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

We decided that the Plan does not have to waive the copayments for the esophagogastroduodenoscopy (EGD) with dilation procedure and the computed tomography (CT) scan you had at an outpatient hospital facility on March 2, 2021.  You asked the Plan to waive the copayments for the EGD procedure and the CT scan. You say that you did not consent to the CT scan.  You also stated that because the EGD didn't involve cutting, it should not be considered surgery.  You believe you should only be responsible for the emergency room copayment. 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 @325 copayment for outpatient surgery in an outpatient hospital facility and a $225 copayment for advanced imaging services.   The records show that you presented to the emergency room with a obstruction in your throat.  You left the ER and were taken to an operating room where you received the EGD procedure and the CT scan. You have been asked to pay a $325 copayment for the EGD procedure and a $225 copayment for the CT scan. Medicare considers the EGD procedure to be a surgical procedure, so it falls within the outpatient surgery in an outpatient hospital facility benefit category. In addition, the CT scan is considered an advanced imaging service. This means that you have been asked to pay the correct amounts 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 esophagogastroduodenoscopy (EGD) with dilation procedure and the computed tomography (CT) scan you had at an outpatient hospital facility on March 2, 2021.   Your complaint about not consenting to the CT scan 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for skilled nursing facility services provided from April 16, 2021, to June 1, 2021.  You asked the Plan to waive the copayment for skilled nursing facility services. You say that the first twenty days of the first stay were covered in February and March, but the first twenty days of the second stay were not covered because the need for care was not over 60 days apart. 
You also say that the second stay at the skilled nursing facility was a completely different problem and was unrelated to the first stay.  You also say that this has created an out of pocket expense that you were not prepared for. The Plan denied your request. The Plan says you were charged the correct cost sharing amount.  
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $178 copayment for days 21-100 for skilled nursing facility (SNF) care. The enrollee's contract with the Plan also clearly says that a benefit period begins on the first day the enrollee goes to a Medicare-covered skilled nursing facility (SNF). The benefit period ends when the enrollee has not been an inpatient of a hospital or a skilled nursing facility for 60 days in a row. An individual may be discharged from and readmitted to a hospital or SNF several times during a benefit period and still be in the same benefit period if 60 consecutive days have not elapsed between discharge and readmission  
The enrollee has been asked to pay a $178 copayment for 20 days for skilled nursing facility services, which is a total of $3,560 ($178 x 20 = $3,560). The records show that 60 consecutive days had not passed before the enrollee was admitted again for skilled nursing facility care. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for skilled nursing facility services provided from April 16, 2021, to June 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a crown (D2740) provided on May 13, 2021 by an out-of-network (OON) provider.  
You asked the Plan to pay for a crown. You say that the crown replacement procedure was needed. You also say that the payment made by the insurance is far below the cost of a crown. You are requesting the covered cost to be reviewed again. The Plan denied your request. The Plan says since the provider was OON, the difference of the billed amount and allowed paid amount became your responsibility.  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. The records show that the provider billed amount for this service was $1,587. The maximum allowed amount for this service was $578. 
The Plan paid 50% of the maximum allowed amount for a total of $289. The records also show that since the provider was OON, you are responsible for the remaining balance.   Based on this information, we decided that the Plan's rules for coverage of a crown have not been met. Therefore, we decided that the Plan does not have to pay for a crown (D2740) provided on May 13, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for drug testing services (procedure code G0483) provided to the enrollee on June 8, 2021.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the records do not contain documentation to support the coding criteria for code billed on date of service.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.   
In this case, the CPT Code Manual definition of Healthcare Common Procedure Coding System (HCPCS) G0483 is "Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed."  
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case supported by the medical records. Our reviewer found drug testing was performed. The records support that 22 or more drug classes were tested in this case. THC, Clonazepam, Hydrocodone were positive. The report shows more than 22 drug classes were tested on 6/8/2021.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for drug testing services (procedure code G0483) provided to the enrollee on June 8, 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient mental health services you received from an outpatient hospital on July 29, 2021.  You asked the Plan to waive the copayment for the outpatient mental health services. You say that this was a telehealth visit. 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 for outpatient mental health services at an outpatient hospital.      
You have been asked to pay a $100 copayment for the outpatient mental health services. There is nothing in the bill submitted by the hospital that would indicate this was a telehealth visit. 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 outpatient mental health services you received from an outpatient hospital on July 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the intravenous infusion (96365) provided on January 1, 2021.  You asked the Plan to waive the copayment for the infusion. You say that you were advised that you would require infection fighting drugs. You say that you were not advised that the infusions would be so costly. You say that if you had known the cost was so high, you would have opted for the pill. You also say that you feel the doctor did not inform you and you feel it is not honest for you to be charged this much. The Plan denied your request. 
The Plan says there is a $225 copayment for intravenous infusion services you receive at an outpatient hospital. The Plan says that the allowed amount for this service is $183.42 which is less than the $225 copayment. The Plan also says you will not be charged more than the allowable 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 outpatient surgery and other medical services provided at hospital outpatient facilities.   You have been asked to pay a $183.42 copayment for the infusion. The infusion falls within the outpatient surgery and other medical services provided at hospital outpatient facilities benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan as the allowed amount is less than the listed copayment of $225. 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 intravenous infusion (96365) provided on January 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) to the left sacroiliac (SI) joint.  You asked the Plan to pre-approve medical services. You say that these services are medically necessary for the enrollee's condition. The Plan denied your request. The Plan says these services remain experimental for the enrollee's condition.  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 medical services. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that according to the literature, sacral lateral nerve branch blocks and/or ablations/neurotomies for the diagnosis and/or treatment of sacroiliac joint mediated pain is considered experimental and investigational. Studies completed say that this procedure does not improve outcomes compared to standard treatment of SIJ pain. Radiofrequency ablation for denervation, whether performed using traditional, cooled, or pulsed radiofrequency, is considered investigational and therefore, not medically necessary. 
The review has determined that the requested SI joint RFA 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 medical services have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) to the left sacroiliac (SI) joint.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a repeat diagnostic colonoscopy with anesthesia.  You asked the Plan to pre-approve a repeat colonoscopy. You say that the repeat colonoscopy request was due to a poor prep after a screening colonoscopy in May of 2021. The Plan denied your request. The Plan says a repeat colonoscopy is not 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 a repeat colonoscopy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the provided documentation does not indicate that the enrollee is at high risk for colon cancer. The reviewer also found that the provided documentation does not indicate that the enrollee has red flag signs/symptoms to warrant a repeat colonoscopy at the requested 6-month time frame. Therefore, the reviewer found that the repeat colonoscopy 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 a repeat colonoscopy have not been met.  Specifically, the file shows that the enrollee is not a high risk for colon cancer. Therefore, we decided that the Plan does not have to pre-approve a repeat diagnostic colonoscopy with anesthesia.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for wound debridement services you received at an outpatient hospital facility (16020) rendered on April 2, 2021.  
You asked the Plan to reduce the copayment for wound debridement services you received at an outpatient hospital facility. You say that that these visits were supposed to be office visits with just a $25 copayment. You said that you had a burn that did not require surgery. You stated that you were never advised that this would be considered an outpatient procedure and if you had known, you would not have gone as often The Plan denied your request. The Plan says you were charged the correct cost sharing amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for each visit to a hospital outpatient surgical department.    
You have been asked to pay a $250 copayment for the wound debridement services. Wound debridement is considered a surgical service. In addition, these services occurred in an outpatient hospital facility. That is why the wound debridement services fall within the outpatient surgery in an outpatient hospital facility 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 reduce the copayment for wound debridement services you received at an outpatient hospital facility (16020) rendered on April 2, 2021.
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. You say that the enrollee needs multiple therapies and care provided in an inpatient rehabilitation setting. The Plan denied your request. 
The Plan says the criteria for admission to an IRF are not met. The enrollee's necessary care can be provided in an alternate setting.  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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found based on the documentation provided, the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to be able to perform fifteen hours of rehabilitative services per week with regular physician evaluation. 
The enrollee's needs can be met in 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 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 pay for the electrocardiogram provided to you on June 29, 2021.  You asked the Plan to pay for the electrocardiogram. The Plan denied your request. The Plan says the diagnosis does not support this service.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The test at issue in this appeal, the electrocardiogram, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the electrocardiogram provided to you on June 29, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided April 10, 2021 to April 16, 2021 and April 21 through May 3, 2021 and May 6, 2021 to May 9, 2021.  You asked the Plan to pay for the SNF services. You say that the medical records provided support the necessity of the services in dispute The Plan denied your request. The Plan says medical necessity cannot be established for continued SNF level of coverage.  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 pay for the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis and does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.  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 SNF services have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided April 10, 2021 to April 16, 2021 and April 21 through May 3, 2021 and May 6, 2021 to May 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the x-rays you had on January 12, 2021, and January 29, 2021, and the computed tomography (CT) scan you had on February 2, 2021, at an outpatient hospital facility.  You asked the Plan to waive the copayments for the x-rays and the CT scan. 
You say that you had COVID-19, so these services were coded as 'COVID pneumonia.' The Plan denied your request. 
The Plan says its COVID-related copayment waiver program was only in effect until December 31, 2020.  These services occurred after that date, so you are responsible for these copayments.  
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 $15 copayment each for x-rays and a $90 copayment for other radiological diagnostic services.   You have been asked to pay a $15 copayment each for the x-rays and a $90 copayment for the CT scan. 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 x-rays you had on January 12, 2021, and January 29, 2021, and the computed tomography (CT) scan you had on February 2, 2021, at an outpatient hospital facility.
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. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically necessary.  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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found based on the documentation you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met 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 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.