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

We decided that the Plan has to waive the copayment for an urgent care visit (99202) provided on August 18,
2021.
You asked the Plan to waive the copayment for an urgent care visit. You say that the services should be
covered as all you had done was a covid-19 test and you were under the impression that it would be covered in
full for that reason. The Plan denied your request. The Plan says that the cost sharing applied correctly as you
were being billed for a new patient exam and not the covid-19 test itself.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. There were no records attached to prove that any other services provided would
solicit a copay for a new patient exam. We are unable to confirm that this visit was for anything more than
furnishing a covid-19 test. Therefore, we decided that the Plan has to waive the copayment for an urgent care
visit (99202) provided on August 18, 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung
cancer screening (71271).
You asked the Plan to pre-approve a LDCT scan for lung cancer screening. You say that the services are
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria
has not been met.
The Plan follows Medicare rules. Medicare rules say that lung cancer screening with LDCT is covered when
beneficiaries meet specific criteria.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve a LDCT scan for lung cancer screening.
Our reviewer says that the services are not medically necessary. Our physician reviewer found the report for a
computed tomography angiography (CTA) of September 13, 2021 included the description of semi solid lung
nodules up to 1.1 cm in diameter for which an appropriate recommendation for a 3-month follow-up CT was
made. Clearly such a follow-up is necessary but since there is a prior abnormality needing CT evaluation, a CT
of the chest (CPT 71250) is the appropriate exam rather than the requested CPT 71271.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a LDCT scan for lung cancer screening have not been met. Therefore, we
decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung
cancer screening (71271).
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. The Plan denied your request. The Plan says the enrollee does not
need frequent monitoring or three hours of therapy a day.
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 physician reviewer found
that the enrollee was admitted to the acute care hospital for a cervical fracture, laceration of the spleen, and a
mesenteric artery after a motor vehicle collision. He had bowel resection and had wound dehiscence after
surgery. He was transferred to long term acute care then to skilled nursing facility for ongoing wound care.
His medical problems are stable. He does not require treatment by multiple therapies in an intensive
rehabilitation therapy program. While he has a need for physical and/or occupational therapy, there is no
documentation of a need for an intensive rehabilitation program.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) of the spine you had on April 17, 2021.
You asked the Plan to waive the copayment for the MRI. You say that you had to wear a mask while you were in the MRI machine. You said that you were in the scanner less than 10 minutes and were unable to breathe. You stated that you had a panic attack and had to be removed from the MRI. You said that because the MRI was not completed, you should not have to pay. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that the medical records show you were in the MRI machine for 51 minutes.
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 radiology services. You have been asked to pay a $125 copayment for the MRI. The MRI falls within the diagnostic radiology services benefit category. This copayment applies regardless of the outcome of this test.
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 magnetic resonance imaging (MRI) of the spine you had on April 17, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Skilled Nursing Facility (SNF) services provided through March 5, 2021, to, April 3, 2021.

You asked the Plan to waive the copayment for SNF services. You say that the services should be covered as you wanted to leave but were advised to stay. 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 $184 copayment for days 21-53 of Skilled nursing facility (SNF) care.

You have been asked to pay a $1656 copayment for days 21-29 of your SNF stay ($184 x 9 = $1,656). 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 Skilled Nursing Facility (SNF) services provided through March 5, 2021, to, April 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the continuous positive airway pressure (CPAP) supplies you received on July 9, 2021.  You asked the Plan to waive the coinsurance for the CPAP supplies. You say that this has been covered in full in the past. 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 durable medical equipment.   You have been asked to pay 20% coinsurance for the CPAP supplies. The CPAP supplies fall within the durable medical equipment benefit category. This coinsurance applies regardless of what you may have paid in the past. 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 continuous positive airway pressure (CPAP) supplies you received on July 9, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance transport provided on March 10,
2020.
You asked the Plan to waive this copayment. You say that you would like to appeal the bill for $225 because
the Corona Virus began March 1, 2020 and you were picked up on March 10, 2020. You stated the paramedics
were not wearing face masks and you should not have to pay this. The Plan denied your request. The Plan says
the Plan says that this copayment applies per your plan contract.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees
must pay $225 copayment for ambulance transport.
You have been asked to pay the correct amount based on the contract with the Plan. It should also be noted that
Medicare and the CDC began to require face masks to be worn by first responders as of March 15, 2020. In
addition, Medicare is not waiving copayments for ambulance transport due to the pandemic. 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 ambulance transport provided on March 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the nitrous provided on August 9, 2021.

You asked the Plan to pay for the nitrous. You say that you have very sensitive roots, and it is important for you to have the nitrous. The Plan denied your request. The Plan says this procedure is not a benefit under the 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 nitrous provided on August 9, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pay for the electroencephalogram (EEG) provided on April 19, 2021.  You asked the Plan to pay for the electroencephalogram (EEG). You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the services were not reported with an appropriate diagnosis.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan states that this procedure was not reported with an appropriate diagnosis according to the Local Coverage Determination (LCD). The Plan did not provide the LCD used to validate this decision. In addition, there is no documentation provided to support why the diagnosis billed with this procedure is not covered. This means the Plan did not substantiate their denial. Therefore, we decided that the Plan has to pay for the electroencephalogram (EEG) provided on April 19, 2021.   If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for smoking cessation items under the Flex Benefit
provided from March 31, 2021, through May 12, 2021.
You asked the Plan to reimburse you for smoking cessation items. The Plan denied your request. The Plan says
a handwritten payment details you provided could not be verified as proof of payment. Your request did not
show the payment method for services received. You provided a handwritten payment details that included the
dates of service, check numbers, payment amounts, and your bank account information. The handwritten
payment details you provided could not be verified as proof of payment.
The Plan contract covers a Flex Benefit for the purchase of non-Medicare healthcare items.
We looked at the file and the Plan's rules. The file shows that the handwritten details you provided could not be
verified as proof of payment. Therefore, we decided that the Plan does not have to reimburse you for smoking
cessation items under the Flex Benefit provided from March 31, 2021, through May 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory service (0013M) rendered by the out-of-network (OON) provider on July 19, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says this service was rendered by an out of network provider, without 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 had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the laboratory service (0013M) rendered by the out-of-network (OON) provider on July 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve reconstruction of the lower jaw (21244), lower jawbone graft (21215), nerve repair (64912) and reconstruction of the jaw (21249).  You asked the Plan to pre-approve reconstruction of the lower jaw, lower jawbone graft, nerve repair and reconstruction of the jaw. You say that this service is needed as your lower denture is nonfunctional and you are unable to eat. The Plan denied your request. The Plan says you are undergoing treatment of mandibular atrophy to prepare the mouth for dental implants. The Plan also says that the services requested are purely dental in nature.    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 reconstruction of the lower jaw, lower jawbone graft, nerve repair and reconstruction of the jaw have not been met. Therefore, we decided that the Plan does not have to pre-approve reconstruction of the lower jaw (21244), lower jawbone graft (21215), nerve repair (64912) and reconstruction of the jaw (21249).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99309) rendered by the out-of-network (OON) provider from April 9, 2021, through May 7, 2021.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without 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 had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue.

We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99309) rendered by the out-of-network (OON) provider from April 9, 2021, through May 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an automatic external defibrillator, garment type, provided on January 28 to March 28, 2021, by an out-of-network provider.

You asked the Plan to pay for an automatic external defibrillator, garment type. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for out-of-network care have not been met.

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 an automatic external defibrillator, garment type, provided on January 28 to March 28, 2021, by an out-of-network provider.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to pay for service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service (CPT code 99053), emergency department visit for the evaluation and management of a patient (CPT code 99285), and electrocardiogram, routine ECG with at least 12 leads; interpretation and report only (CPT code 93010) provided to the enrollee on July 25, 2021.  You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not covered as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  Based on this information, we decided that Medicare rules for coverage of the services have not been met. A secondary only diagnosis cannot be used as the primary, first-listed or principal diagnosis for any procedure or service. Additionally, code 99053 is not separately payable as this service exhibits a status of "B" per the Medicare Fee Schedule, indicating bundling. Separate payment is never made for routinely bundled services. Therefore, we decided that the Plan does not have to pay for service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service (CPT code 99053), emergency department visit for the evaluation and management of a patient (CPT code 99285), and electrocardiogram, routine ECG with at least 12 leads; interpretation and report only (CPT code 93010) provided to the enrollee on July 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay an additional amount for the inpatient hospital care provided from November 20, 2019, to November 27, 2019.  You asked the Plan to pay an additional amount for the inpatient care. You say that the original billing was correct. The Plan denied your request. The Plan says the billing of principal diagnosis code, A49.1, is not supported.  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 principal diagnosis code, A41.9, defined as sepsis, unspecified organism. 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 an additional amount for the inpatient care. Our physician reviewer found the provided documentation did not support the billing of principal diagnosis code, A41.9, Sepsis, unspecified organism. The reviewer found that there was insufficient evidence of end-organ failure. Acute on chronic respiratory is not sufficient evidence of end-organ failure in this clinical scenario. Therefore, the reviewer found that the billing of principal diagnosis code was not supported.   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 an additional amount for the inpatient hospital care provided from November 20, 2019, to November 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) (CPT code 90715) and immunization administration (CPT code 90471) provided on August 5, 2021.
You asked the Plan to pay for the services. You say that your doctor administered the vaccine as a preventive measure during your wellness visit. The Plan denied your request. The Plan says the diagnosis billed on the claim for CPT code 90715 include: encounter for immunization (Z23). The Plan states the diagnosis was not considered appropriate diagnoses for a tetanus vaccine.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the services. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the services. Therefore, we decided that the Plan does not have to pay for tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) (CPT code 90715) and immunization administration (CPT code 90471) provided on August 5, 2021.