Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided the Plan does not have to waive the cost share charged for orthotics provided on June 1, 2021.  You asked the Plan to waive the cost share for this equipment. You say that the orthotics have not been adjuster properly and cause blisters.  The Plan denied your request. The Plan says this cost share was charged based on the claim submitted by the provider and the Plan contract agreement. Any issues you have with the product itself self as fit must be adjusted and resolved by the provider.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for durable medical equipment. The Plan has paid its portion of the cost of this equipment. Unfortunately, the Plan cannot waive the cost share because you are not satisfied with the adjustments made by the provider. Repair and or replacement must be resolved between you and the provider.    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 cost share charged for orthotics provided by East Coast Orthotic and Prosthetic on June 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for services provided by an out-of-network provider on April 2, 2021.  You asked the Plan to waive the deductible for the out-of-network services. You say that the enrollee qualifies for provider assistance, and she is on permanent disability. The Plan denied your request. The Plan says this deductible was applied correctly.  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 there is a $1000 deductible which applies to out-of-network services.   The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1000 deductible which applies to out-of-network services. This cost sharing is a contractual obligation that had not been met at the time the out-of-network services were received on April 2, 2021. Therefore, we decided that the Plan does not have to waive the deductible for services provided by an out-of-network provider on April 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for a radiofrequency ablation of the right sacroiliac joint (64625) provided on May 26, 2021.  You asked the Plan to pay for a radiofrequency ablation of the right sacroiliac joint. You say that the service at issue is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met because the procedure at issue 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 pay for a radiofrequency ablation of the right sacroiliac joint. Our reviewer says that the services at issue are not considered medically reasonable and necessary in this case. Our physician reviewer found that sacral lateral nerve branch blocks and/or ablations/neurotomies for the diagnosis and/or treatment of sacroiliac joint mediated pain are considered experimental and investigational.  Radiofrequency ablation for denervation, whether performed using traditional, cooled, or pulsed radiofrequency, is considered investigational and therefore not 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 a radiofrequency ablation of the right sacroiliac joint have not been met. Therefore, we decided that the Plan does not have to pay for a radiofrequency ablation of the right sacroiliac joint (64625) provided on May 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on July 6, 2021.  You asked the Plan to pay for the dental service. You say that your original dentist went out of business due to the coronavirus. You say that you had to find a new dentist. You say that the new dentist referred you to a specialist for gum work. You also say that this bill will add a detrimental amount of burden to your already struggling family. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 3 plan years. The Plan also says that the frequency limit has been exceeded.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage and comprehensive oral evaluation is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation that you received on May 25, 2021. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on July 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an extra portable oxygen concentrator battery  You asked the Plan to pre-approve the extra battery. You say that you would like reconsideration because the batteries you have only last 2 hours each and greatly restrict your mobility. The Plan denied your request. The Plan says it is the responsibility of your supplier to provide you with accessories and equipment.  The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. The rules also say that the supplier who provides oxygen equipment for the first month must continue to provide any necessary oxygen equipment and all related items and services through the 36-month rental period.  The file shows that you have a portable oxygen concentrator battery. The requested battery serves the same purpose. Additionally, it is the responsibility of your oxygen supplier to provide you with necessary equipment and accessories. Therefore, we decided that the Plan does not have to pre-approve an extra portable oxygen concentrator battery
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve the SNF services. You say that you need continued care. The Plan denied your request. The Plan says the services needed can be provided in a setting that is not inpatient.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had stable vital signs, and clear lungs. The enrollee received physical therapy and occupational therapy in the SNF. The enrollee was at a supervision to minimal assist level with functional mobility, including gait to 1-2 feet. The enrollee required varying assist with activities of daily living. There are no identifiable skilled therapy service needs. There are no identifiable skilled nursing service needs. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting.   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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to reduce the copayment for cataract surgery you had at an outpatient hospital facility on July 19, 2021.  You asked the Plan to reduce the copayment for the cataract surgery. You say that you were not aware of the difference between an outpatient hospital and an ambulatory surgery center.  You said that you didn't know that you would have a lower copayment if you had used an ambulatory surgery center. 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 $225 copayment for outpatient surgery at an outpatient hospital facility.   You have been asked to pay a $225 copayment for the cataract surgery. Your Evidence of Coverage clearly spells out the different cost sharing amounts for outpatient hospital versus ambulatory surgical center services. You had this procedure 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 copayment for cataract surgery you had at an outpatient hospital facility on July 19, 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 service 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 two Orthopedic societies have published position papers that do not support this use of the requested device. The procedure is still considered experimental/investigational.  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).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for the cardiology visit and the transthoracic echocardiography (TTE) you had on May 5, 2021.  You asked the Plan to waive the deductible for the cardiology visit and the TTE. You say that the Plan should give you a break and pay at least 90% of the bill. The Plan denied your request. The Plan says you had not met your deductible at the time of these services.  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 there is a $550 deductible which applies to specialist services and diagnostic tests.   The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $550 deductible which applies to specialist services and diagnostic tests. This cost sharing is a contractual obligation that had not been met at the time the cardiology visit and the TTE were received on May 5, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the cardiology visit and the transthoracic echocardiography (TTE) you had on May 5, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to pay for the emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function (CPT code 99285-25) provided to the enrollee on April 29, 2021.  You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records.  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 asked our coder 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 services. Our reviewer found the reviewed documentation indicates that there was no medical decision making of high complexity. The review has determined that the services were not supported by the medical records provided.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the emergency department visit for the evaluation and management of a patient (CPT code 99285-25) provided to the enrollee on April 29, 2021.
Appeal type: Lab
Decision: Favorable

 We decided that the Plan has to pay for GeneSight pharmacogenomic testing provided on November 6, 2020.  You asked the Plan to pay for GeneSight testing. You say that this testing is covered by Medicare and there is no basis for the Plan to deny coverage. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because this test is not covered by Medicare and the testing did not include the Z-code as required by Medicare billing and coding rules.  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. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. Medicare rules say that pharmacogenomics testing should be billed with the appropriate Current Procedural Terminology (CPT) code, 1 unit of service, the appropriate DEX Z-Code, and the appropriate International Classification of Diseases 10 Clinical Modification (ICD-10-CM) code.   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 specify whether the ordering physician was in-network or out-of-network with the Plan. The documentation submitted does not include prior notice from the Plan that this testing would not be covered. Without this information, we cannot determine whether the lab order made constituted plan-directed care. Furthermore, the Plan says that this testing was not billed with the appropriate Z-Code. However, the Plan did not submit a copy of the original claim form for this testing. Without a copy of the claim, we cannot determine whether this testing was billed in accordance with Medicare's billing and coding requirements for pharmacogenomics testing. Therefore, the Plan has not shown that its decision to deny payment for this testing is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for GeneSight pharmacogenomic testing provided on November 6, 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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the genetic test you had on May 17, 2021.  You asked the Plan to waive the coinsurance for the genetic test. You say that you were never informed that you would be receiving this test.  You said that you did not know what the test was for. The Plan denied your request. The Plan says you were charged this coinsurance 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 molecular and predisposed genetic testing.   You have been asked to pay 20% coinsurance for the genetic test. The genetic test falls within the molecular and predisposed genetic testing benefit category. The records show that your doctor ordered this test for you. 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 genetic test you had on May 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the white glass with high gold content cap for bridge (D6750), ready-made post for filling for a crown (D2954) and false tooth (D6240).  You asked the Plan to pre-approve the white glass with high gold content cap for bridge, ready-made post for filling for a crown and false tooth. You say that the service should be covered. The Plan denied your request. The Plan says you have exhausted your Plan benefits for these services.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the white glass with high gold content cap for bridge (D6750), ready-made post for filling for a crown (D2954) and false tooth (D6240).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the genetic testing provided to the enrollee on May 21, 2021.  You asked the Plan to pay for the genetic testing. You say that the services were necessary. The Plan denied your request. The Plan says your request for genetic testing does not meet the requirements for approval of the claim to be paid.  The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. The enrollee's medical records show they do not have any inherited type of cancers such as breast or ovarian. Also, the enrollee does not have any acquired cancers that are recurrent, relapsed, refractory, metastatic, or advanced stage III or IV. Therefore, we decided that the Plan does not have to pay for the genetic testing provided to the enrollee on May 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for tube thoracostomy (32551) provided on August 21, 2020.  You asked the Plan to pay for tube thoracostomy. You say that intervention was absolutely necessary to prevent serious deterioration in the enrollee's clinical status. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the record does not support the code billed.  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 32551 is tube thoracostomy, includes connection to drainage system (e.g., water seal), when performed, open (separate procedure).  We asked our coder 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 tube thoracostomy. Our reviewer says that this code does not meet the criteria for payment. Our reviewer found the documentation submitted does not support that a tube thoracostomy procedure was performed.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of tube thoracostomy have not been met. Therefore, we decided that the Plan does not have to pay for tube thoracostomy (32551) provided on August 21, 2020.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a diagnostic or therapeutic agent injection of the paravertebral facet joint with image guidance, lumbar or sacral (64493) rendered on July 7, 2021.  You asked the Plan to waive the copayment for a diagnostic or therapeutic agent injection of the paravertebral facet joint with image guidance, lumbar or sacral. You say that you were told this service would be covered by your insurance. You also say that at no time was it mentioned to you that you would be responsible for a copayment. 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 $175 deductible for in network Medicare-covered surgery services at an ambulatory surgical center.   You have been asked to pay a $175 deductible for a diagnostic or therapeutic agent injection of the paravertebral facet joint with image guidance, lumbar or sacral. A diagnostic or therapeutic agent injection of the paravertebral facet joint with image guidance, lumbar or sacral falls within the Outpatient Surgery, including services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. Although the service is covered by the Plan, there is still a copayment for this service. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a diagnostic or therapeutic agent injection of the paravertebral facet joint with image guidance, lumbar or sacral (64493) rendered on July 7, 2021.