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

We decided that the Plan does not have to waive the copayment for wound debridement services you received
at an outpatient hospital facility from May 20, 2021, to June 22, 2021.
You asked the Plan to waive the copayment for the wound debridement services. You say that you do not
believe these services should be considered surgical procedures. 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 $150
copayment for outpatient hospital surgery services.
You have been asked to pay a $150 copayment for the wound debridement services. Medicare considers wound
debridement to be a surgical service, so the wound debridement services falls within the outpatient hospital
surgery 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 wound debridement
services you received at an outpatient hospital facility from May 20, 2021, to June 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the durvalumab injection provided on May 
13, 2021. 
 
You asked the Plan to waive the coinsurance for the durvalumab injection. You say that you'd like an 
explanation for the bill. The Plan denied your request. The Plan says the coinsurance 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 20% 
coinsurance for Medicare Part B prescription drugs. 

You have been asked to pay $475.05, which is less than the standard 20% coinsurance for the durvalumab 
injection. The durvalumab injection falls within the "Medicare Part B prescription drugs" benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the coinsurance for the durvalumab injection provided on May 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a total hip arthroplasty (27130). 
 
You asked the Plan to pre-approve a total hip arthroplasty. You say that the requested procedure is a medical 
necessity for you. The Plan denied your request. The Plan says medical necessity rules for the requested 
procedure 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 a total hip arthroplasty. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that detailed documentation is not evident regarding trial and failure of recent, 
reasonable, and comprehensive less invasive conservative care measures, including, but not limited to, physical 
therapy or physician directed home exercise program. In addition, the provided imaging is not noted to 
demonstrate any subchondral cysts, subchondral sclerosis, periarticular osteophytes, joint subluxation, joint 
space narrowing, avascular necrosis, or bone on bone articulations. Relatively early osteoarthritis is 
documented. However, a full-thickness tear of the anterior labrum at the chondrolabral junction is noted on 
imaging. There is only limited published, large-scale, long-term peer-reviewed literature that shows the 
requested surgery to be an effective and/or safe treatment for the noted pathology of full-thickness labral tear 
without demonstration of severe osteoarthritis in the joint. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. 
 
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 total hip arthroplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a total hip arthroplasty (27130).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on May 18, 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 were not billed correctly.

The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. 

We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479.

Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on May 18, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ophthalmic biometry by partial coherence interferometry with intraocular lens power calculation (92136) provided June 2, 2021.

You asked the Plan to waive the copayment for the ophthalmic biometry. You say that you do not know what the service is and don't believe you should have to pay for it. The Plan denied your request. The Plan says the cost of the service was less than the required copayment.

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 $125 copayment for diagnostic procedures and tests at any location other than a physician's office.

You have been asked to pay a $52.42 copayment for the ophthalmic biometry. This service falls within the Outpatient diagnostic tests and therapeutic service and supplies benefit category. This means that you have been asked to pay less than or equal to 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 ophthalmic biometry by partial coherence interferometry with intraocular lens power calculation (92136) provided June 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extractions provided on May 4, 2021. 
 
You asked the Plan to pay for the extractions. You say that the radiation treatment and chemotherapy has 
destroyed your teeth. You say that the claim should be considered a medical necessity and covered by your 
medical insurance. The Plan denied your request. The Plan says extractions are not covered under your medical 
benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
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 your medical plan. Therefore, we decided that the Plan does not have to pay for the extractions provided 
on May 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213), electrocardiogram (93000), and the 
programming device evaluations (93283, 93284) rendered by an out-of-network (OON) provider on  
January 22, 2020. 
 
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 office visit (99213), electrocardiogram (93000), and the programming device 
evaluations (93283, 93284) rendered by an out-of-network (OON) provider on January 22, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic radiology services provided on January 21, 2021.

You asked the Plan to pay for diagnostic radiology services. You say that the patient was not enrollee in hospice on this date of service. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.

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 January 4, 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 diagnostic radiology services provided on January 21, 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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
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 the enrollee does not require an intensive, complex, multidisciplinary approach to daily therapy. While the enrollee may benefit from physical therapy and occupational therapy, the enrollee's rehab needs can be safely met in an alternate and low intensity setting such as a skilled nursing facility. 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health aide services (G0156 x 160) provided from 
May 20, 2021, to May 28, 2021. 
 
You asked the Plan to pay for the home health services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the provider in this case is not Medicare certified. The Plan says 
that a provider that is not Medicare certified is not eligible to receive payment. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the home health aide services (G0156 x 
160) provided from May 20, 2021, to May 28, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services rendered 
from May 24, 2021 to May 28, 2021. 
 
You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. The 
Plan denied your request. The Plan says 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 $150 
copayment per day for days 105 for each time you are admitted to an acute care hospital.  
 
Review of the file shows that you received three days of inpatient hospital services from May 24, 2021 to May 
28, 2021. You were not assessed a copayment for your date of discharge on May 28, 2021. You have been asked to pay a $350 copayment per day for days 1-5 for these services, for a total of $1,050. These services fall 
within the each time you are admitted to an acute care hospital 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 inpatient hospital services rendered from May 24, 2021 to May 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a tooth extraction (D7210) and periodontal scaling and root planing (D4341) provided on June 11, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for a tooth extraction and periodontal scaling and root planing. You say that you were not aware that the services provided were not in network. You also say that you would like to know if scaling is a covered benefit. The Plan denied your request. The Plan says services performed by an OON provider are not covered.

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 EOC confirms that periodontal scaling and root planing are not a covered benefit with Medicare or the Plan. The EOC also confirms that a tooth extraction is covered if you receive services from an in-network provider. The services were rendered by an OON provider. Based on this information, we decided that the Plan's rules for coverage of a tooth extraction and periodontal scaling and root planing have not been met. Therefore, we decided that the Plan does not have to pay for a tooth extraction (D7210) and periodontal scaling and root planing (D4341) provided on June 11, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided April 9, 2021 to May 1, 2021.

You asked the Plan to waive the copayment for the inpatient stay. You say that you are being charged for two copays and you are requesting reconsideration. The Plan denied your request. The Plan says the claim was reprocessed with the correct copayment applied per the Evidence of Coverage.

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 $375 copayment per day for days 1-5 and $0 copayment per day for days 6-90. 

You have been asked to pay $1875.00 ($375 x 5 days) for the inpatient stay. The Plan had reprocessed dates of service 04/20/2021 to 05/01/2021 and overturned the second copayment that was applied as this had been continuous stay at the same facility and you cannot be charged twice for inpatient hospital stay copay. The inpatient stay falls within the Inpatient hospital 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 inpatient hospital stay provided April 9, 2021 to May 1, 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 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 the complexity of your nursing, medical and rehabilitation needs do not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. 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. 
 
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: Lab
Decision: Favorable

We decided that the Plan has to pre-approve lab services (88112) provided December 14, 2020 
 
You asked the Plan to pre-approve lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says that the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The plan did not provide any medical records, a claim form, or denial rationale 
to the IRE for review. Therefore, we decided that the Plan has to pre-approve lab services (88112) provided 
December 14, 2020  
 
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction provided on April 23, 2021. 
 
You asked the Plan to pay for an eye refraction. The Plan denied your request. The Plan says Medicare doesn't 
cover eye exam (sometimes called "eye refractions") for eyeglasses or contact lenses. 
 
Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state 
of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered 
diagnosis or treatment of illness or injury.  
 
We looked at the file and the Medicare rules. The file shows that you received an eye exam for a Medicare-
covered eye condition and not a routine eye exam. The file shows that part of this exam was for a refraction. 
Medicare does not cover refractive procedures even when done in connection with otherwise covered diagnosis 
or treatment of illness or injury. Therefore, we decided that the Plan does not have to pay for an eye refraction 
provided on April 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of torus mandibularis (D7473) provided on April 21, 2021.
You asked the Plan to pay for the removal of torus mandibularis (D7473). You say that he tried to heal this with medication, but it would not heal. You say that this was removed and should have been sent as a medical procedure. The Plan denied your request. The Plan says the service is not a covered 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 your dental or medical benefit. Therefore, we decided that the Plan does not have to pay for the removal of torus mandibularis (D7473) provided on April 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869). 
 
You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested procedure 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 procedure 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 Vertiflex procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the requested procedure is considered experimental/investigational because it has 
not been proven to be superior to the standard surgical intervention and it is not part of the accepted algorithms 
for the management of spinal stenosis. 
 
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 Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Vertiflex procedure (22869).