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

 We decided that the Plan does not have to waive the copayments for cataract surgeries provided by an in-network provider on September 29, 2020, and August 31, 2021.  You asked the Plan to waive the copayments for the cataract surgeries. You say that you want to be reimbursed the copayment amounts because insurance must cover these services. 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 $350 copayment per day for other outpatient procedures and services, including, but not limited to, diagnostic and therapeutic endoscopy, and outpatient surgery performed in an outpatient hospital or ambulatory surgical center.     You have been asked to pay a $350 copayment for each of the cataract surgeries. The cataract surgeries fall within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 cataract surgeries provided by an in-network provider on September 29, 2020, and August 31, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services (87631, 87798) provided on March 2, 2021.  You asked the Plan to pay for laboratory services. You say that this is supported in the records. The Plan denied your request. The Plan says this cannot be paid as billed.  The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).   We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (87631, 87798) provided on March 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a porcelain/ceramic pontic (D6245) and porcelain/ceramic retainer crowns (D6740) for a dental bridge.  You asked the Plan to pre-approve the dental bridge. You say that these services are necessary. The Plan denied your request. The Plan says the specific codes requested for these services are not covered by your dental benefit.  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. Please note that dental bridges are covered by your dental benefit, and the Plan does offer coverage of pontics and retainer crowns which are made of other materials and therefore billed with other procedure codes. You may wish to work with your provider and the Plan to find out if the dental bridge is medically necessary based on the Plan's criteria and can be completed with other pontic and retainer crown options which are listed as covered by the Plan. The specific porcelain/ceramic components, billed with codes D6245 and D6740 are not listed as covered. Therefore, we decided that the Plan does not have to pre-approve a porcelain/ceramic pontic (D6245) and porcelain/ceramic retainer crowns (D6740) for a dental bridge.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ambulance service, basic life support, non-emergency transport (A0428) and ground mileage (A0425) provided April 3, 2021.  You asked the Plan to waive the copayment for the non-emergency ambulance service and ground mileage. You say that you were told the copayment would be waived since it was related to coronavirus (COVID). The Plan denied your request. The Plan says they did not find any evidence that a Plan representative informed you that the cost-sharing would be waived. The copayment was applied 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 $215 copayment for each one-way Medicare-covered ground ambulance trip.   You have been asked to pay a $215 copayment for the non-emergency ambulance service and ground mileage. The non-emergency ambulance service and ground mileage falls within the Ambulance 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 ambulance service, basic life support, non-emergency transport (A0428) and ground mileage (A0425) provided April 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the prefabricated post and core in addition to crown (D2954) provided on October 1, 2021.  You asked the Plan to pay for the prefabricated post and core. The Plan denied your request. The Plan says this service is not covered.  Medicare generally does not cover dental services. The Plan follows the same rule.  The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the prefabricated post and core in addition to crown (D2954) provided on October 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for inpatient hospital services you received from December 12, 2020, to January 14, 2021.  You asked the Plan to waive the copayment for the inpatient hospital services. You say that you were told that all copayments for services related to COVID-19 are waived. The Plan denied your request. The Plan says you were charged this copayment correctly.  The Plan says that all COVID-19-related copayment waivers ended in June of 2020, months before your hospitalization.  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 per day for days 1-7 for inpatient hospital services.    Records show that you were in the hospital for 33 days. You were charged a $225 copayment per day for each of the first 7 days, for a total of $1575. There is no provision in your contract for a waiver of this amount, even if the hospitalization was due to COVID-19. 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 inpatient hospital services you received from December 12, 2020, to January 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941) rendered by the out-of-network (OON) provider on August 30, 2021.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says 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 chiropractic manipulative treatment (98941) rendered by the out-of-network (OON) provider on August 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for specialist visits provided on September 13, 2021, and September 23, 2021.  You asked the Plan to waive the copayments for specialist visits. You say that you were told that you would not owe a copayment for the surgical procedures. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $40 copayment for specialist visits.   The medical records show that you received specialist visits on September 13, 2021, and September 23, 2021. Therefore, you are responsible to pay a $40 copayment per each visit.   The total amount you owe is: $40 (copayment) x 2 (specialist visits) = $80.   You have been asked to pay the total copayment amount of $80 for specialist visits. Specialist visits fall 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 specialist visits provided on September 13, 2021, and September 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the eyewear services (92341, V2020, V2203) provided on July 13, 2021, by an out-of-network provider.  You asked the Plan to pay for the out-of-network vision care. You say that the enrollee did not have a choice in who provided these services. The Plan denied your request. The Plan says that routine eyewear services are only covered when they are received by a provider in the Plan's specified routine vision vendor network.  Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when they are purchased from a provider in the Plan's specified routine vision vendor network.  We looked at the file and the Plan's rules. The provider in this case is not part of the Plan's specified network. Based on this information, we decided that the Plan's rules for coverage of out-of-network vision care have not been met. Therefore, we decided that the Plan does not have to pay for the eyewear services (92341, V2020, V2203) provided on July 13, 2021, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for therapeutic parenteral drugs (D9612), and removal of lateral exostosis (D7471) to be provided by a participating provider.  You asked the Plan to pay for therapeutic parenteral drugs and removal of lateral exostosis. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says the requested dental services are not a covered dental benefit.  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 therapeutic parenteral drugs (D9612), and removal of lateral exostosis (D7471) to be provided by a participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).  You asked the Plan to pre-approve a pneumatic compression device. You say that the enrollee's clinical presentation necessitates this device. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because the record shows that the enrollee has been using a pump and compression wraps with improvement in leg swelling and there is no evidence of truncal or abdominal swelling.  The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.  We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the acne surgery provided on September 7, 2021.  You asked the Plan to pay for the surgery. The Plan denied your request. The Plan says this was a cosmetic procedure.  The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are coverable.    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 surgery. Our reviewer says that the requested surgery was not medically reasonable and necessary. Our reviewer found that based on the medical records provided there is no documentation of pain, impairment, concern for skin cancer, infection or condition which would indicate this surgery was performed for any other reasons except cosmesis.  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 surgery have not been met. Therefore, we decided that the Plan does not have to pay for the acne surgery provided on September 7, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoperative neuromonitoring (IONM) services provided on November 13, 2020.

You asked the Plan to pay for the IONM services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says these services should be billed to the facility.

The Plan must follow Medicare rules. Medicare rules say that radiology and other diagnostic services furnished to hospital outpatients are paid under the Outpatient Prospective Payment System (OPPS) to the hospital. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the IONM services have not been met. Specifically, payment for these services is included in the payment to the outpatient facility and is the responsibility of the facility to any vendor. Therefore, we decided that the Plan does not have to pay for the intraoperative neuromonitoring (IONM) services provided on November 13, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound provided by a network provider on August 5, 2021.

You asked the Plan to waive the copayment for the ultrasound. You say that this should be covered because you had an office visit scheduled and the provider wanted the ultrasound done before the office visit. You say you were not aware there would be a $100 copayment. 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 $100 copayment per day for a Medicare-covered ultrasound. 

You have been asked to pay a $100 copayment for the ultrasound. The ultrasound 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 the ultrasound provided by a network provider on August 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the GeneSight testing rendered on September 1, 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. Medicare rules say that the appropriate DEX Z-Code must be billed adjacent to the CPT code for GeneSight testing. 

We looked at the file and Medicare rules. The file shows that the claim was not billed with the required DEX Z-Code. 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 GeneSight testing rendered on September 1, 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. The Plan denied your request. The Plan says LTACH admission is not medically necessary.

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 that there is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he/she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a CPAP machine (E0562) provided on September 21, 2021.

You asked the Plan to waive the coinsurance for the CPAP machine. You say that the item should be covered as it would cause financial hardship. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the item provided.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Durable medical equipment (DME) and related supplies.

You have been asked to pay a 20% coinsurance for a CPAP machine (allowed is $357 x 20% = $71.40). CPAP machines fall 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 a CPAP machine (E0562) provided on September 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on April 16, 2021, by an OON
provider.

You asked the Plan to pay for the office visit. You say that the service was medically necessary. The Plan
denied your request. The Plan says no prior authorization was obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we
decided that the Plan does not have to pay for the office visit provided on April 16, 2021, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s) received from September 24, 2021 to September 28, 2021.

You asked the Plan to pay for the additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s). You say that the office contacted your insurance and was advised that you would be covered for these services. The Plan denied your request. The Plan says the services received are not a covered benefit.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s) received from September 24, 2021 to September 28, 2021.