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

We decided that the Plan does not have to waive the copayments for wound debridement provided from March 13, 2019 to November 5, 2019.You asked the Plan to waive the copayments forwound debridement. You say that you disagree with 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 $275 copayment for outpatient services provided in an outpatient hospital facility.You received wound debridement from March 13, 2019 to November 5, 2019 for a total of 3 visits. Wound debridement is considered an outpatient surgical procedure. Therefore, you are responsible to paythe total amount of $580.72, which is less than the total copayment amount.  You have been asked to pay the total amount of $580.72 for wound debridement. Wound debridement 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 copayments forwound debridement provided from March 13, 2019 to November 5, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay formedical services provided to the enrollee on August 7, 2018.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says this claim was not filed timely per Medicare guidelines.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 this service was not filed until December 23, 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 formedical services provided to the enrollee on August 7, 2018
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forinpatient mental health care provided to the enrollee from October 4, 2019 through October 7, 2019.You asked the Plan to pay forinpatient mental health care. You say that the stay was 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 inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient mental health care. Our physician reviewer found this enrollee did not appear to require inpatient mental health treatment as she was not a danger to herselfor others and was cooperative with care without any aggressive behaviors. It did not appear that active treatment was taking place. It did not appear that the services were reasonably expected to improve the patient's condition or for the purpose of diagnosis. I am unable to find an individualized treatment however the entire record is not present. It did appear that the records were supervised and evaluated by a physician. Based upon review the records provided for the admission of this patient does not meet criteria for acute inpatient mental health treatment as she was not shown to be a danger to herself or others, no auditory or visual hallucinations. She is noted to be cooperative and compliant with treatment while not showing any acute threats to safety and not showing any aggressive behaviors. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health care have not been met.Therefore, we decided that the Plan does not have to pay forinpatient mental health care provided to the enrollee from October 4, 2019 through October 7, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from November 9, 2019 to November 16, 2019 and billed under code S9328.
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 Medicare billing criteria are not met.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, the code billed has a status code indicator of "I" which that does not allow payment on Medicare claims. Therefore, we decided that the Plan does not have to pay for home health services provided to the enrollee from November 9, 2019 to November 16, 2019 and billed under code S9328.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from
November 23, 2019 to November 26, 2019.
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 Federal Information Processing Standards (FIPS) code is missing or is invalid on the
claim submitted.
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 claim is lacking a valid FIPS code. The Plan states a correct Therefore, we decided that the
Plan does not have to pay for home health services provided to the enrollee from November 23, 2019 to
November 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the 20% coinsurance charged for a life vest provided on October 26, 2019.You asked the Plan to waive this coinsurance. You say that you do not believe this coinsurance is correct.The Plan denied your request. The Plan says this coinsurance was charged based on the claim submitted by the provider and the Plan contract agreement.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for durable medical equipment. 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 20% coinsurance charged for a life vest provided on October 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit rendered to the enrollee on September 24, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 99204 is not supported.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 99204 is Level 4 new patient office or other outpatient visit, typically 45 minutes.We find that CPT code 99204 is not supported in the medical record. Specifically, this code is for a new patient office visit and the file shows that the Plan previously paid for a new patient office visit on March 22, 2019 for this enrollee. A new patient office visit is not valid for September 24, 2019. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe office visit rendered to the enrollee on September 24, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2751) for tooth # 28 to be provided by an out
of network provider.
You asked the Plan to pre-approve the dental service. You say that you suffer from anxiety. You say that you
are highly susceptible to infections. You also say that you would like to stay with this provider as he is certified
in special needs sedation. The Plan denied your request. The Plan says the requested provider in this case is not
a network provider. The Plan also says that you must obtain services from an in network dentist in order for the
services to be 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 requested crown for tooth # 28 is
not covered when you obtain this service from an out of network provider. Therefore, we decided that the Plan
does not have to pre-approve a crown (D2751) for tooth # 28 to be provided by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4342) for teeth #
19 and 29.
You asked the Plan to pre-approve the dental services. You say that after your dental exam on January 7, 2020,
your dentist recommended a deep cleaning to eliminate bleeding gums and future infections. The Plan denied
your request. The Plan says periodontal scaling and root planing is not a covered service.
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 periodontal scaling and
root planing is not among those covered under this benefit. Therefore, we decided that the Plan does not have
to pre-approve periodontal scaling and root planing (D4342) for teeth # 19 and 29.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay foreye refraction (CPT Code 92015) provided on December 12, 2019 by a non-participating provider.You asked the Plan to pay forthe eye refraction. You say that this was a routine examination.The Plan denied your request. The Plan says eye refractions are only covered at an annual routine eye exam when provided by a network provider. Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and 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. Based on this information, we decided that the Plan's rules for coverage of the eye refraction have not been met. You saw this provider to check on your eye pressure due to being diagnosed with Glaucoma. The Glaucoma diagnosis can be seen in the 92015 line of the claim, was verified by the provider's office, and you admit having Glaucoma in the appeal request.  While at the provider's office having your eye pressure checked, due to Glaucoma, you requested an eye exam for new glasses, which the provider then performed. Per the 2019 EOC, eye refractions are only covered when performed at a routine annual eye exam, and when performed by a network provider. The purpose of the visit to the provideron December 12, 2019 was medical, not routine. While this provider is a participating provider with the plan, he is not an approved network provider. Therefore, this service is not covered.Therefore, we decided that the Plan doesnot have to pay foreye refraction (CPT Code 92015) provided on December 12, 2019 by a non-participating provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for other neurology and neuromuscular procedures (95999) provided June 18, 2019.
You asked the Plan to pay for Other Neurology and Neuromuscular Procedures. You say that intraoperative neurophysiological monitoring services are medically necessary as per the ordering physician. The Plan denied your request. The Plan says this item or service is considered a bundled procedure as the cost is included in the cost of the primary procedure.
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, we have confirmed that code 95999 has a bundled relationship with the primary surgical procedure and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for other neurology and neuromuscular procedures (95999) provided June 18, 2019.
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 you have medical issues and feel the inserts will
provide relief from your foot pain. 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the leuprolide acetate suspension and chemotherapy administration provided on July 9, 2019.
You asked the Plan to waive the coinsurance for the leuprolide acetate suspension and chemotherapy administration. You say that the shots are needed every 3 months. You say that you need help with the cost. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for each Medicare-covered Part B drug and 20% of the total cost for each Medicare-covered service provided in an outpatient hospital or an ambulatory surgical center, including but not limited to hospital or facility charges, observation room/stay charges, physician charges and surgical charges. You have been asked to pay a total of $150.52 for the leuprolide acetate suspension and chemotherapy administration.
Service
Allowed Amount
Coinsurance
Member Liability
Leuprolide Acetate Suspension
$710.97
20%
$142.19
Chemotherapy Administration
$41.61
20%
$8.33
TOTAL:
$150.52
The leuprolide acetate suspension falls within the "Medicare Part B prescription drugs" benefit category. The chemotherapy administration 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 coinsurance for the leuprolide acetate suspension and chemotherapy administration provided on July 9, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Urolift surgery.

You asked the Plan to pre-approve Urolift. You say that it is very painful for you to urinate, and you need this surgery as soon as possible. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the work-up to determine medical necessity for Urolift was incomplete.

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 Urolift. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found Urolift is medically necessary and indicated when the enrollee is age 50 or above, prostate volume is less than 90 cubic centimeters on ultrasound imaging, no obstructive median lobe of the prostate is identified on cystoscopy, and there has been failure, contraindication, or intolerance to at least 6 months of conventional medical therapy. You do not meet these criteria.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Urolift have not been met. Therefore, we decided that the Plan does not have to pre-approve Urolift surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the prosthetic leg to be provided by an out of network (OON) provider.You asked the Plan to pre-approve the prosthetic leg. You say that you are a mobile company willing to see the enrollee at home.The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says if an enrollee requires medical care that Medicare requires the plan to cover and there are no in-network providers who can provide the care then the enrollee can receive the care from an out-of-network provider. The plan has confirmed there are in-network prosthetic suppliers.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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.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. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approve the prosthetic leg to be provided by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care.You asked the Plan to pre-approveSNF care. You say that the services are necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 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 enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria foran inpatient basis in a skilled nursing facility setting.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care rendered on November 7, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 99232 is not separately payable.The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.The provider submitted a claim for procedure codes 99232 and 99233. Code 99232 is a column II code with a modifier indicator of 1 when billed with column I code 99233. Code 99232 was not billed with an appropriate modifier to allow for separate payment.Therefore, we decided that the Plan does not have to pay forthe subsequent hospital care rendered on November 7, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aid check; binaural (CPT Code 92593) provided on November 14, 2019 by anon-participating provider.You asked the Plan to pay for the hearing aid check. You say that you did not know of a network change for your audiology providers and you would like this claim paid at your in-network benefit level.The Plan denied your request. The Plan says you did not use an in-network provider.Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid 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. Based on this information, we decided that the Plan's rules for coverage of the hearing aid check have not been met. Review of the file show that you received a hearing aid check; binaural (CPT Code 92593) provided on November 14, 2019 by a non-participating provider. You did not use an in-network provider. Your EOC clearly states, you must see a TruHearing provider to use this benefit.Therefore, we decided that the Plan does not have to pay for hearing aid check; binaural (CPT Code 92593) provided on November 14, 2019 by a non-participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit provided on August 13, 2017.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 were submitted untimely.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 office visit was not filed until November 12, 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 forthe office visit provided on August 13, 2017.