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

 We decided that the Plan does not have to waive the copayment for skilled nursing facility services rendered from February 5, 2021, to March 4, 2021.  You asked the Plan to waive the copayment for skilled nursing facility services. You say that these two claims should be paid at 100% through the Plan after the Plan already paid your hospital stay at 100%. You also say that you would like to verify that you already talked to the Plan and asked them to review the procedure codes and the diagnoses as a coronavirus (Covid-19) patient. 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 $160 copayment per day, per admission for days 21-100 of skilled nursing facility (SNF) care.   You have been asked to pay a $160 copayment per day, for four days, which is a total of $640 for skilled nursing facility services ($160 x 4 = $640) from February 5, 2021, to February 28, 2021. You have also been asked to pay a $160 copayment per day, for three days, which is a total of $480 for skilled nursing facility services ($160 x 3 = $480) from March 1, 2021, to March 4, 2021. The record shows the total copayment is $1,120 ($640 + $480 = $1,120), which is appropriate for 27 days of skilled nursing facility services. 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 skilled nursing facility services rendered from February 5, 2021, to March 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the eyeglasses (V2020, V2750, V2781, V2784) purchased on July 7, 2021.  You asked the Plan to pay for the eyeglasses. You say that your prescription changed, and you needed new glasses. You feel this benefit should cover more, especially when it is necessary. The Plan denied your request. The Plan says you previously purchased a pair of eyeglasses in February 2020, which were covered by the Plan at that time. Eyeglasses may only be covered once every two years. Therefore, the eyeglasses purchased on July 7, 2021, exceeded the benefit's frequency limitation as two years had not passed since your last purchase of covered eyewear.  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 one pair of eyeglasses (lenses and frames) every two years.  We looked at the file and the Plan's rules. Documentation shows that you previously purchased a pair of routine eyeglasses less than two years before the date in question, and these services were covered by the Plan at that time. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for the eyeglasses (V2020, V2750, V2781, V2784) purchased on July 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost sharing for the infusion procedure you had at an outpatient hospital facility on June 28, 2021.

You asked the Plan to reduce the cost sharing for the infusion procedure. You say that you should only be paying 20% coinsurance for this service, which would equal $158.12. Instead, you are being billed $222.06. The Plan denied your request. The Plan says because the infusion service occurred in an outpatient hospital setting, the outpatient hospital copayment applies. Because the allowed amount for the hospital service ($222.06) is less than your copayment obligation, you are responsible for the full allowed 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 $370 copayment for outpatient surgery or other services at an outpatient hospital facility. 

You have been asked to pay a $370 copayment for the infusion procedure. The Plan contract says that when you receive a Part B drug, in addition to the drug itself, for the administration of that drug, you will pay the cost-sharing that applies to outpatient hospital services. You received this infusion at an outpatient hospital facility. 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 cost sharing for the infusion procedure you had at an outpatient hospital facility on June 28, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ground mileage (A0425) and non-emergency ambulance transportation (A0428) provided on April 8, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the ground mileage and non-emergency ambulance transportation. You say that this was a non-emergency medically necessary transportation. The Plan denied your request. The Plan says prior authorization was not 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. Therefore, we decided that the Plan does not have to pay for the ground mileage (A0425) and non-emergency ambulance transportation (A0428) provided on April 8, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for assistant surgery services provided to the enrollee on March 
15, 2021 coded as 61783. 
 You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request.  The Plan says Current Procedural Terminology (CPT) code 61783-AS (1 Unit) remains not supported. Current  
Procedural Terminology (CPT) code 61783 has an assistant surgeon indicator of 0 ? Statutory payment  
restriction for assistants at surgery applies to this procedure. Assistant at surgery may not be paid. Therefore, 
the billed code is not eligible for reimbursement when performed by an assistant surgeon. The Plan notes  
multiple attempts were made to contact the provider for additional information. 
 The Plan follows Medicare rules. Medicare rules say that items and services that are not medically necessary 
are not covered. Medicare rules say that for procedures with an assistant surgery indicator of 0, the payment 
restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to 
establish medical necessity. In this case, you billed assistant surgery services for Current Procedural 
Terminology (CPT) code 61783. The Medicare Fee Schedule Database contains a surgical indicator of 0 for 
this procedure. Therefore, we decided that the Plan does not have to pay for assistant surgery services provided 
to the enrollee on March 15, 2021 coded as 61783.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) and extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) provided May 26, 2021.  You asked the Plan to pay for the panoramic x-ray and tooth extraction. You say that you would like the services covered. The Plan denied your request. The Plan says this provider has opted out of Medicare and therefore the services 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. The Plan covers x-rays and tooth extraction when performed by a licensed dental provider who has not opted out of Medicare.  We looked at this physician's review, the file, and Medicare rules. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the panoramic radiographic image (D0330) and extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) provided May 26, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a SNF stay provided from January 7, 2021, to January 28, 2021.  You asked the Plan to waive the copayment for a SNF stay. You say that you feel that the SNF stay was unnecessary and the enrollee could have recovered at home. The Plan denied your request. The Plan says the claims were processed correctly and they 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $0 copayment for days 1-20 and a $164 copayment for days 21-100 for SNF care.   The enrollee had a SNF stay from January 7, 2021, to January 28, 2021. The enrollee is not being charged a copayment for days 1-20 (January 7, 2021, to January 26, 2021). The enrollee is responsible to pay a $164 copayment for day 21 (January 27, 2021).   The enrollee has been asked to pay a $164 copayment for a SNF stay. A SNF stay falls within the SNF care benefit category. 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 a SNF stay provided from January 7, 2021, to January 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a polysomnography test.  You asked the Plan to pre-approve a polysomnography test. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  The Plan follows Medicare rules. Medicare rules say that PSG is covered when specific criteria are met.  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 polysomnography test. Our reviewer says that the services are not medically necessary. Our physician reviewer found the clinical information received does not have documentation of the enrollee's sleep history with symptoms including, but not limited to, snoring, observed apneas, choking or gasping during sleep, morning headaches, her neck circumference (neck size) and her body mass index (BMI). The review has determined that the enrollee does not meet the coverage criteria detailed in the LCD.  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 polysomnography test have not been met. Therefore, we decided that the Plan does not have to pre-approve a polysomnography test.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Superion interspinous spacer device.  You asked the Plan to pre-approve the Superion interspinous spacer device. The Plan denied your request. The Plan says this 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 the Superion interspinous spacer device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the Superion spacer device is experimental. More research is needed to show safety and efficacy of this device.  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 Superion interspinous spacer device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Superion interspinous spacer device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional routine transportation trips.  You asked the Plan to pre-approve additional routine transportation trips. You say that your relatives live far and there is no one who can take you to your doctor's appointments. The Plan denied your request. The Plan says you have exhausted all of the transportation trips for this year.  Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 20 one-way trips per year.   We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a scooter.  You asked the Plan to pre-approve a scooter. You say that you are bedbound without a scooter. The Plan denied your request. The Plan says rules for coverage have not been met.  The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.   The file does not show that you can safely operate the PMD being requested. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a scooter.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve anterior cervical fusion surgery.  You asked the Plan to pre-approve anterior cervical fusion surgery. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the record does not show that the enrollee meets the criteria for this surgery.  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 anterior cervical fusion surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record does not show that the enrollee has had adequate conservative measures including physical therapy.       We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of anterior cervical fusion surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve anterior cervical fusion surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the moderate sedation services (99153) provided on March 26, 2021  You asked the Plan to pay for the moderate sedation services. You say that you would like reconsideration because the member had multiple services rendered on the billed date of service. The Plan denied your request. The Plan says CPT code 99153 may not be paid if furnished to a hospital inpatients or patients in a hospital outpatient department.  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 99153 is not supported in the record. Specifically, the record shows that this claim was billed with an inpatient place of service code. CPT code 99153 has a status indicator of 3 meaning that this is a technical component only code. The technical component of diagnostic tests is not separately reimbursable. Payment for this service is the responsibility of the facility to any vendor. Based on this information, we decided that Medicare rules for coverage of the moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services (99153) provided on March 26, 2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from October 13, 2020, to October 17, 2020.  You asked the Plan to waive the copayment for the inpatient hospital services. You say that you were never in the intensive care unit, and you did not receive occupational therapy, so you are disputing these charges. 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 $295 copayment per day for days 1-6 for inpatient hospital services.     Records show that you were in the hospital for 4 days. You were charged a $295 copayment per day, for a total of $1180. This inpatient hospital copayment applies, regardless of the extent of services you receive while you are an inpatient. 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 provided from October 13, 2020, to October 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from April 23, 2021, to May 1, 2021.  You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you received inpatient hospital care due to complications from the coronavirus. 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 $390 copayment for days 1-5 for inpatient hospital care.   You had an inpatient hospital stay from April 23, 2021, to May 1, 2021. The coronavirus waiver expired prior to you receiving the services. Therefore, you are responsible to pay a $390 copayment for days 1-5 (April 23, 2021, to April 27, 2021). The total amount you owe is: $390 (copayment) x 5 (inpatient days) = $1,950.     You have been asked to pay the total copayment amount of $1,950 for an inpatient hospital stay. An inpatient hospital 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 an inpatient hospital stay provided from April 23, 2021, to May 1, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had from April 15, 2021, to April 16, 2021.

You asked the Plan to waive the copayment for the ER visit. You did not provide an argument in your appeal request. 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 $90 copayment for emergency room services. 

You have been asked to pay a $90 copayment for the ER 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 the emergency room (ER) visit you had from April 15, 2021, to April 16, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on May 19, 2021.

You asked the Plan to pay for ambulance response and treatment, no transport. You say that while you were dining out your blood sugar went low, and the restaurant called the ambulance. You say that when the ambulance arrived, they checked your blood sugar then they left and you drove home on your own. The Plan denied your request. The Plan says since there was no transport, the ambulance charges are not covered.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on May 19, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on May 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for genetic testing provided to the enrollee on April 22, 2020. 
 You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your 
request. The Plan says screening tests due to family history are not covered. 
 
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 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 genetic testing 
provided to the enrollee on April 22, 2020.