Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for resin-based composite (D2392 and D2394), two (2) surgical tooth removal (D7210) scaling and root planning (D4341), application of desensitizing medicament (D9910), gingival irrigation (D4921) and localized delivery of antimicrobial (D4381) provided on December 4, 2019 and December 5, 2019.
You asked the Plan to pay for the dental services. You say that you already made a payment. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 dental benefits.
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. Gingival irrigation (D4921), application of desensitizing medicament (D9910) and localized delivery of antimicrobial (D4381) are not listed in your EOC as a covered benefit; therefore, the services are not covered. For resin-based composite (D2392 and D2394), two (2) surgical tooth removal (D7210) scaling and root planning (D4341); All of the codes that were submitted and paid are listed as covered with the appropriate cost-share amounts. All of the claims paid appropriately and the provider charged you a discounted amount for all non-covered items that are not listed in the handbook. Therefore, you are responsible for the remaining balance of $417.58. Therefore, we decided that the Plan does not have to pay for resin-based composite (D2392 and D2394), two (2) surgical tooth removal (D7210) scaling and root planning (D4341), application of desensitizing medicament (D9910), gingival irrigation (D4921) and localized delivery of antimicrobial (D4381) provided on December 4, 2019 and December 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye exam and refraction provided on November 12, 2019.You asked the Plan to pay for the vision care. You say that this was a yearly normal eye exam.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.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. Review of the file show that you received an eye exam and eye refraction on November 12, 2019. Original Medicare doesn't cover routine eye exams (eye refractions) for eyeglasses/contacts. The Plan states that your provider has been informed to submit this claim to your supplemental vision plan.Therefore, we decided that the Plan does not have to pay for the eye exam and refraction provided on November 12, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from December 5, 2019 to January 3, 2020.You asked the Plan to pay for SNF care. You say that this should be covered by Medicare.The Plan denied your request. The Plan says the enrollee did not require skilled 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the records show that on the dates at issue, the enrollee did not have any identifiable skilled nursing or therapy service needs. She did not meet severity of illness or intensity of service criteria for an 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 pay for skilled nursing facility (SNF) care provided from December 5, 2019 to January 3, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ER visit provided on December 17, 2019.You asked the Plan to waive the copayment for an ER visit. 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 $90 copayment for emergency care. You have been asked to pay a $90 copayment for an ER visit. An ER 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 waive the copayment for an ER visit provided on December 17, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyewear (V2020) provided on December 31, 2019.You asked the Plan to pay for the eyewear. You say that you are requesting reimbursement of services rendered.The Plan denied your request. The Plan says you received a promotional discount in lieu of Plan's benefits.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. Your services were provided in connection with an optical promotion. Providers do not submit a claim in connection with promotions. Benefits are not combined with retail promotions; therefore,your request is denied.Therefore, we decided that the Plan does not have to pay for eyewear (V2020) provided on December 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe dental services provided on February 27, 2020  by a non-Medicare provider.You asked the Plan to pay forthe dental services. You say that you are appealing for reconsideration of the denied charges.The Plan denied your request. The Plan says the provider does not accept Medicare and you were not provided incorrect information.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.Review of the file show that you received dental services on February 27, 2020 from a provider that has opted out of Medicare. The Medicare rules say Medicare Advantage Plans may not make payment directly or indirectly for Medicare covered services furnished to a Medicare beneficiary by a physician or practitioner who has opted out of Medicare except in cases involving emergency or urgent care services furnished to a beneficiary who has not previously entered into a private contract with the physician or practitioner. 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 forthe dental services provided on February 27, 2020  by a non-Medicare provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance fornasal interface (mask or cannula type) used with positive airway pressure device, with or without head strap (A7034), filter, disposable, used with positive airway pressure device (A7038), tubing with integrated heating element for use with positive airway pressure device (A4604) and pillow for use on nasal cannula type interface, replacement only, pair (A7033) provided on March 2, 2020.You asked the Plan to waive the coinsurance forthe DME. You say that you are appealing your cost-share responsibility for the services you received.The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received DME provided on March 2, 2020. You were asked to pay 20% coinsurance for any DME received. 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 fornasal interface (mask or cannula type) used with positive airway pressure device, with or without head strap (A7034), filter, disposable, used with positive airway pressure device (A7038), tubing with integrated heating element for use with positive airway pressure device (A4604) and pillow for use on nasal cannula type interface, replacement only, pair (A7033) provided on March 2, 2020.
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 January 19, 2020 through January 28, 2020.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 the enrollee was not a danger to herself or 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. Our physician review was unable to find an individualized treatment plan 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 the enrollee was not shown to be a danger to themselves or others. The enrollee has auditory no visual hallucinations. The enrollee is noted to be cooperative and compliant with treatment while not showing any aggressive behaviors or any acute threats of safety.  We looked at this physician's review, thefile, 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 January 19, 2020 through January 28, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF care provided to the enrollee from January 17, 2020 through February 12, 2020.You asked the Plan to pay for SNF 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 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The beneficiary does not require skilled nursing or therapy services on a daily basis. This beneficiary does not meet severity of illness or intensity of service criteria for an 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 pay for SNF care provided to the enrollee from January 17, 2020 through February 12, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 molecular pathology genomic profiling
provided to the enrollee on March 17, 2020.
You asked the Plan to pay for the test. You say that this should be paid for. The Plan denied your request. The
Plan says Medicare requires use of CPT 81479 to report a Guardant360 molecular pathology genomic profiling
for NSCLC, and the appropriate DEX Z-Code identifier must be entered adjacent to the CPT code [81479] in
the comment/narrative field.
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 81479 is "unlisted molecular pathology procedure."
We find that the denied test is not supported in the medical record. Specifically, this specific test must be billed
with CPT 81479. The test was billed with multiple CPT code. Based on this information, we decided that
Medicare rules for coverage of the test have not been met. Therefore, we decided that the Plan does not have to
pay for the Guardant360 molecular pathology genomic profiling provided to the enrollee on March 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the records provided support the need for LTACH care. The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage of LTACH care. The Plan says that the enrollee is not medically stable to transfer to another level of care at this time.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was admitted to the acute care hospital after multiple falls at home. He was treated with IV antibiotics for sepsis and required pressors, left knee prosthetic joint debridement and irrigation. Current needs include ongoing use of IV antibiotics until July 22, 2020 and the frequent monitoring, nursing and physician management of his condition due to his chronic kidney insufficiency, heart failure, and nutritional needs. He appears to be improving gradually with a more recent normal white blood cell count. The enrollee appears to be gradually improving with current acute care needs, but appears not well enough to transfer. Also, based on the improvement thus far, it is unlikely he will require acute care services for more than 25 additional days. The enrollee does not require services at the proposed LTACH that are not already available at the current acute care hospital. There are no services available at the LTACH that the enrollee requires that are not already available and covered for the enrollee. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe specialist office visit provided on November 25, 2019.You asked the Plan to waive the copayment forthe specialist office visit. You say that the enrollee was out of town and ran out of his medication. You say you would like the Plan to reconsider the claim. The Plan denied your request. The Plan saysthe claim was reprocessed and 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $40 copayment for each Medicare-covered specialist visit. The enrollee has been asked to pay a $40 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" 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 copayment forthe specialist office visit provided on November 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit with a specialist (99213) provided on March 9, 2020.
You asked the Plan to waive the copayment for an office visit with a specialist. You say that you should not be charged for this service. The Plan denied your request. The Plan says this processed 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 $50 copayment for specialist visits. You have been asked to pay a $50 copayment for an office visit with a specialist. 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 an office visit with a specialist (99213) provided on March 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for colon mobilization (44139) provided on December 3, 2019.
You asked the Plan to pay for colon mobilization. You say that this was billed correctly. The Plan denied your request. The Plan says this was not billed with an appropriate primary code.
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 44139 is mobilization (take-down) of splenic flexure performed in conjunction with partial colectomy (List separately in addition to primary procedure). Use 44139 in conjunction with 44140-44147. We find that CPT code 44139 is not supported in the medical record. Specifically, this code was not billed in conjunction with an appropriate primary procedure (CPT codes 44140-44147). Based on this information, we decided that Medicare rules for coverage of colon mobilization have not been met. Therefore, we decided that the Plan does not have to pay for colon mobilization (44139) provided on December 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214) provided on December 30, 2019.
You asked the Plan to pay for the office visit. You say that you would like reconsideration because this charge
is not included in the global surgery period. The Plan denied your request. The Plan says when an evaluation
and management visit is reported within 90 days of the major surgical procedure, it will be bundled as part of
the global surgical fee.
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for these
procedures includes payment for post-operative visits related to the surgery when furnished by the physician
who performs the surgery.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the office visit have not been met. Specifically, the record indicates the surgery with a 90-day
global period was rendered on October 9, 2019. The medical records state the evaluation and management
service at issue was for a follow up to the tonsillitis surgery. This service was provided within 90 days of the
major surgery. The Medicare approved amount for the major surgery includes payment for the post-operative
visit. Therefore, we decided that the Plan does not have to pay for an office visit (99214) provided on
December 30, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 99190 provided on February 26, 2020.
You asked the Plan to pay for CPT code 99190. 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 does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient. We looked at the file and Medicare rules. In this case, the file shows the enrollee received these services during an inpatient hospitalization. Payment for these services were included in the facility payment. Therefore, we decided that the Plan does not have to pay for CPT code 99190 provided on February 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 99235 provided on February 7, 2020.
You asked the Plan to pay for CPT code 99235. 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.
In this case, the CPT Code Manual definition of code 99235 is Observation or inpatient hospital care, for the
evaluation and management of a patient including admission and discharge on the same date, which requires
these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision
making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified
health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's
and/or family's needs. Usually the presenting problem(s) requiring admission are of moderate severity.
Typically, 50 minutes are spent at the bedside and on the patient's hospital floor or unit.
We find that CPT code 99235 is not supported in the medical record. Specifically, the file only includes
discharge documentation. The code billed in this case should include documentation of admission as well for
the same date of service. Based on this information, we decided that Medicare rules for coverage of CPT code
99235 have not been met. Therefore, we decided that the Plan does not have to pay for CPT code 99235
provided on February 7, 2020.