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

We decided that the Plan does not have to waive the copayment for the esophagogastroduodenoscopy (EGD) you received at an outpatient hospital facility on May 28, 2021.
You asked the Plan to waive the copayment for the EGD. You say that you had a colonoscopy to find the source of your anemia. You said that your doctor wouldn't sign off on your knee surgery until a colonoscopy was done. 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 $350 copayment for outpatient surgery at an outpatient hospital facility. Records show that you were charged this copayment for an EGD, not a colonoscopy. You have been asked to pay a $350 copayment for the EGD.
The EGD falls within the outpatient surgery at an outpatient hospital facility benefit category. This copayment applies regardless of the reason for the 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 esophagogastroduodenoscopy (EGD) you received at an outpatient hospital facility on May 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional intraoral x-ray and limited oral evaluation
provided on June 7, 2021.
You asked the Plan to pay for the additional intraoral x-ray and limited oral evaluation. You say that you were
there as a new patient and only wanted the exam and x-rays allowed by insurance. You say that you couldn't
believe this was billed as an emergency limited oral evaluation and want to be billed as previously agreed upon.
The Plan denied your request. The Plan says the claim processed correctly.
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 also have a maximum benefit of
one intraoral x-ray per calendar year. The Plan paid for one intraoral x-ray provided on June 7, 2021, which
exhausted your benefit. The limited oral evaluation remains denied as a non-covered benefit. Therefore, we
decided that the Plan does not have to pay for the additional intraoral x-ray and limited oral evaluation
provided on June 7, 2021.
Your complaint about being taken advantage of is not a valid appeal for medical coverage. This part of your
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision
about these types of complaints.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 16 additional physical therapy visits.

You asked the Plan to pre-approve 16 additional physical therapy visits. The Plan denied your request. The Plan says additional visits are 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 16 additional physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that you were approved for therapy for the right shoulder which includes a home exercise program. Our reviewer says that the unique skills of a professional therapist are not required to safely and effectively provide ongoing treatment. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 16 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 16 additional physical therapy visits.
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 May 19, 2021, to May 21, 2021, and June 23, 2021, to June 27, 2021.
You asked the Plan to waive the copayment for two inpatient hospital admissions. You say that you feel you have already met your out-of-pocket maximum for services this year. The Plan denied your request. The Plan says there is a $500 copayment for each inpatient hospital admission. There is a $1,500 out-of-pocket limit for inpatient care each year, but you had not had three prior inpatient admissions at the time of service. You also had not yet met your maximum out-of-pocket costs for medical care during the calendar year.
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 $500 copayment for each inpatient hospital admission.
You have been asked to pay a $1,000 copayment for two inpatient hospital admissions. 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 May 19, 2021, to May 21, 2021, and June 23, 2021, to June 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray (CPT code 71045-26) provided to the
enrollee on August 6, 2021.
You asked the Plan to pay for the chest x-ray. You say that the enrollee had multiple exams on this date of
service. The Plan denied your request. The Plan says the services are not supported by the records.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. Review of the file shows the enrollee had
professional interpretation of a chest x-ray on August 6, 2021. The submitted documentation supports one (1)
unit of 71045-26, which was previously approved/paid. The Plan states there is no additional documentation
supporting an additional study by the billing provider which was billed for the same date of service and
remains denied. Based on this information, we decided that Medicare rules for coverage of the chest x-ray have
not been met. Therefore, we decided that the Plan does not have to pay for the chest x-ray (CPT code 71045-
26) provided to the enrollee on August 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the spinal surgery (CPT code(s): 20936, 22614, 22630, 2630, 22633, 22842, 2846, 22853 and 63047).
You asked the Plan to pre-approve the spinal surgery. You say that you have been experiencing pain in your lumbar spine since September 27, 2021, the result of a pulling motion. The Plan denied your request. The Plan says the requested procedure is supported when you have had treatment that did not help. The Plan states the treatment must include at least two (2) out of three (3) of the following types. The Plan states 1: drugs for pain and/or inflammation (swelling) for six (6) weeks, 2: an exercise program given by your treating provider for 6 weeks and 3: epidural steroid injections/selective nerve root blocks (types of injections in your spine). The Plan states there was no documentation submitted with this appeal that shows you have tried and failed any of these treatments.
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 spinal surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the criteria for spinal surgery not met. There is no documentation of adequate conservative measures for back pain to include physical therapy.
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 spinal surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve the spinal surgery (CPT code(s): 20936, 22614, 22630, 2630, 22633, 22842, 2846, 22853 and 63047).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for electrocardiogram, routine ECG with at
least 12 leads (93000) provided June 24, 2021.
You asked the Plan to waive the copayment for the diagnostic service. You say that your copay for specialist
office visits is only $35.00. There should not be a separate charge with a separate copay. The Plan denied your
request. The Plan says the claim was processed with the correct copayment of $13.54 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). Your contract with the Plan clearly says that you must pay $25
copayment for Medicare covered non-radiological diagnostic services.
You have been asked to pay $13.54 for the diagnostic service. Since the allowed amount of $13.54 was less
than the Plan's copayment amount of $25.00, you are responsible for the lesser amount of $13.54.
The diagnostic service 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 electrocardiogram, routine ECG with at least 12
leads (93000) provided June 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept procedure.
You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria
have not been met.
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 an Intracept 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 an Intracept procedure have not been met. Therefore, we decided that the Plan
does not have to pre-approve an Intracept procedure.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance service, advanced life support, emergency
transport (A0427) and ground mileage (A0425) provided on February 9, 2021.
You asked the Plan to pay for the ambulance services. You say that the services should be covered. The Plan
denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in
which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Original Medicare is responsible for payment for services until the first day of the month after the
hospice election has been revoked or terminated.
The enrollee ended Medicare Hospice benefits on February 9, 2021. The services in question were provided
before the end of that month. Therefore, we decided that the Plan does not have to pay for the ambulance
service, advanced life support, emergency transport (A0427) and ground mileage (A0425) provided on
February 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a transthoracic echocardiogram (TTE) and a single positron emission computed tomography (SPECT) scan of the heart.  You asked the Plan to pre-approve the cardiac imaging studies. You say that it is felt that this imaging is needed to monitor the enrollee's condition. The Plan denied your request. The Plan says this imaging is not currently medically necessary.  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 cardiac imaging studies. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a 73-year-old female with hypertension, hyperlipidemia, and a pacemaker. Based on the records, the patient has been clinically stable. Based on guidelines, there is no evidence to support the requested TTE and SPECT studies at this time.  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 cardiac imaging studies have not been met. Therefore, we decided that the Plan does not have to pre-approve a transthoracic echocardiogram (TTE) and a single positron emission computed tomography (SPECT) scan of the heart.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided by physical therapy assistant on August 4, 2020.
You asked the Plan to pay for the physical therapy services. You say that plans are required to pay non-contracted providers at the preferred provider rate if services are not available from preferred providers in the service area. You say that the in-network benefits should be honored, and the claim processed for payment. The Plan denied your request. The Plan says the records do not support the code billed.
The Plan must follow Medicare rules. Medicare rules say that the services of a physical therapy assistant (PTA) shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the physical therapy services have not been met. Specifically, the billing provider is a nurse practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services provided by physical therapy assistant on August 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspiration.
You asked the Plan to pre-approve bone marrow aspiration. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
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 bone marrow aspiration. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found bone marrow aspiration remains experimental for use in spinal surgery. More research is needed to show safety and efficacy of bone marrow aspiration when used as bone graft material. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bone marrow aspiration have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspiration.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) you had on July 19, 2021.
You asked the Plan to waive the copayment for the MRI. You say that you were not aware there was a copayment for MRIs. 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 $325 copayment for diagnostic radiology services.
You have been asked to pay a $325 copayment for the MRI. The MRI falls within the diagnostic radiology 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 magnetic resonance imaging (MRI) you had on July 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99204) rendered by the out-of-network
(OON) provider on December 29, 2020.
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 the 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 office visit (99204) rendered by the out-of-network (OON) provider on
December 29, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lipid panel (80061), the five additional units of code
85027 (complete blood count), the hemoglobin test (85018), the hematocrit test (85014), the automated platelet
count (85049), and the high resolution fractionation and quantitation of lipoproteins (83701) billed for lab
services provided on May 13, 2021.
You asked the Plan to pay for the testing as billed. You say that this claim should be paid in full. The Plan
denied your request. The Plan says only the codes supported have been paid.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. The rules also say that there a Column
1/Column 2 edits which are codes that cannot be billed together without a mvalid modifier.
In this case, the provider billed 6 units of code 85027 for complete blood count (CBC). There is no evidence
that 6 complete blood count tests were done on this date of service. The Plan agreed to pay for one, which is
supported by the lab results. Codes 85014, 85018, and 85049 are for individual components of the CBC. These
codes are Column 2 codes in relation to the approved unit of code 85027. No modifier was used to bypass the
edit, and the records show no evidence of these being done separately from the paid CBC test. Codes 80061
and 83701 are Column 2 codes in relation to 83704 which was approved on appeal. No modifier was used to
bypass this edit. Based on this information, we decided that Medicare rules for coverage of the testing as billed
have not been met. Therefore, we decided that the Plan does not have to pay for the lipid panel (80061), the
five additional units of code 85027 (complete blood count), the hemoglobin test (85018), the hematocrit test
(85014), the automated platelet count (85049), and the high resolution fractionation and quantitation of
lipoproteins (83701) billed for lab services provided on May 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for oxygen equipment you rented from January 23, 2020, to September 15, 2021.  You asked the Plan to waive the coinsurance for the oxygen equipment. You say that you filed a complaint with your state's attorney general because you are getting billed even though you have paid on this same unit for a long time.  You do not think you should have to pay until you need a new one. The Plan denied your request. The Plan says it has adjusted your cost sharing so you are only responsible for 20% coinsurance.  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 oxygen equipment. The oxygen equipment falls within the durable medical equipment 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 oxygen equipment you rented from January 23, 2020, to September 15, 2021.