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

We decided that the Plan does not have to pay for CPT code 27640 provided on October 29, 2019.
You asked the Plan to pay for CPT code 27640. You say that the medical records support the billing of CPT code 27640. The Plan denied your request. The Plan says the medical records do not support the billing of CPT code 27640.
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 27640 is Partial excision (craterization, saucerization, or diaphysectomy), bone (eg, osteomyelitis); tibia. 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 CPT code 27640. Our reviewer says that the medical records do not support the billing of CPT code 27640. Our physician reviewer found CPT code 27640 does not meet criteria for billing or reimbursement consideration. The medical records provided do not include documentation of a Partial excision (craterization, saucerization, or diaphysectomy), bone (eg, osteomyelitis); tibia being performed on October 29, 2019, therefore this service cannot be verified. There are certain types of improper coding that physicians must avoid. Procedures should be reported with the most comprehensive CPT code that describes the services performed. Physicians must avoid upcoding. A HCPCS/CPT code may be reported only if all services described by that code have been performed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CPT code 27640 have not been met. Therefore, we decided that the Plan does not have to pay for CPT code 27640 provided on October 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services you received from May 12, 2019, to August 3, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider is not certified for Medicare.The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program. We looked at the file and Medicare rules.The services in question were rendered by a provider who is not enrolled in the Medicare program.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 forthe services you received from May 12, 2019, to August 3, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay fora colonoscopy with biopsy (45380) provided on September 11, 2019.You asked the Plan to pay for a colonoscopy with biopsy. You say that this should be reprocessed.The Plan denied your request. The Plan says the records do not support this service.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 45380 is colonoscopy, flexible; with biopsy, single or multiple.We find that CPT code 45380 is not supported in the medical record. Specifically, the medical records submitted do not contain documentation of a biopsy being performed. Based on this information, we decided that Medicare rules for coverage of a colonoscopy with biopsy have not been met.Therefore, we decided that the Plan does not have to pay fora colonoscopy with biopsy (45380) provided on September 11, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 29, 2019 by an
out of network (OON) provider.
You asked the Plan to pay for drug test. You say that you cannot turn away specimens for lab testing as the
results are crucial to the enrollee's care with the referring physician. The Plan denied your request. The Plan
says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and
the ordering provider is also out-of-network with the Plan.
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 has network providers
available who can provide 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 medical services provided on November 29,
2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care (99232) rendered by out of network (OON) provider, 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment as the physician provided medically necessary services to the enrollee in good faith. The Plan denied your request. The Plan says the services were provided by an out of network provider, without prior authorization.
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 has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care (99232) rendered by the out of network (OON) provider on July 28, 2019 and July 29, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for office visits provided on January 13, 2020 by an out of network (OON) provider.
You asked the Plan to pay for office visits. You say that you were not aware that authorization was required. The Plan denied your request. The Plan says prior authorization was not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide 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 office visits provided on January 13, 2020 by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) services rendered to you on November 30, 2019.
You asked the Plan to waive the copayment for these services. You say that the ER did not do its job. The Plan denied your request. The Plan says the copayment was 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 a $90 copayment for emergency care.
Review of the file shows that you received ER services on November 30, 2019. You have been asked to pay a $90 copayment for these services. These services fall within the emergency 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 emergency room (ER) services rendered to you on November 30, 2019.
Your complaint is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a InterSpinous back spacer (22867).You asked the Plan to pre-approve a InterSpinous back spacer. You say that the service is necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.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 InterSpinous back spacer. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer remains experimental. More research is needed.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 InterSpinous back spacer have not been met.Therefore, we decided that the Plan does not have to pre-approve a InterSpinous back spacer (22867)
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump with oxygenator or heat exchanger (99190 and 99192) provided on September 23, 2019.You asked the Plan to pay for the assembly and operation of a pump with oxygenator or heat exchanger. You say that this should be covered.The Plan denied your request. The Plan says these codes are not supported in the record.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 99190 is assembly and operation of pump with oxygenator or heat exchanger (with or without ECG and/or pressure monitoring); each hour and 99192 is assembly and operation of pump with oxygenator or heat exchanger (with or without ECG and/or pressure monitoring); 30 minutes.We find that CPT code 99190 and 99192 is not supported in the medical record. Specifically, these are time-based codes and the submitted medical records do not document the time spent on these services. Based on this information, we decided that Medicare rules for coverage of the assembly and operation of a pump with oxygenator or heat exchanger have not been met.Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump with oxygenator or heat exchanger (99190 and 99192) provided on September 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray and comprehensive oral evaluation provided on September 16, 2019. You asked the Plan to pay for the panoramic x-ray and comprehensive oral evaluation. You say that you were given false information by the Plan. You also say that you are on a set income. The Plan denied your request. The Plan says you exceeded the limits set in the subscriber agreement. 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 Plan offers an annual maximum benefit of $1,000 every year. The contract says that after your annual maximum benefit maximum has been met, you are responsible for the full charges of any additional dental services. The record shows that you met the annual maximum benefit on July 26, 2019 and your annual maximum benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray and comprehensive oral evaluation provided on September 16, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above 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 SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found the provided medical records do not indicate a
need for daily skilled services or inpatient services. Care in the long term care facility appears to be
appropriate.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 23, 2019 by an out of network (OON) provider.
You asked the Plan to pay for office visit. You say that you are appealing. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and prior authorization was not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide 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 medical services provided on October 23, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that the orthotics are essential to help ameliorate a painful foot ailment. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on November 29, 2019 by an out of
network (OON) provider.
You asked the Plan to pay for lab work. You say that your lab does not collect the specimens. You say that you
would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no
prior authorization was obtained. The Plan says that the referring provider is also out-of-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 has network providers
available who can provide 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 lab work provided on November 29, 2019 by an
out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the periodontal scaling and root planing.
You asked the Plan to pre-approve the periodontal scaling and root planing. You say that there is calculus and mild bone loss. You say that scaling and root planing is a necessary treatment. The Plan denied your request. The Plan says the services are not necessary.
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 the periodontal scaling and root planing when the services are medically necessary and reasonable. 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 periodontal scaling and root planing. Our reviewer says that the criteria for coverage has not been met. Our physician reviewer found there are not four or more teeth in any quadrant that appear to have notable bone loss. Our physician reviewer found that given the limited number of teeth that are showing notable bone loss in each quadrant, the requested procedure is not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the periodontal scaling and root planing have not been met. Therefore, we decided that the Plan does not have to pre-approve the periodontal scaling and root planing.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis, periodic oral evaluation, and bitewing x-rays provided on July 24, 2019.
You asked the Plan to pay for the prophylaxis, periodic oral evaluation, and bitewings. You say that this provider was in-network when the work was completed. The Plan denied your request. The Plan says the rendering provider had opted out of Medicare prior to this date of service. The Plan also says they are unable to make payments for services provided by a dentist who has opted out of Medicare under your plan.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by this provider. This provider has opted out of the Medicare program. The file shows that this provider entered into a private contract with you regarding payment. Therefore, we decided that the Plan does not have to pay for the prophylaxis, periodic oral evaluation, and bitewing x-rays provided on July 24, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an implant /abutment supported removable denture for edentulous arch -mandibular (D6111), two implant procedures (D6199 x2), and two semi-precision attachment abutments (D6052 x2).You asked the Plan to pre-approve the implant /abutment supported removable denture, implant procedures, and semi-precision attachment abutments. You say that the enrollee cannot chew with her dentures and they are painful. You also say that these services are not just a dental issue, but a medical issue.The Plan denied your request. The Plan says these services are not covered under the enrollee's benefit package.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 an implant /abutment supported removable denture for edentulous arch -mandibular (D6111), two implant procedures (D6199 x2), and two semi-precision attachment abutments (D6052 x2).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the copayment applied to the inpatient hospital care provided from September 11, 2019 to September 16, 2019.
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says that the cost sharing has been applied correctly per the Plan benefits for the inpatient hospital care 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 $395 copayment per day, for days 1-4 for Medicare-covered inpatient hospital care. You have been asked to pay a $1,580 copayment ($395 x 4 days) for inpatient hospital care. 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 issue reimbursement for the copayment applied to the inpatient hospital care provided September 11, 2019 to September 16, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to reduce the copayment forthe MRI provided on December 31, 2019.You asked the Plan to reduce the copayment forthe MRI. You say that you feel you were overcharged for the MRI since the copayment for an MRI is $140.The Plan denied your request. The Plan says that 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. Your contract with the Plan says that enrollees must pay a $140 copayment for each advanced imaging service (e.g., MRI, CT, and PET scan, nuclear medicine, and stress tests). The Plan says you must pay a $250 copayment for the MRI. Based on the Plan contract, however, you cannot be asked to pay more than a $140 copayment for the MRI. The record shows that the MRI copayment is based on the type of service provided and not the place of service. Therefore, we decided that the Plan has to reduce the copayment forthe MRI provided on December 31, 2019.