Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services provided by out of network provider.
You asked the Plan to pay for the psychotherapy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
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 psychotherapy services provided by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe arthrocentesis coded 20610 and the Methylprednisolone injection coded J1030 provided on February 18, 2019.You asked the Plan to pay forthe arthrocentesis and the Methylprednisolone injection. You say that you would like the plan to reconsider their denial.The Plandenied your request. The Plan says the services billed are not supported by the documentation.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 codes 20610 and J1030 are not supported in the medical record. Specifically, the number of rural health clinic services exceeds the one allowed per date of service. Review of claim 820192480299773 indicates revenue 0521/99214/CG wasdenied by this edit because the facility reported another line with modifier CG of 0521/20610 on the same claim (which isthe support line for this edit). According to CMS, RHCs shall report modifier CG on one revenue code 052x and/or 0900 service line,which includes all charges subject to coinsurance and deductible for the visit. Modifier CG should only be used to indicate which revenue code 052x and/or 0900 service line should receive the all-inclusive rate (AIR) and be subject to coinsurance and deductible.Based on this information, we decided that Medicare rules for coverage of the arthrocentesis and the Methylprednisolone injection have not been met. Therefore, we decided that the Plan does not have to pay forthe arthrocentesis coded 20610 and the Methylprednisolone injection coded J1030 provided on February 18, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a contact lens fitting providedon September 9, 2019.You asked the Plan to reimburse you for the contact lens fitting. The Plan denied your request. The Plan says contact lens fitting fees are excluded from coverageMedicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.We looked at the file and the Plan's rules. The file shows that contact lens fitting is excluded from coverage. Therefore,we decided that the Plan does not have to reimburse you for a contact lens fitting providedon September 9, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the wound care on September 12, 2019.You asked the Plan to waive the copayment for the wound care. You say that you need the wound care but you cannot afford the $250 copayment every week. 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 $250 copayment per visit for Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient facility. You have been asked to pay a $250 copayment for the wound care. The wound care falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 wound care provided on September 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the cold cap rental provided from December 10, 2018 to July 9, 2019 by out of network provider.You asked the Plan to reimburse you for the Cold Caps. You say that the cold caps were recommended for your condition by medical staff.The Plan denied your request. The Plan says you did not request 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 reimburse you 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 reimburse you for these items/services.Therefore, we decided that the Plan does not have to reimburse you for the cold cap rental provided from December10, 2018 to July 9, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for moderate sedation services (99152) provided on June 21, 2019.You asked the Plan to pay for the moderate sedation services. You say that the record indicates that moderate sedation was administered and monitored. The Plan denied your request. The Plan says the documentation submitted did not include documentation of the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers mustreport services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 99152 is moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit provided on May 7, 2019 by an out of network provider.You asked the Plan to pay forthe office visit. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services received are not a covered benefit.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 thePlan does not have to pay forthe office visit provided on May 7, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay forthe emergency department visit provided to the enrollee on June 18, 2019.You asked the Plan to pay forthe emergency department visit. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says theservices billed were not submitted to the enrollee's primary insurer first.The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the emergency department visit until the primary insurer has denied the claim for these services.Therefore, we decided that the Plan does not have to pay forthe emergency department visit provided to the enrollee on June 18, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on August 21, 2019 through August 28, 2019.
You asked the Plan to pay for the home infusion therapy. You say that CPT code S9328 is valid per CMS. The Plan denied your request. The Plan says procedure code S9328 has a status code of I which is not valid for Medicare purposes.
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 S9328 is not supported in the record. Specifically, per the 2019 Physician Fee Schedule, S9328 has a status code of "I." This means that it is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) provided on August 21, 2019 through August 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe hospital discharge day management services coded 99239 provided to the enrollee on July 6, 2019.You asked the Plan to pay forthe hospital discharge day management services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not supported by the documentation.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 99239 is Hospital discharge day management; more than 30 minutes.We find that CPT code 99239 is not supported in the medical record. Specifically, the documentation does not support hospital discharge day management of more than 30 minutes was performed on the billed date of service. A documented duration of 31 minutes or more is required to support this code. Based on this information, we decided that Medicare rules for coverage of the hospital discharge day management services have not been met.Therefore, we decided that the Plan does not have to pay forthe hospital discharge day management services coded 99239 provided on July 6, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment forthe emergency room visit provided on September 2, 2019.You asked the Plan to reduce the copayment forthe emergency room visit. You say that you were billed $1,516.33 for the emergency room service. You say it was your impression you are responsible for a $90 copayment.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 $90 copayment for emergency services at an in-network emergency room. You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls 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 reduce the copayment forthe emergency room visit provided on September 2, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay fora colonoscopy provided to "the beneficiary" on December 20, 2016.You asked the Plan to pay forthe services. You say that this should be paid for.The Plan denied your request. The Plan says the claim was not filed timely.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service.The record shows that a claim for the services was not filed until August 28, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay fora colonoscopy provided to"the beneficiary" on December 20, 2016.Sincerely,
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided to the enrollee from July 1, 2017 through July 31, 2017.You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says that the enrollee was medically stable with no clinical evidence of any unstable medical or rehabilitation conditions requiring a skilled nursing facility level of care.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 pay for the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition did not meet Medicare criteria for SNF services.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the SNF services have not been met.Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided to the enrollee from July 1, 2017 through July 31, 2017.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Cancer Detect Extended genetic testing panel provided on April 11, 2019.You asked the Plan to pay for the genetic testing panel. You say that the enrollee has a history of colonic polyps and has family history of cancer. For this reason, cancer screening is necessary.The Plan denied your request. The Plan says this testing does not meet Medicare coverage criteria. The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. Although the enrollee has a history of colon polyps, there is no evidence of any signs/symptoms of disease for which this testing is indicated. There is no evidence that this testing was ordered by a physician overseeing the enrollee's treatment or that the results will impact therapeutic decision-making. As such, this is considered non covered screening testing. Therefore, we decided that the Plan does not have to pay for the Cancer Detect Extended genetic testing panel provided on April 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe immediate mandibular denture (D5140), and the immediate maxillary denture (D5130) provided on May 22, 2019.You asked the Plan to pay forthe dental services. You say that you were misinformed by the Plan representative. You also say that you will have a difficult time paying this off.The Plan denied your request. The Plan says that services received out of network are not covered. The Plan also says that the provider is not a network provider with the Plan.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 dentures are listed as a covered service, they are not covered when you receive them out of network.Therefore, we decided that the Plan does not have to pay forthe immediate mandibular denture (D5140), and the immediate maxillary denture (D5130) provided on May 22, 2019.Your complaint about being misinformed by a Plan representative 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 waive the copayment foran urgent care visit (99212) provided by "the provider" on July 29, 2019.You asked the Plan to waive the copayment foran urgent care visit. You say that they did nothing for you and sent you to the emergency room. You do not feel that you should have to pay for the urgent care visit.The Plan denied your request. The Plan says urgently needed services have a $45 copayment for each care visit.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 mustpay a $45 copayment for urgently needed services. You have been asked to pay a $44.40copayment for an urgent care visit. This servicefalls within the urgently needed services benefit category. The record shows that you have the "the plan" insurance plan which has a $45 copayment for urgently needed services. The allowable amount is $44.40. 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 foran urgent care visit (99212) provided by "the provider" on July 29, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the inpatient hospitalization services provided January 20, 2019 to January 23, 2019.You asked the Plan to pay for these services. You say that you should receive payment in the amount of$11,465.67 for these services.The Plan denied your request. The Plan says that the claim was billed incorrectly with an unrecognizable NPI number, therefore could not be priced properly. Additionally, an accurate W-9 form or corrected claim would be needed in order for the claim to be paid.The Plan must follow Medicare rules. Medicare rules say that all physicians and non-physician practitioners who order services or refer Medicare beneficiaries must report their NPI number.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have been met.Specifically, the NPI number submitted for the rendering and billing providers in this case were both valid. Both NPI numbers were recognizable by the CMS NPI Registry.Therefore, we decided that the Plan has to pay for the inpatient hospitalization services provided January 20, 2019 to January 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement of muscle or fascia provided on August 14, 2019 by the out of network provider.You asked the Plan to pay for the wound care. You say that the services were provided to the enrollee at the request of the enrollee's primary care physician (PCP).The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan says the services were not urgent or emergent in nature. The Plan also says that the enrollee's primary care physician did not refer them for the services.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 referring provider is not the enrollee's primary care physician, nor a network provider. 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 debridement of muscle or fascia provided on August 14, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the cardiac catheterization provided on January 8, 2018.You asked the Plan to pay for the cardiac procedure. You say that the Plan should pay this claim.The Plan denied your request. The Plan says that the claim was processed correctly.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. Therefore, we decided that the Plan has to pay for the cardiac catheterization (93458) provided on January 8, 2018.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance fora gel-one injection (J7326) provided on July 9, 2019.You asked the Plan to waive the coinsurance fora gel-one injection. You say that you were not told there would be this high a charge.The Plan denied your request. The Plan says the correct cost-share was applied.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles andcoinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare Part B drugs. You have been asked to pay $466.40 ($2,332 allowed amount x 20% = $466.40) for a gel-one injection, which falls within the Medicare Part B drugs 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 coinsurance fora gel-one injection (J7326) provided on July 9, 2019.