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

We decided that the Plan does not have to pay for the medical services provided on October 1, 2020 by a nonparticipating provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services were rendered by a non-participating 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 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 1, 2020
by a non-participating provider
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay fora cardiovascular risk assessment panel provided to the enrollee on April 21, 2020.You asked the Planto pay forthe testing. You say that this is medically necessary.The Plandenied your request. The Plansaysthe diagnosis does not substantiate the service.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 pay for the testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found Medicare denies coverage for all cardiovascular risk assessment testing/ panels, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular disease. The review has determined that the enrollee does not meet the criteria for this testing. e looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the testing have not been met.Therefore, we decided that the Plandoes not haveto pay fora cardiovascular risk assessment panel provided to the enrollee on April 21, 2020
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services provided on May 20, 2020.You asked the Plan to pay forthe laboratory services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the enrollee enrolled in hospice from August 21, 2019,through July 7, 2020. The Plan says, per Medicare guidelines, the provider should bill Original Medicare for the services provided on May 20, 2020.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay forthe laboratory services provided on May 20, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forthe routine venipuncture, laboratory services, imaging services, and ED visit provided on March 11, 2020.You asked the Plan to pay forthe routine venipuncture, laboratory services, imaging services, and ED visit. You saythat this claim has not been paid in full or under the terms of the contract for the services provided to this enrollee.The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay forthe routine venipuncture, laboratory services, imaging services, and ED visit provided on March 11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the inpatient hospital stay provided from
August 13, 2020, to August 14, 2020.
You asked the Plan to reduce the copayment for the inpatient hospital stay. You say that you were scheduled
for an outpatient surgery and will agree to pay the outpatient 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 $375
copayment per day, days 1-5 for each in-network Medicare-covered hospital admission/stay.
You have been asked to pay a $375 copayment for the inpatient hospital stay. The inpatient hospital stay falls
within the "Inpatient hospital care" benefit category. The medical record shows you were considered an
inpatient for the surgery.
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 for the inpatient hospital stay provided from August 13, 2020,
to August 14, 2020.
Our decision is only about the August 13, 2020, to August 14, 2020 service. If you have any questions about
prior years billing, please contact the plan directly.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe sterile needle with CPT code A4215 provided on October 3, 2019.You asked the Plan to pay forCPT code A4215. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not covered.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 looked at the file and Medicare rules. In this case, CPT code A4215 has a status code of "X" under the MPFSDB and represents a service that is not in the statutory definition of "physician services" for fee schedule payment purposes.Therefore, we decided that the Plan does not have to pay forthe sterile needle with CPT code A4215 provided on October 3, 2019.
Appeal type: Drugs
Decision: Favorable

The rules state that procedure code S9502 -home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 8 hours, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem -has a Status Code of "I", indicating that this code is not valid for Medicare purposes and is not payable. Medicare uses another code (or codes) for the reporting of, and payment for, these services. You can find this rule in the 2020 National Physician Fee Schedule Relative Value File.The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and (b).The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules saythat coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2.If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on September 28, 2020, by
an out-of-network (OON) provider.
You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent
nor urgent and prior authorization was not obtained to provide 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 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 physician services provided on September 28,
2020, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance fornursing facility care services (99308) provided at an out-of-network provider on June 30, 2020.You asked the Plan to waive the coinsurance fornursing facility care services. You say that you disagree with the charges for out of network careThe Plan denied your request. The Plan says coinsurance was correctly applied.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay 40% coinsurance per day,days 1-100, for out of network skilled nursing facility (SNF) care.The enrollee has been asked to pay a coinsurance of $24.39 ($60.98 x 40% coinsurance)for out-of-network nursing facility careservices. This service fallswithin the out-of-network skilled nursing facility (SNF) care benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.Therefore, we decided that the Plan does not have to waive the coinsurance fornursing facility care services (99308) provided at an out-of-network provider on June 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for.the medical services provided by an out-of-network provider.

You asked the Plan to pay for the medical services. You say that the services were medically necessary.The Plan denied your request. The Plan says the services were not previously authorized by 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 by an out-of-network provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit (99214) provided on June 8, 2020.You asked the Plan to pay forthe office visit. You say that the services were medically necessary.The Plan denied your request. The Plan says the services were non-emergent and there were network providers available.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 services at issue in this appeal. The Plan did not pre-approve the service 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 forthe office visit (99214) provided on June 8, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pay fordental services (D0140, D6010 and D7140) provided to the enrollee on August 4, 2020, and August 18, 2020.You asked the Planto pay forthe services. You say that you don't understand why this wasn't paid.The Plandenied your request. The Plansaysthis is not a covered benefit.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 Plandoes not haveto pay fordental services (D0140, D6010 and D7140) provided to the enrollee on August 4, 2020, and August 18, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 2, 2020 by an out of
network (OON) provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services were rendered 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 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 June 2, 2020 by
an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in other settings, for example: a skilled nursing facility.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 complexity of nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for confusion and falls associated with Parkinson's disease. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve(CPT Code E2377), (E2313), (K0108) and (E2311).You asked the Plan to pre-approvethe DME. You say that you are requesting review of denial of services.The Plan denied your request. The Plan says the DME is not necessary.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. Upgraded electronics (electronic connection, expandable controller and harness) cannot be covered per Medicare rules. They are necessary when there is a medical need to control power options though the joystick. The notes do not show a medical need to control the power options through the joystick. The power options can be controlled using their own switches. These switches can be made any size without asking for a separate request. They can be made from any material without asking for a separate request. All of this can be done without the need to use the joystick to control the power features. Because you can the control the three power options with their own switches, there 
is no need to control the power option through the joystick. DME are covered it is appropriate for use in the member's home. The transit kit is used to strap the wheelchair to a vehicle to travel outside the home. Therefore, the transit kit is not necessary.Therefore, we decided that the Plan does not have to pre-approve(CPT Code E2377), (E2313), (K0108) and (E2311).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 3, 2020 by a non-participating provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-participating 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 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 February 3, 2020 by a non-participating provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe inpatient hospital stay provided from May 22, 2020,to May 27, 2020.You asked the Plan to waive the copayment foryour five-day inpatient hospital stay. You say that you should not have to pay a copay because you already pay your Plan's monthly premium.The Plan denied your request. The Plan says that enrollees must pay a $250 copay for each of the first five days of a medically necessary inpatient hospital stay.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 copay for each of the first five days of an inpatient hospital stay. You have been asked to pay $250 for each day of your inpatient hospital stay. Your hospital stay was five days. The Plan requested a total of $1,250 for the services provided. 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 forthe five-day inpatient hospital stayprovided to you from May 22, 2020,to May 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pay foran additional dental filling (D2332) received on August 25, 2020.You asked the Planto pay forthe filling. You say that this should be paid for.The Plandenied your request. The Plansaysan additional filling is not a covered benefit.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 filling when the services are medically necessary and reasonable. The plan already paid for a filling on the same date of service. A second filling cannot be covered at this time. Based on this information, we decided that the Plan's rules for coverageof the filling have not been met.Therefore, we decided that the Plandoes not haveto pay foran additional dental filling (D2332) received on August 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe outpatient hospital services rendered on July 5, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claim was not billed correctly.The Plan must follow Medicare rules. Medicare rules say that outpatient hospital services must be billed with TOB code 13x.We looked at the file and Medicare rules. The file shows that the services were not billed with the required 13x TOB code. 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 outpatient hospital services rendered on July 5, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe surgical services rendered on November 12, 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 the services are not covered.The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied.In this case, the MUE for CPT code 66821 is 1. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of these services have notbeen met.Therefore, we decided that the Plan does not have to pay forthe surgical services rendered on November 12, 2019.