Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from October 20, 2020, to October 27, 2020.

You asked the Plan to waive the copayment for the inpatient care. You say that you thought you would not be liable for cost-sharing for services rendered due to COVID-19. The Plan denied your request. The Plan says the Plan's waiver for COVID-related cost-sharing ended on June 1, 2020. This claim was processed correctly, and your copayment was assessed in accordance with your 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). Your contract with the Plan clearly says that you must pay a $225 copayment for each of the first seven days of an inpatient hospital stay.

You have been asked to pay a $1,575 copayment for the seven-day inpatient hospital stay ($225 x 7 days = $1,575). 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 inpatient hospital care provided from October 20, 2020, to October 27, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on April 7, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are not
payable.
The Plan must follow Medicare rules. Medicare rules say that the non-Outpatient Prospective Payment System
(OPPS) Outpatient Code Editor (OCE) will be integrated into the OPPS OCE. This integration will result in the
routing of all institutional outpatient claims, including non-OPPS hospital claims, through a single integrated
OCE.
We looked at the file and Medicare rules. A review of the OCE data files shows that a missing device code will
produce Edit 92, which requires the claim to be returned to the provider. As such, the outpatient hospital claim
is not payable as billed. Based on this information, we decided that Medicare rules for coverage of the services
have not been met. Therefore, we decided that the Plan does not have to pay for the services provided on April
7, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the three podiatry visits you had from August 5, 2021, to August 26, 2021.

You asked the Plan to waive the copayments for the three podiatry visits. You say that these visits were to make adjustments to orthotics. You assumed you would not be charged a copayment for orthotic adjustments. The Plan denied your request. The Plan says you were charged these copayments correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment per visit for podiatry services. 

You have been asked to pay a $40 copayment per visit for the three podiatry visits. These copayments apply regardless of the reason for the visits. 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 three podiatry visits you had from August 5, 2021, to August 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the nasal endoscopy you had in your
otolaryngologist's office on January 20, 2021.
You asked the Plan to waive the copayment for the nasal endoscopy. You say that you feel as though this
copayment should be waived because this service was the result of after-effects of COVID-19. The Plan denied
your request. The Plan says you were charged this copayment correctly. The Plan says that because this service
was not provided for a diagnosis of COVID-19, no copayment waiver is permitted.
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 surgery services in a specialist's office.
You have been asked to pay a $40 copayment for the nasal endoscopy. According to Plan documentation, the
Plan is only waiving cost sharing for COVID-19 treatment and testing. The records show that this nasal
endoscopy was performed due to a diagnosis of nosebleed, not because of a diagnosis of COVID-19. As a
result, normal cost sharing applies. The nasal endoscopy falls within the surgery services in a specialist's office.
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 nasal endoscopy you had in
your otolaryngologist's office on January 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for MLS laser therapy, unlisted therapeutic procedure (97139)
provided April 26, 2021
You asked the Plan to pay for laser therapy. You say that the medical records provided support the necessity of
the services in dispute. The Plan denied your request. The Plan says this service 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 looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of laser therapy have not been met. Therefore, we decided that the Plan does not have to pay for MLS
laser therapy, unlisted therapeutic procedure (97139) provided April 26, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (99072, S1015, S8301) provided on April 29, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are not covered.  The Plan must follow Medicare rules. Medicare rules say that a status indicator of "B" under the Physician Fee Schedule indicates that payment for covered services is always bundled into payment for other services not specified. The rules also say that a status indicator of "I" under the Physician Fee Schedule indicates that the code in question is not valid for Medicare purposes.   We looked at the file and Medicare rules. Code 99072 is assigned a status indicator of "B" under the Physician Fee Schedule, which means that this is a bundled service. Payment for this service is bundled into payment for other services. No separate payment can be made for the anesthesia services (99100). Code S1015 and S8301 are assigned a status indicator of "I" under the Physician Fee Schedule, which means that these codes are not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (99072, S1015, S8301) provided on April 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second diagnostic facet injection of the lower spine
(CPT code(s): 64493 and 64494) for the enrollee.
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan
denied your request. The Plan says the documentation did not show enough pain relief from the first shot.
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 services. Our physician reviewer
found the first diagnostic facet injection did not achieve greater than 50% improvement in pain. The criteria
states that a second confirmatory diagnostic facet joint procedure is considered medically reasonable and
necessary when after the first diagnostic facet joint procedure, there was a consistent positive response of at
least 80% relief of primary (index) pain (with the duration of relief being consistent with the agent used). The
review has determined that the requested repeat diagnostic facet joint block 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 services have not been met. Therefore, we decided that the Plan
does not have to pre-approve a second diagnostic facet injection of the lower spine (CPT code(s): 64493 and
64494) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the knee brace you received on December 8, 2020.

You asked the Plan to waive the coinsurance for the knee brace. You say that you have the knee brace but you have no idea how you got it. The Plan denied your request. The Plan says you were charged the coinsurance correctly. The Plan says that your doctor ordered this brace for you and you signed the prescription form for this item.

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 10% coinsurance for prosthetics (including braces). 

You have been asked to pay 10% coinsurance for the knee brace. The knee brace falls within the prosthetics 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 knee brace you received on December 8, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the fundus photography rendered on May 26, 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 procedure code 92250 is 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 92250 (fundus photography) and 92134 (scanning
computerized ophthalmic diagnostic imaging). Code 92250 is a column II code with a modifier indicator of 1
when billed with column I code 92134. Code 92250 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 fundus photography
rendered on May 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the immunohistochemistry rendered on January 15, 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. The rules say that immunohistochemical stains are covered when reasonable and medically necessary. We looked at the file and Medicare rules. There are no records to support that the testing meets the criteria for coverage. 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 immunohistochemistry rendered on January 15, 2021
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 you cannot independently take care of yourself. The Plan denied your request. The Plan says that you do not have skilled nursing or therapy needs that need to be provided on a daily basis as an inpatient only status.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections (CPT code(s): 64635 and 64636).
You asked the Plan to pre-approve the injections. You say that the facet joint injections are medically necessary
and beneficial to you. The Plan denied your request. The Plan says the requested procedure is supported when
two facet joint injections/medial branch blocks (MBB) provided 80% or more pain relief for the duration of the
agent used. The Plan states the clinical information provided does not meet this criterion and, therefore, the
requested procedure is not indicated at this time.
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 injections. Our physician reviewer
found the record indicates that you have not had diagnostic blocks. The elements of the coverage criteria are
not satisfied. The requested service is not recommended.
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 injections have not been met. Therefore, we decided that the Plan does not
have to pre-approve facet joint injections (CPT code(s): 64635 and 64636)
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued 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 the records do not support the need for daily therapy on an inpatient basis.

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 continued 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 continued skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on May 10, 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 billed correctly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of
service (POS) code.

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory
services rendered on May 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve inpatient psychiatric treatment.  You asked the Plan to pre-approve inpatient psychiatric treatment. 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 must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.   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 inpatient psychiatric treatment. Our reviewer says that the services are not medically necessary. Our physician reviewer found based upon review of the records provided, you do not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of December 9, 2021 forward and could have been treated in a lesser restrictive setting. You were not showing any suicidal or homicidal ideation, auditory or visual hallucinations, or delusions and was not showing any behaviors or aggression. You were being cooperative and compliant while not showing any acute threats to safety.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric treatment.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prefabricated abutments (D6056) and abutment supported
crowns (D6058) provided on June 22, 2021.

You asked the Plan to pay for the prefabricated abutments (D6056) and abutment supported crowns (D6058).
You say that you were not made aware that crowns covering implants would be excluded from coverage. You
say that this should be reconsidered based on the lack of clarity on the topic. The Plan denied your request. The
Plan says the services are not covered 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.

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
prefabricated abutments (D6056) and abutment supported crowns (D6058) provided on June 22, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied
your request. The Plan says your request does not show you have skilled nursing or therapy needs that need to
be provided on a daily basis as an inpatient only status. The Plan states the services you require can safely be
received at a different setting, for example, home with home health, in residential care, or home with close
follow-up with your doctor.
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 care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found you do not qualify for SNF coverage. You do
not have documented skilled nursing needs. You do not have documented skilled therapy needs. Daily skilled
services are not required to establish a maintenance program or to prevent deterioration of your condition. Your
care needs, as a practical matter, can be provided at a lower level of care.
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 care have not been met. Therefore, we decided that the Plan does not have
to pre-approve SNF care.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for ambulance services you received on July 14, 2021.  You asked the Plan to waive the copayment for the ambulance services. You say that you had to be transported due to an error by a lab. You said that the transport was not needed and was a waste of money. The Plan denied your request. The Plan says you were charged this copayment correctly.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 copayment per trip for ambulance services.   You have been asked to pay a $100 copayment per trip for the ambulance services. This copayment applies regardless of the reason for the transport. 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 ambulance services you received on July 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the intracept procedure (CPT code(s): 22899 and C9752).  You asked the Plan to pre-approve the procedure. You say that this procedure fills a treatment gap for those patients that do not receive adequate relief from traditional conservative methods and do not have instability to indicate that fusion is the appropriate treatment. You state you have tried and failed conservative treatment without relief. The Plan denied your request. The Plan says your request is not medically necessary because there is little evidence in the medical literature to suggest that this is an appropriate procedure for your back pain. The Plan states it is not an accepted standard of medical practice for the diagnosis or treatment of back pain and it is considered experimental and 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 the procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the intracept procedure is experimental. More research is needed to show safety and efficacy.  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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the intracept procedure (CPT code(s): 22899 and C9752).