you would like reconsideration
because the requested procedure is medically necessary. The Plan denied your request. The Plan says this
procedure under ultrasound guidance is not a covered benefit.
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 facet joint injections. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the requested CPT codes, 64490 and 64491, are performed under image guidance
(fluoroscpy or CT), and are bundled for billing purposes.
However, the provider has requested the procedures to be performed under ultrasound guidance, which are not
covered.
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 facet joint injections have not been met. Therefore, we decided that the Plan
does not have to pre-approve the facet joint injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120) and prophylaxis - adult (D1110) provided July 16, 2021.
You asked the Plan to pay for the oral exam and dental cleaning. You say that you have always been covered for two oral exams and two cleanings per year, and you don't understand why the services are not covered. The Plan denied your request. The Plan says you have exceeded the frequency limit for these services.
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 oral exam and dental cleaning once per calendar year. We looked at the file and Medicare rules. The Plan provided documentation showing that an oral exam and dental cleaning were previously covered on January 15, 2021. Based on this information, we decided that the
Plan's frequency limits for coverage of the oral exam and dental cleaning have been exceeded. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120) and prophylaxis - adult (D1110) provided July 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient services provided September 21, 2020 to 
October 1, 2020, billed with secondary diagnosis code S32.591A.

You asked the Plan to pay for the inpatient services billed with secondary diagnosis code S32.591A.. You say 
that you would like the plan to reconsider their denial The Plan denied your request. The Plan says the services 
are not payable as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes. 

In this case, you billed the inpatient services provided with S32.591A, defined as other specified fracture of 
right pubis, initial encounter for closed fracture. 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 inpatient services billed with secondary diagnosis code S32.591A. Our reviewer says that the 
documentation does not support the DRG billed. Our physician reviewer found the documentation shows that a 
possible nondisplaced fracture of the right and left superior and inferior ischiopubic rami was noted in the 
history and physical exam and attending progress notes, other provider documentation was unclear and 
inconsistent regarding this condition. The documentation available for this review supported an admission for 
further evaluation and treatment of a closed, comminuted, intraarticular, distal right femur fracture after a 
mechanical fall for which a right femur open reduction and internal fixation (ORIF) was performed. The 
orthopedic consultant consistently documented a right comminuted distal femur fracture and the operative 
report additionally noted pre- and post-operative diagnoses of right supracondylar distal femur fracture. 
Although the attending provider documented possible pelvic fracture, possible right sided ischiopubic rami 
fracture on admission and in the progress notes, this diagnosis was not confirmed or documented as continued 
to be suspected at the time of discharge and was not noted in the orthopedic specialist's documentation during 
the encounter. From the medical record submitted for review, the documentation of a "possible nondisplaced 
fracture of the right and left superior and inferior ischiopubic rami"; was an uncertain diagnosis that was neither 
confirmed or documented as an uncertain diagnosis at the time of discharge. Therefore, the secondary diagnosis 
of S32.591A is not supported by the documentation.
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient services provided September 21, 2020 to October 1, 2020, billed with secondary diagnosis 
code S32.591A.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the colonoscopy with polyp removal you had at an outpatient hospital facility on August 17, 2021.  You asked the Plan to waive the copayment for the colonoscopy with polyp removal. You say that you had this procedure done as a preventive measure. You said that the polyp removal should be covered in full as part of your preventive care. 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 says that generally, colorectal cancer screenings have no cost sharing.  However, if any abnormality is found during the procedure, the service is no longer a screening, and the outpatient surgery copayment will apply. The contract also says that you must pay a $100 copayment for outpatient surgery at an outpatient hospital facility.   You have been asked to pay a $100 copayment for the colonoscopy with polyp removal. The records show that you had two polyps removed during this procedure.  Polyps are abnormalities.  Your contract says that if any abnormality is found, you must pay the outpatient surgery 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 the colonoscopy with polyp removal you had at an outpatient hospital facility on August 17, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the dialysis services provided to the enrollee on July 1, 2021, through
July 30, 2021.

You asked the Plan to pay for the dialysis services. You say that the enrollee was at a nursing facility at the
time services were rendered. The Plan denied your request. The Plan says that the number of days/units
exceeds the acceptable maximum.

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.

We looked at the file and the rules. The Plan has not provided Medicare rules or coding guidelines regarding
maximum units allowed. The Plan has not made reasonable and diligent efforts to gather and forward to us
information regarding their decision to deny your request. Therefore, we decided that the Plan has to pay for
the dialysis services provided to the enrollee on July 1, 2021, through July 30, 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound of the abdomen provided on September 2, 2021. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you feel that the Plan did not pay anything and you should not be responsible for the copayment. 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 $125 copayment for diagnostic procedures and tests, including ultrasounds
  
You have been asked to pay $62.72, which is less than the $125 copayment for the ultrasound. The ultrasound falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an ultrasound of the abdomen provided on September 2, 2021.