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

We decided that the Plan does not have to pay for the lab services provided on August 18, 2020.
You asked the Plan to pay for the lab services. You say it is crucial for providers to track the levels of various substances. The Plan denied your request. The Plan says the billed codes cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. We find that the claim lists the place of service as an independent laboratory. The records do not indicate the specimen at issue was obtained at an independent laboratory. 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 the lab services provided on August 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a three level cervical facet joint injection (C3-4, C4-5, C5-6) for the enrollee.
You asked the Plan to pre-approve the three levels. You say that this is medically necessary. The Plan denied your request. The Plan says the records show that more than the allowable number of spinal levels has been requested.
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 three levels. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that in this case, the records show that more than the allowable number of spinal levels has been requested. The review has determined that the requested injection is not medically necessary or reasonable. 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 three levels have not been met. Therefore, we decided that the Plan does not have to pre-approve a three level cervical facet joint injection (C3-4, C4-5, C5-6) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the total hip arthroplasty and the physical therapy provided on December 4, 2020.

You asked the Plan to waive the copayments for the total hip arthroplasty and the physical therapy. You say that you were told the copayment would be waived. You say you should not be responsible for this amount. 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 $395 copayment for Medicare-covered surgery or other services provided to you at an in-network outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges and a $40 copayment for each in-network Medicare-covered physical therapy and speech-language therapy visit. 

You have been asked to pay a $395 copayment for the total hip arthroplasty and a $40 copayment for the physical therapy. The total hip arthroplasty falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The physical therapy falls within "Outpatient Rehabilitation Services" 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 total hip arthroplasty and the physical therapy provided on December 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the hysteroscopy biopsy provided on April
29, 2021.

You asked the Plan to waive the copayment for the hysteroscopy biopsy. You say that this procedure was not a
surgery. 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 $250
copayment per day for outpatient procedures and services, including, but not limited to, outpatient surgery
performed in an outpatient hospital or ambulatory surgical center.

You have been asked to pay a $250 copayment for the hysteroscopy biopsy. The hysteroscopy biopsy falls
within the "Outpatient hospital services" benefit category. The record shows the hysteroscopy biopsy is
considered a surgical procedure. 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 hysteroscopy biopsy
provided on April 29, 2021.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for the prophylaxis (D1110). We decided that the Plan does not have to
pay more for the comprehensive oral evaluation, bitewing x-rays, and scaling and planing.
You asked the Plan to pay for the prophylaxis (D1110) and to pay more for the comprehensive oral evaluation
(D0150), bitewing x-rays (D0274), and periodontal scaling and root planing (D4342). You say that you live in
a very rural area and the nearest in-network provider would be about an hour away. You also say that this
treating provider is just a few miles away from where you live. The Plan says that the prophylaxis is not
payable within 30 days of active periodontal therapy. The Plan also says that these services were performed by
a non-participating provider, and you are responsible for any difference between the Maximum Allowable Fee
and the amount the provider bills you for the services.
We decided that the Plan has to pay for the prophylaxis.
The Plan follows Medicare rules. Medicare rules say that the health plan must provide you with a clear and
accurate description of the Original Medicare and/or mandatory/optional supplemental benefits offered under
your plan contract including applicable conditions and limitations and any other conditions associated with the
use or receipt of the benefits.
The record shows that you received a prophylaxis (D1110) which the Plan denied saying this service is not
payable within 30 days of active periodontal therapy. The 2021 Evidence of Coverage (EOC) states that you
are allowed two prophylaxes per calendar year. The EOC does not clearly state that receiving a prophylaxis
(D1110) within 30 days of receiving periodontal therapy is an exclusion. You reasonably believed the
prophylaxis would be covered because it is listed as a covered procedure two times per calendar year.
Therefore, we decided that the Plan has to pay for the prophylaxis.
We also decided that the Plan does not have to pay more for the comprehensive oral evaluation, bitewing
x-rays, and scaling and planing.
The Plan follows Medicare rules. 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, you are responsible for the coinsurance
amounts plus the difference between the billed and allowed amounts for dental services that are received OON.
Therefore, we decided that the Plan does not have to pay more for the comprehensive oral evaluation, bitewing
x-rays, and scaling and planing.
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 pre-approve genicular radiofrequency ablation services.

You asked the Plan to pre-approve genicular radiofrequency ablation services. You say that this request is medically reasonable and necessary. The Plan denied your request. The Plan says this procedure is considered experimental/investigational.

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 genicular radiofrequency ablation services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found genicular nerve blocks and genicular nerve radiofrequency ablation are considered investigational and not medically necessary for the treatment of chronic knee pain, including, but not limited to any of the following: degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a treatment following knee replacement; or as a treatment for individuals who are not candidates for knee replacement surgery. 

The review has determined that the requested genicular nerve radiofrequency ablation of the left knee is not medically reasonable or necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genicular radiofrequency ablation services have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular radiofrequency ablation services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan
denied your request. The Plan says that you do not require daily skilled services on an inpatient basis at the
SNF level of care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet
Medicare criteria for SNF services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral x-ray and palliative treatment provided by a
non-participating dentist on July 19, 2021.

You asked the Plan to pay for the intraoral x-ray and palliative treatment. You say that you had debilitating
pain in your mouth and services were not available with the Plan dentist. You say that your existing dentist
proceeded with emergency dental protocol and the claim should be considered. The Plan denied your request.
The Plan says out-of-network services are not covered.

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, out-of-network dental services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
intraoral x-ray and palliative treatment provided by a non-participating dentist on July 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance angiography (MRA) rendered on June 14, 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 separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 70544 (MRA head) and 70551 (magnetic resonance imaging for the brain stem). Code 70544 is a column II code with a modifier indicator of 1 when billed with column I code 70551. Code 70544 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the magnetic resonance angiography (MRA) rendered on June 14, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional PT.

You asked the Plan to pre-approve additional PT. You say that additional PT is medically necessary. The Plan
denied your request. The Plan says additional PT is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.

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 additional PT. Our reviewer says that
skilled services are not necessary to restore or maintain function or to prevent deterioration of your condition.
Our physician reviewer found that the additional requested therapy is not generally accepted as specific and
effective therapy for your condition beyond what was approved by the health Plan. You have had prior therapy
and the records do not demonstrate that the unique skills of a professional therapist are required to provide
treatment safely and effectively, that the services can be safely and effectively performed only by a therapist, or
by or under the supervision of a therapist. You have been instructed in a home exercise program. The requested
services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a
qualified therapist required to establish, design and/or deliver a program to maintain your current condition or
to prevent or slow further deterioration.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of additional PT have not been met. Therefore, we decided that the Plan does not
have to pre-approve additional PT.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance ride provided on April 26,
2021.

You asked the Plan to waive the copayment for the ambulance ride. You say that the hospital staff should have
informed you that there would be a charge for the ambulance ride. 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 $225
copayment per one-way trip for domestic ground ambulance.

You have been asked to pay a $225 copayment for the ambulance ride. The ambulance ride falls within the
"Ambulance 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 the
ambulance ride provided on April 26, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient hospital visits provided from
June 2, 2021, to July 7, 2021.
You asked the Plan to waive the copayments for outpatient hospital visits. You say that you disagree with the
facility charges and cannot afford them. 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 $150
copayment for outpatient hospital services.
You had outpatient hospital visits from June 2, 2021, to July 7, 2021, for a total of 3 visits. Therefore, you are
responsible to pay the allowed amount of $110.51, which is less than the $150 copayment, per each visit. The
total amount you owe is: $331.53.
You have been asked to pay the total copayment amount of $331.53 for outpatient hospital visits. Outpatient
hospital visits 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 copayments for outpatient hospital visits provided from June 2, 2021, to July 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a breast cancer screening provided on May 5, 2021.
You asked the Plan to waive the coinsurance for a breast cancer screening. You say that you were not informed that the provider was out-of-network and this is a preventative procedure so you should not owe anything. 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 50% coinsurance for out-of-network breast cancer screenings. You had a breast cancer screening from an out-of-network provider on May 5, 2021. Therefore, you are responsible to pay your share of the out-of-network cost-sharing charges. The total allowed amount is $96.07 and 50% of that is $48.03.
You have been asked to pay the total coinsurance amount of $48.03 for a breast cancer screening. A breast cancer screening falls within the breast cancer screenings 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 a breast cancer screening provided on May 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME and related supplies provided on July 22, 2021.
You asked the Plan to waive the coinsurance for DME and related supplies. You say that the device got recalled and the enrollee should be given a replacement and not owe the charges. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay 20% coinsurance for DME and related supplies. The enrollee received DME and related supplies on July 22, 2021. Therefore, they are responsible to pay their share of the cost-sharing charges. The total allowed amount is $349.50 and 20% of that is $69.87.
The enrollee has been asked to pay the total coinsurance amount of $69.87 for DME and related supplies. DME and related supplies fall within the DME and related supplies 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 coinsurance for DME and related supplies provided on July 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal procedure (D4999) and two bone replacement grafts for ridge preservation (D7953 x2) provided on April 28, 2021.
You asked the Plan to pay for the periodontal procedure and bone replacement grafts. You say that you do not agree with the Plan only reimbursing you $792.00 out of the original paid amount of $3,170.00. The Plan denied your request. The Plan says these services are not covered.
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 periodontal procedure (D4999) and two bone replacement grafts for ridge preservation (D7953 x2) provided on April 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI provided on April 30, 2021.
You asked the Plan to waive the copayment for an MRI. You say that the limited ability of the MRI to detect splinters should have been conveyed to the physician. You state that the MRI was unable to detect your splinter and you should not be responsible for 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 $225 copayment for advanced radiology services. You have been asked to pay a $225 copayment for an MRI. An MRI 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 MRI provided on April 30, 2021.