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

We decided that the Plan does not have to waive the coinsurance for the ceftriaxone sodium injection (J0696)
and the triamcinolone acetonide injection (J3301) provided on January 5, 2021.

You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to
the services provided.

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 20%
coinsurance for Medicare covered Part B Chemotherapy drugs and other Part B drugs.

You have been asked to pay $2.42 which includes the Plan allowed amount of $1.12 x 20% coinsurance=$.22
for the ceftriaxone sodium injection and the Plan allowed amount of $11.00 x 20% coinsurance=$2.20 for the
triamcinolone injection provided. The Plan contract says that you must pay a 20% coinsurance for Medicare
covered Part B drugs. 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 ceftriaxone sodium injection
(J0696) and the triamcinolone acetonide injection (J3301) provided on January 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network provider services rendered to the enrollee on October 26, 2020.

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 provider services rendered to the enrollee on October 26, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for reconstruction of the mouth (40845) provided October 21, 2020.
You asked the Plan to pay for reconstruction of the mouth. You say that the services provided were medically necessary. The Plan denied your request. The Plan says the records do not support that the service is separately payable.
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 reconstruction of the mouth. Our reviewer says that the billed service is not supported as separately payable. Our reviewer found the record indicates that the enrollee underwent a free muscle or myocutaneous flap with microvascular anastomosis. The requested code 40845 is
included in the description of the main code, 15756. The elements of the coverage rule are not satisfied. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of reconstruction of the mouth have not been met. Therefore, we decided that the Plan does not have to pay for reconstruction of the mouth (40845) provided October 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute inpatient hospital care.
You asked the Plan to pre-approve acute inpatient hospital care. You say that inpatient care is medically necessary. The Plan denied your request. The Plan says the inpatient medical care is not medically necessary following the elective surgery.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.
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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the patient is a 66-year-old female with right knee pain and associated difficulty walking who was admitted to the hospital for an elective non-emergent right knee arthroplasty procedure. Recent notes did not suggest the patient had a medical history that would expect a complicated hospital course. The documentation did not support that the patient would require hospital services that would likely cross 2 midnights for this lower risk procedure. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve the acute inpatient hospital care.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation with medical services (90792) provided March 10, 2021.
You asked the Plan to pay for the psychiatric diagnostic evaluation with medical services. You say that you would like this claim reprocessed for medical necessity of the billed code. The Plan denied your request. The Plan says the services were not submitted with an appropriate primary diagnosis code.
The Plan must follow Medicare rules. Medicare rules say that providers need to abide by the Coding Guidelines for billing services. We looked at the file and Medicare rules. In this case, F05 was reported as the primary diagnosis code. This code is marked as a manifestation code due to the Code First note, which instructs to Code the underlying physiological condition first. This was not completed correctly. Based on this information, we decided that Medicare rules for coverage of the psychiatric diagnostic evaluation with medical services have not been met. Therefore, we decided that the Plan does not have to pay for the psychiatric diagnostic evaluation with medical services (90792) provided March 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a medical eye exam (92014) provided on January 22, 2021.
You asked the Plan to waive the copayment for a medical eye exam. You say that you visited your provider for a routine eye exam. You also stated that you get these annual exams every two years and have never paid for a visit. The Plan denied your request. The Plan says the copayment you are being charged is correct.
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 $50 copayment for one supplemental routine eye exam every year. You have been asked to pay a $50 copayment for a medical eye exam. The EOC confirms that $50 is the required copayment for this service. A medical 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 a medical eye exam (92014) provided on January 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (87496, 87498, 87631, 87798, 87486, 87541, 87581, 87640) provided on November 23, 2020.

You asked the Plan to pay for laboratory services. You say that this is supported by the records. The Plan denied your request. The Plan says this was not billed with the correct place of service.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place
where the sample was taken is reported as the Place of Service (POS).

We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent
laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we
decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that
the Plan does not have to pay for laboratory services (87496, 87498, 87631, 87798, 87486, 87541, 87581,
87640) provided on November 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), prophylaxis (D1110),
the filling (D2330) for tooth #11, and the fillings (D2331) for teeth #8 and 9 provided on April 2, 2021.
You asked the Plan to pay for the dental services. You say that this was dental work. You say that you feel that
at least some of the bill should be deducted or reduced. The Plan denied your request. The Plan says the
provider in this case is out of network. The Plan also says that dental services 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 dental service you received out of
network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to
pay for the periodic oral evaluation (D0120), prophylaxis (D1110), the filling (D2330) for tooth #11, and the
fillings (D2331) for teeth #8 and 9 provided on April 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MyoPro orthotic device.
You asked the Plan to pre-approve the requested device. You say that this is the only available treatment that can meet the enrollee's minimal functional needs. The Plan denied your request. The Plan says there is a lack of clinical evidence demonstrating an impact on improved health outcomes.
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 requested device. Our physician reviewer found that the MyoPro device is not known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes in stroke patients. The device is not in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro orthosis will improve the long-term outcomes for this enrollee, improve hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the literature that this device will increase participation in bimanual activities. Therefore, the requested device is 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 the requested device have not been met. Therefore, we decided that the Plan does not have to pre-approve a MyoPro orthotic device.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the breast ultrasounds (76641 x 2) provided on April 9, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the services provided.
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 $155 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a network physician's office or at a network free-standing facility. Additionally, the Plan covers one screening mammogram every 12 months for breast cancer screening, with no cost share liability. You have been asked to pay a $155 copayment for the Medicare-covered radiological diagnostic services provided. On this day, these services were provided in addition to a screening mammogram that was paid for by the Plan, with no member liability. 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 breast ultrasounds (76641 x 2) provided on April 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for arthroplasty provided on March 22, 2021.
You asked the Plan to pay for revision of total knee arthroplasty (27487-AS). You say that the Plan should pay this claim. The Plan denied your request. The Plan says certified surgical technicians are not recognized for payment per Medicare guidelines.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS. In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of
practitioners. Therefore, we decided that the Plan does not have to pay for arthroplasty provided on March 22, 2021.
Appeal type: Outpatient Mental Health
Decision: Favorable

We decided that the Plan has to pay for psychotherapy services (90837) provided on April 2, 2021.
You asked the Plan to pay for psychotherapy services. You say that the services at issue were a necessity for the enrollee. The Plan denied your request. The Plan says that rules for psychotherapy services have not been met because there is no documentation of consultation with the attending or primary care physician.
The Plan must follow Medicare rules. Medicare rules say that the only exception to the consultation requirement for clinical social workers is in cases where the patient's primary care or attending physician refers the patient to the clinical social worker. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of psychotherapy services have been met. The medical records document that the enrollee was referred to the clinical social worker by the enrollee's primary care physician. Therefore, we decided that the Plan has to pay for psychotherapy services (90837) provided on April 2, 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient rehabilitation admission and services provided from February 26, 2021, to March 7, 2021.

You asked the Plan to waive the copayment for the inpatient care. You say that you cannot afford this bill as it is too expensive. The Plan denied your request. The Plan says this copayment has been applied correctly and in accordance with your contract.

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 for each of the first five days of inpatient hospital care. There is a $0 copayment after the fifth day. Inpatient hospital care includes inpatient acute, inpatient rehabilitation, long-term care hospitals and other types of inpatient hospital services.

You have been asked to pay a $1,850 for the inpatient care. The inpatient stay was greater than five days, and
you have been charged the applicable copayment for the first five days of care ($370 x 5 = $1,850). This means
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan
does not have to waive the copayment for the inpatient rehabilitation admission and services provided from
February 26, 2021, to March 7, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services provided on April 1, 2021.

You asked the Plan to pay for the physical therapy services. You say that the claim was denied incorrectly without appropriate review of the medical records. You say that the medical records should be thoroughly reviewed, and the claim reprocessed for necessary payment. The Plan denied your request. The Plan says there is insufficient documentation to corroborate the billed services.

The Plan must follow Medicare rules. Medicare rules say that services of a physical therapist billed as services incident to a physician/non-physician practitioner's service must meet all incident requirements. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy services have not been met. Specifically, the billing provider is a physician assistant, which is a non-physician practitioner. As such, PT services cannot be paid incident to this provider's professional services. Additionally, the record does not include the rendering providers credentials, so we are unable to verify the billed services. Therefore, we decided that the Plan does not have to pay for the physical therapy services provided on April 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and services provided from February 23, 2021.
You asked the Plan to waive the copayment for the inpatient care. You say that you are surprised you have to pay this amount for your hospital care and feel this payment is the responsibility of your insurance. The Plan denied your request. The Plan says this claim was processed correctly, and these services are covered. Your copayment (your share of the cost) was applied in accordance with your contract.
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 copayment for each of the first seven days of inpatient hospital care.
You have been asked to pay a $350 copayment for two days of inpatient care ($175 x 2 = $350). The provider billed the Plan a total of $68,200.18 for the rendered services, and the Plan has provided discounts and paid their portion. However, you are still responsible for your share of the cost (your copayment). This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital admission and services provided from February 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for compression stockings purchased on March 5, 2021.
You asked the Plan to pay for compression stockings. You say that these compression stockings should be covered by the Plan. The Plan denied your request. The Plan says you did not have prior authorization.
Medicare rules say 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 contract also states durable medical equipment requires prior authorization. You purchased compression stockings out of network without prior authorization. Therefore, we decided that the Plan does not have to pay for compression stockings purchased on March 5, 2021.