Persius/hicric huggingface dataset:
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 23, 2019, to December 27, 2019.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you should not have to pay this copayment because it took so long for the hospital to bill you. You said that this wasn't a new admission, but a transfer. The Plan denied your request. The Plan says you were charged this copayment correctly because the copayment is charged per-admission.
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 $195 copayment per day for days 1-7, per admission for inpatient hospital care.
Records show that you were in one hospital and were transferred to another hospital for further care. You were admitted to the second hospital on December 23, 2019, and remained there for four days. You have been asked to pay a $195 copayment per day for the inpatient hospital services. According to your contract, the inpatient hospital copayment is charged per admission. Each time you move from one hospital to another, it is considered a new admission. 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 23, 2019, to December 27, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), bitewing x-ray (D0270), the periapical x-ray (D0220), and the extraction (D7210) provided on April 30, 2021.
You asked the Plan to pay for the dental service. You say that you have been seeing this dentist for 3 years because they are in network. You say that you needed an emergency tooth extraction. You say that you were not informed prior to the procedure that the dentist was not in network. You also say that you feel you should not be responsible for this bill. The Plan denied your request. The Plan says limited oral evaluation is not listed as a covered service. The Plan says that the provider in this case is out of network. The Plan also says that dental services that you receive out of network 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. Though the Plan offers a dental benefit in excess of Medicare coverage, the limited oral evaluation is not among those covered under this benefit, regardless of the provider's network status. Additionally, although the x-rays, and extraction are listed as covered, dental services received out of network are not covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), bitewing x-ray (D0270), the periapical x-ray (D0220), and the extraction (D7210) provided on April 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex Superion Device placement surgery.

You asked the Plan to pre-approve these services. You say that these services are medically necessary to relieve back pain. The Plan denied your request. The Plan says that this is not covered by Medicare due to insufficient evidence of efficacy.

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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The vertiflex procedure is experimental. More research is needed to show safety and efficacy. Our physician reviewer found that your condition does not meet criteria for these services. 

We looked at this physician's review, the file, and Medicare rules. 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 pre-approve Vertiflex Superion Device placement surgery.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on September 28,
2020.
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 due to the enrollee's hospice status at the time of service, this claim must be submitted to
Original Medicare first.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit
for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for
medical services provided to the enrollee on September 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on March 25, 2021.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
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 items/services at issue in this appeal. 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 out of network physician services provided to the enrollee on March 25, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to adjust the cost share liability from $4,192.18 to $250 for the electrophysiologic evaluation and cardiac ablation (93653) provided from February 26, 2021 to February 27, 2021.
You asked the Plan to adjust the cost share. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the coinsurance has been applied correctly to the service provided.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay a $250 copayment for in-network surgery provided at an outpatient hospital. The Plan says you must pay a $4,192.18 cost share for the in-network outpatient surgery provided. Based on the Plan contract, however, you cannot be asked to pay more than $250 for this service. An outpatient surgery was performed in this case, not a diagnostic procedure or test as indicated. Therefore, we decided that the Plan has to adjust the cost share liability from $4,192.18 to $250 for the electrophysiologic evaluation and cardiac ablation (93653) provided from February 26, 2021 to February 27, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a therapeutic continuous blood glucose monitor (CGM).
You asked the Plan to pay for the CGM. You say that the claim should be paid. The Plan denied your request. The Plan says you do not meet Medicare criteria for coverage.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, or require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to pay for a therapeutic continuous blood glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a fibrinolysins or coagulopathy screening (85390) provided on December 24, 2020.
You asked the Plan to pay for a fibrinolysins or coagulopathy screening. You say that this was billed correctly. The Plan denied your request. The Plan says this is not a covered screening test.
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, a fibrinolysins or coagulopathy screening, 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 a fibrinolysins or coagulopathy screening (85390) provided on December 24, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the DXA bone density scan (77080) provided on March 26, 2021.
You asked the Plan to pay for the DXA bone density scan. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 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, the DXA bone density scan, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the DXA bone density scan (77080) provided on March 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hematopathology testing rendered on October 8, 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 testing was not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that molecular pathology testing 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 pay for these services. Our reviewer says that the testing was not medically necessary. Our physician reviewer found the enrollee has a diagnosis of chronic myeloproliferative disease. The documentation does not support that the criteria for coverage of the testing is met. The testing was therefore not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the hematopathology testing rendered on October 8, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the services provided from February 12, 2021, to February 26, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that physician and
facility claims must be submitted as a package bill.
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. In this case, the Plan is citing a contract. However, the services were provided by
a non-contract provider. If there is a contract in this case, the Plan has not supplied it to show how it should be
paid. The documentation submitted does not substantiate the Plan's denial. Therefore, we decided that the Plan
has to pay for the services provided from February 12, 2021, to February 26, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on November 5, 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 procedure code 33405 is not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

In this case, the CPT Code Manual definition of code 33405 is replacement, aortic valve, open, with cardiopulmonary bypass; with prosthetic valve other than homograft or stentless valve. 

We find that CPT code 33405 is not supported in the medical record. Specifically, the operative report does not contain documentation of increased procedure services of an open replacement of the aortic valve with cardiopulmonary bypass.

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 surgical services rendered on November 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an injection of betamethasone acetate (a Medicare Part B
drug), X-Ray examination, office visit, and arthrocentesis procedure provided by an out-of-network provider
on March 8, 2021.
You asked the Plan to pay for Part B drug, X-Ray, and specialist services. You say that this provider would not
accept your insurance so you paid in full and should be reimbursed. The Plan denied your request. The Plan
says the cost-sharing amounts you are being charged are correct and the Plan is not responsible for payment of
the balance bill beyond the Medicare allowable amounts for these 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). The rules say that for a non-contracting provider, the Plan does not
pay balance billing but may pay the difference between the enrollee's cost-sharing and the Medicare allowable
amount for a service. Although this provider is out-of-network with the Plan, you have only been asked to pay
the in-network cost-sharing amounts. Your contract with the Plan clearly says that you must pay 20%
coinsurance for Part B drug, $35 copayment for X-Ray, and $40 copayment for specialist services. The allowed
amount of the Part B drug is $14.42, resulting in a coinsurance amount of $2.88. Your total cost-sharing is
therefore $77.88. Therefore, the Plan paid a total reimbursement amount of $266.28, which is the $344.16 total
allowable amount of the claim less the $77.88 cost-sharing amount you have been asked to pay.
You have been asked to pay 20% coinsurance for Part B drug, $35 copayment for X-Ray, and $40 copayment
for specialist services. Part B drug, X-Ray, and specialist services fall within the "Medicare Part B Prescription
Drugs", "Outpatient Diagnostic Tests and Therapeutic Services and Supplies", and "Physician/Practitioner
Services, Including Doctor's Office Visits" benefit categories. 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. Although - according to Medicare rules - you may not be responsible for
the balance bill of these services, the Plan is also not responsible for payment this amount. Please contact the
provider regarding reimbursement of any amount you were charged beyond the Medicare allowed amount for
the claim. Therefore, we decided that the Plan does not have to pay for an injection of betamethasone acetate (a
Medicare Part B drug), X-Ray examination, office visit, and arthrocentesis procedure provided by an out-ofnetwork
provider on March 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two extractions to be performed by an oral surgeon.
You asked the Plan to pre-approve two extractions to be performed by an oral surgeon. 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.
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 says services must be performed by a participating general dentist. We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of two extractions to be performed by an oral surgeon have not been met. Therefore, we decided that the Plan does not have to pre-approve two extractions to be performed by an oral surgeon.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on November 25, 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 procedure code 15002 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 15002 is surgical preparation or creation of recipient site
by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar
contracture, trunk, arms, legs; first 100 sq cm or 1% of body area of infants and children.
We find that CPT code 15002 is not supported in the medical record. Specifically, there is no documentation of
surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar, or incisional
release of scar contracture. 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 surgical services
rendered on November 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).

You asked the Plan to pre-approve a CGM. You say that this is medically necessary. The Plan denied your request. The Plan says that you do not meet criteria for coverage.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. 

We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
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 the requested admission to a LTACH is medically necessary The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.
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 the enrollee does not have respiratory stability as evidenced by hypoxia with minimal exertion. The enrollee is not required to discharge elsewhere to receive ongoing acute level care. The enrollee is receiving appropriate care at the present acute care hospital. 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.
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.