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

 We decided that the Plan does not have to waive the copayment for a hospital outpatient clinic visit (G0463), tangential biopsy of a skin growth (11102), and the destruction of a precancer skin growth (17000) provided on May 5, 2021, and September 13, 2021.  You asked the Plan to waive the copayment for a hospital clinic visit and treatment of a precancer skin growth. You say that you were referred by your primary care physician and do not think you should pay. The Plan denied your request. The Plan says the cost-share was applied correctly according to your benefit for Medicare-covered surgery or other services provided at an outpatient hospital.     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 and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers.   You have been asked to pay a total copayment of $482.15 for a hospital clinic visit and the treatment of a precancer skin growth. The services at issue fall within the Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. The allowed amount for services received on May 5, 2021, is $286.39. Meanwhile, the allowed amount for services received on September 13, 2021, is $195.76. Since the allowed amount for each date of service is less than the contractual cost-share of $325, you are only responsible for the lesser amount ($286.39 + $195.76 = $482.15).   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 a hospital outpatient clinic visit (G0463), tangential biopsy of a skin growth (11102), and the destruction of a precancer skin growth (17000) provided on May 5, 2021, and September 13, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ambulance transportation services (A0427, A0425) provided on August 26, 2021.  You asked the Plan to waive the copayment for the ambulance transportation. You say that you should not be responsible for this cost, as you could not go to the hospital you usually go to. The Plan denied your request. The Plan says this service is covered, and your claim was processed in accordance with your contract. You are responsible for a $150 copayment for Medicare-covered one-way ground ambulance transportation.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 copayment for ground ambulance transportation.    You have been asked to pay a $150 copayment for the ambulance transportation. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance transportation services (A0427, A0425) provided on August 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that you are ready for transfer to the LTACH. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found you are unstable and require additional short-term acute care hospital services that can be safely administered at the current facility. You do not require services at the LTACH that are not already available at the current facility. Transfer may be considered when you are more stable and treatment has been completed.  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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for esophagogastroduodenoscopy (43235) provided on April 29, 2021.  You asked the Plan to pay for the esophagogastroduodenoscopy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says payment for this service has already been made to the physician.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  We find that CPT code 43235 is not supported in the record. Specifically, the record indicates that payment for the professional services have already been made to the rendering physician. Additionally, the service at issue was not billed on a facility claim. There is no indication that this service was rendered more than once. Based on this information, we decided that Medicare rules for coverage of the esophagogastroduodenoscopy have not been met. Therefore, we decided that the Plan does not have to pay for esophagogastroduodenoscopy (43235) provided on April 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the abutment supported porcelain fused to metal crown (D6059), provided on October 12, 2021.  You asked the Plan to pay for the implant service. You say that the service should be covered. The Plan denied your request. The Plan says there's no coverage for implants and implant-related services including crowns attached to it.  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 abutment supported porcelain fused to metal crown (D6059), provided on October 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a MyoPro 2 Motion G orthotic device (L8702).  You asked the Plan to pre-approve a MyoPro device. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested item is experimental/investigational.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a MyoPro device. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found that provided records document right upper extremity spasticity which may be a contraindication to use of the device. Although records from the device vendor argue medical necessity of the requested device, no records from the enrollee's actual treating provider clarify why the requested device is the most appropriate treatment for the enrollee's condition. In addition, current clinical guidelines designate robotic therapy to be of "uncertain utility compared with dose-matched conventional upper limb exercise therapies" with unproven benefit in the home environment.  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 MyoPro device have not been met. Therefore, we decided that the Plan does not have to pre-approve a MyoPro 2 Motion G orthotic device (L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for an automatic external defibrillator, with integrated electrocardiogram analysis, garment type (K0606) provided on September 14, 2021.  You asked the Plan to waive the coinsurance for an automatic external defibrillator, with integrated electrocardiogram analysis, garment type. You say that you did not know you would have a bill and the device was forced on you without you being told the cost or that there would be a cost. 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 20% coinsurance for durable medical equipment (DME) and related supplies.    You have been asked to pay $633.73 in coinsurance, which is 20% of the allowed amount for an automatic external defibrillator, with integrated electrocardiogram analysis, garment type ($3,168.69 allowed amount x 20% coinsurance = $633.73). An automatic external defibrillator, with integrated electrocardiogram analysis, garment type falls within the durable medical equipment (DME) and related 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 coinsurance for an automatic external defibrillator, with integrated electrocardiogram analysis, garment type (K0606) provided on September 14, 2021.   Your complaint about potentially being given no choice but had to take this device and wear it, and potentially not being informed of the cost 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: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a diagnostic imaging service provided on October 5, 2021.  You asked the Plan to waive the copayment for the diagnostic imaging service. You say that you thought the imaging was a part of the treatment. The Plan denied your request. The Plan says the proper copayment was applied for this service.  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 Medicare-covered diagnostic radiology services that are not ultrasounds.     You have been asked to pay a $250 copayment for the diagnostic imaging service. The diagnostic imaging 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 a diagnostic imaging service provided on October 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services (88305, 88312) rendered by the out-of-network (OON) provider on September 23, 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 laboratory services (88305, 88312) rendered by the out-of-network (OON) provider on September 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for injections (62320) provided September 27, 2021.  You asked the Plan to pay for injections. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.  The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.  We looked at the file and Medicare rules. No medical records were submitted to support the claim. Based on this information, we decided that Medicare rules for coverage of injections have not been met. Therefore, we decided that the Plan does not have to pay for injections (62320) provided September 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for an x-ray and a specialist office visit provided on July 21, 2021.  You asked the Plan to waive the copayments for an x-ray and a specialist office visit. You say that the x-ray should be covered, and the bill was already paid. The Plan denied your request. The Plan says the proper copayments were applied for the services.  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 $35 copayment for Medicare-covered x-ray services and a $45 copayment for each Medicare-covered visit with a specialist.     You have been asked to pay a $35 copayment for an x-ray and a $45 copayment for a specialist office visit. The x-ray falls within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. The specialist office visit falls within the Physician/Practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for an x-ray and a specialist office visit provided on July 21, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the emergency room visit provided by an in-network facility on September 1, 2021.  You asked the Plan to waive the copayment for the emergency room visit. You say that you were unaware another copayment would apply. You say you were told to go to the emergency room if there were further complications. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $110 copayment for each covered emergency room visit.    You have been asked to pay a $110 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" 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 emergency room visit provided by an in-network facility on September 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the expanded respiratory panel by nucleic acid provided on April 2, 2021, billed with codes 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, and 87798.  You asked the Plan to pay for the lab testing as billed. You say that this was medically necessary testing. The Plan denied your request. The Plan says the documentation does not support the reported POS code 11.  The Plan must follow Medicare rules. Medicare rules say that for lab services, the POS code must reflect the location in which the sample was taken.   We looked at the file and Medicare rules. The POS code reported was 11 for an office. However, the documentation indicates that this sample was taken from the patient in their assisted living facility. There is no evidence that it was taken in the office setting. As such, POS 11 is not supported. Based on this information, we decided that Medicare rules for coverage of the lab testing as billed have not been met. Therefore, we decided that the Plan does not have to pay for the expanded respiratory panel by nucleic acid provided on April 2, 2021, billed with codes 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, and 87798.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to pay for the emergency room services rendered on October 21, 2020.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not separately payable.  The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.  The provider submitted a claim for procedure codes 99285 (emergency room visit) and 99291 (critical care services). Code 99285 is a column II code with a modifier indicator of 1 when billed with column I code 99291. Code 99285 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 emergency room services rendered on October 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the limited oral evaluations (D0140 x 2), complete series x-ray (D0210), filling (D2392), addition of tooth to denture (D5650 x 2), extractions (D7140 x 2), and denture reline (D5731) provided from June 21, 2021, to September 2, 2021.  You asked the Plan to pay for the dental services. You say that you were advised by a plan representative that this provider was in network and that all the services would be covered. You say that the dental office advised that the dentist was in network. You also say that you cannot afford to pay this bill. The Plan denied your request. The Plan says the limited oral evaluations, complete series x-ray, denture adjustments, and extractions are not listed as covered services. The Plan says there is a 55% coinsurance for filling that you received out of network. The Plan also says that out of network dentists may bill you for any amount greater than what the plan pays the provider for covered services.  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 limited oral evaluations, complete series x-ray, denture adjustments, and extractions are not among those covered under this benefit. Additionally, the record shows that the Plan paid 45% ($59.40) of the allowed amount ($132) for the filling. Out of network dentists may bill you for any amount greater than the plan pays the provider. Therefore, we decided that the Plan does not have to pay for the limited oral evaluations (D0140 x 2), complete series x-ray (D0210), filling (D2392), addition of tooth to denture (D5650 x 2), extractions (D7140 x 2), and denture reline (D5731) provided from June 21, 2021, to September 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the emergency oral evaluation (D0140) provided on July 13, 2021.  You asked the Plan to pay for the dental service. You say that the first and second dentists that you saw did not explain what the problem was with your teeth. You say that you went for a second opinion and now the services are not covered. The Plan denied your request. The Plan says 1 emergency oral evaluation is covered per calendar year. The Plan also says that the frequency limit has been exceeded.  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 and the service is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for an emergency oral evaluation that you received on June 3, 2021. Therefore, we decided that the Plan does not have to pay for the emergency oral evaluation (D0140) provided on July 13, 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 is medically ready for discharge. Due to medical complexity and his current physical needs, an IRF admission is recommended The Plan denied your request. The Plan says criteria for admission to the IRF setting have not been met. The enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care.    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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  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.