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

We decided that the Plan does not have to waive the copayment for the diagnostic abdominal ultrasound and liver elastography provided on July 19, 2021.
You asked the Plan to waive the copayment for the diagnostic tests. You say that you want the Plan to pay the allowed amount. The Plan denied your request. The Plan says you have been 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 $110 copayment for radiological diagnostic services. You have been asked to pay $83.69, which is less than the $110 copayment for the abdominal ultrasound. You have also been asked to pay $31.59, which is less than the $110 copayment for the liver elastography.
The diagnostic tests fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the diagnostic abdominal ultrasound and liver elastography provided on July 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve depo-testosterone injections.

You asked the Plan to pre-approve the depo-testosterone. You say that it is felt that this treatment is needed to maintain the enrollee's androgen levels. The Plan denied your request. The Plan says there is insufficient documentation of medical necessity for this treatment

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 

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 depo-testosterone. Our reviewer says that the requested injections are not considered medically reasonable and necessary. Our physician reviewer found the enrollee is a 68 year old male with a past medical history of low testosterone levels and erectile dysfunction. Treatment with Depo-testosterone has been requested. Based on the medical records provided and the Medicare-approved major drug compendia there is no documentation that the Depo-testosterone meets Medicare and health plan criteria for medically reasonable and necessary for the patient. Provided records do not document the diagnoses of primary hypogonadism (congenital or acquired) or hypogonadotropic hypogonadism. 

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 depo-testosterone have not been met. Therefore, we decided that the Plan does not have to pre-approve depo-testosterone injections.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on July 1,
2021.
You asked the Plan to waive the copayment for laboratory services. You say that you did not receive laboratory
services on this date of service. 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 $10
copayment for laboratory services.
The medical records show that you received laboratory services on July 1, 2021. Therefore, you are responsible
to pay the $10 copayment.
You have been asked to pay a $10 copayment for laboratory services. Laboratory services fall within the
outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have
to waive the copayment for laboratory services provided on July 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. 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 continues to receive acute care services and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) device
(E0601), provided on May 23, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the CPAP device. You say that the item should be covered. The Plan denied your
request. The Plan says durable medical equipment must be obtained from providers in the Plan's network.
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 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 the continuous positive airway pressure (CPAP)
device (E0601), provided on May 23, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composites - two surfaces, anterior (D2331)
and resin-based composite - one surface, posterior (D2391) provided July 2, 2021.
You asked the Plan to pay for three fillings. You say that you cannot afford the cost of the services. The Plan
denied your request. The Plan says you have exceeded the frequency limit 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. The Plan covers two fillings
per calendar year.
We looked at the file and Medicare rules. The Plan provided documentation showing that two fillings were
covered on the same date of service. Based on this information, we decided that the Plan's frequency limit for
coverage of the fillings has been exceeded.
Therefore, we decided that the Plan does not have to pay for the additional resin-based composites - two
surfaces, anterior (D2331) and resin-based composite - one surface, posterior (D2391) provided July 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient paravertebral facet joint surgery you had on September 3, 2021.
You asked the Plan to waive the copayment for the outpatient surgery. You say that you were supposed to have only one surgery that took care of both sides. You had budgeted for only one surgery. You said you had to return for a second surgery because of lost people in the doctor's department. 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 $300 copayment per visit for outpatient surgery in a hospital. You have been asked to pay a $300 copayment per visit for the outpatient surgery. This is a per-visit copayment, and a separate copayment applies each time you have surgery, regardless of the reason. 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 outpatient paravertebral facet joint surgery you had on September 3, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on October 9, 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 services were not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of
service (POS) code.
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory
services rendered on October 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional intraoral x-ray provided on June 16, 2021.
You asked the Plan to pay for the additional intraoral x-ray. You say that you did not order, authorize, or
request any additional services other than those agreed upon under your dental coverage. The Plan denied your
request. The Plan says the frequency limitation 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, you also have a maximum benefit of
one intraoral x-ray per calendar year. The Plan paid for one intraoral x-ray provided on June 16, 2021, which
exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the additional intraoral x-
ray provided on June 16, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient mental health care provided from June 10, 2021, and August 5, 2021.
You asked the Plan to waive the copayments for outpatient mental health care. You say that you thought that the visits were free. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for outpatient mental health care.
The record shows that you received outpatient mental health care on June 10, 2021, and August 5, 2021. Therefore, you are responsible to pay a $40 copayment for each visit. The total amount you owe is: $40 (copayment) x 2 (outpatient mental health care) = $80. You have been asked to pay the total copayment amount of $80 for outpatient mental health care. Outpatient mental health care falls within the outpatient mental health 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 copayments for outpatient mental health care provided from June 10, 2021, and August 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for transurethral electrosurgical resection of the prostate
provided on April 2, 2021.
You asked the Plan to pay for prostate surgery. You say that you are appealing with supporting records. The
Plan denied your request. The Plan says the denial of payment for this service is correct, because the records do
not support this code.
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 52601 is transurethral electrosurgical resection of
prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy,
urethral calibration and/or dilation, and internal urethrotomy are included).
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 prostate surgery. Our reviewer says that this code does not
meet the criteria for payment. Our reviewer found the operative report states "This is an 83-yr-old with a
history of prostate in the past". Therefore, current resection would be considered residual, and therefore a more
appropriate code should be reported for this procedure.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of prostate surgery have not been met. Therefore, we decided that the Plan does
not have to pay for transurethral electrosurgical resection of the prostate provided on April 2, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the subsequent hospital care rendered on July 11, 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 that procedure code 99231 is not separately payable.

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 states that procedure code 99231 (subsequent hospital care) is a
column II code with a modifier indicator of 1 when billed with column I code 36556 (insertion of non-tunneled
centrally inserted venous catheter); however, there are no active National Correct Coding Initiatives (NCCI)
edits to support this. The Plan has not provided any further documentation to support that the claim is not
payable as billed. Therefore, we decided that the Plan has to pay for the subsequent hospital care rendered on
July 11, 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a SNF stay provided from February 18, 2021, to February 28, 2021.
You asked the Plan to waive the copayment for a SNF stay. You say that you were not aware that you would owe anything and cannot afford the charges. 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 $0 copayment for days 1-20 and a $25 copayment for additional days up to 100 for SNF care. You had a SNF stay from February 18, 2021, to February 28, 2021. The record shows that your SNF benefit was exhausted. However, the Plan still paid the claim and are only charging you $275, which is in your financial favor. You have been asked to pay $275 for a SNF stay. A SNF stay falls within the SNF 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 a SNF stay provided from February 18, 2021, to February 28, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on January
19, 2021.
You asked the Plan to waive the copayment for ambulance services. You say that the enrollee was positive with
the coronavirus and this was their transportation home. You state that you were told that the enrollee should not
be held responsible for the charges. The Plan denied your request. The Plan says the claims were processed
correctly and the enrollee is 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 $250 copayment for ambulance services.
The enrollee received ambulance services on January 19, 2021. Ambulance services are not included in the
coronavirus waiver. Therefore, the enrollee is responsible to pay the allowed amount of $240.91, which is less
than the $250 copayment.
The enrollee has been asked to pay $240.91 for ambulance services. Ambulance services fall within the ambulance services 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 ambulance services provided on January 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for chiropractic services provided from May 6, 2021, to July 20, 2021.
You asked the Plan to pay for chiropractic services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says this provider is not in network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that enrollees must use network providers. The provider in this case is not a network provider with the Plan. The Plan did not pre-approve these services. Therefore, we decided that the Plan does not have to pay for chiropractic services provided from May 6, 2021, to July 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. 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 continues to receive acute care services and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (64417) provided May 20, 2021.
You asked the Plan to pay for the anesthesia services. You say that this service was medically necessary. The
Plan denied your request. The Plan says the code was billed with an invalid modifier.
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 64417 is not supported in the medical record. Specifically, CPT code 64417 has a
Professional Component (PC)/Technical Component (TC) indicator of 0 per the 2021 National Physician Fee
Schedule. This code cannot be paid with the 26 modifier. Based on this information, we decided that Medicare
rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not
have to pay for anesthesia services (64417) provided May 20, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam provided on June 9, 2021.
You asked the Plan to waive the copayment for the eye exam. You say that when you're on a fixed income you don't do any extra health screenings unless insurance covers it. You say that you called to make sure it was covered and got a bill after. The Plan denied your request. The Plan says the copayment 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 $40 for each Medicare-covered exam to diagnose and treat diseases or conditions of the eye.
You have been asked to pay a $40 copayment for the eye exam. The eye exam falls within the "Vision 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 eye exam provided on June 9, 2021