Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift mechanism.
You asked the Plan to pre-approve a seat lift mechanism. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested item is not medically necessary.
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed above are met. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a seat lift mechanism. Our reviewer says that the documentation does not support that the requested seat lift mechanism is medically reasonable or necessary. Our physician reviewer found the documentation shows that the enrollee has a diagnosis of osteoarthritis of the hips. The documentation does not reveal objective evidence that the enrollee has severe arthritis of the hip. There is a diagnosis of osteoarthritis of the bilateral hips. The documentation does not reveal that the enrollee has a neuromuscular disease. The documentation does not support that a seat lift is likely to effect improvement in the enrollee's condition or arrest or retard deterioration in the enrollee's condition. Therefore, the enrollee does not meet criteria for the requested item. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a seat lift mechanism have not been met. Therefore, we decided that the Plan does not have to pre-approve a seat lift mechanism.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department services rendered.

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 claim was not filed timely.The Plan follows Medicare rules. 

The rules say that claims for services furnished, must be filed no later than one calendar year after the date of service.

The record shows that a claim for these services was not filed. 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 emergency department services rendered.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe diagnostic mammogram rendered on November 18, 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 claim has not been processed by the primary insurer.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 confirmed on October 22, 2020 that they are not the primary insurer. The Plan has not received an Explanation of Benefits from the primary insurer for this claim. As the secondary insurer, the Plan cannot be held responsible for these services until the primary insurer has denied the claim for these services.Therefore, we decided that the Plan does not have to pay forthe diagnostic mammogram rendered on November 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on September 27, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe oxygen equipment (E1390, E1392). You say that you would like reconsideration based on the records submitted.`The Plan denied your request. The Plan says this equipment was supplied by an out-of-network provider and was not approved in advance.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 forthe medical services provided on September 27, 2020 by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit provided on July 1, 2020.
You asked the Plan to pay for the emergency department visit. 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 separately payable.
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 99282 is Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of low 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) are of low to moderate severity. We find that CPT code 99282 is not supported in the medical record. Specifically, another evaluation and management services (Code 99284) was billed by a different provider on the same date of service. Both providers have the same primary specialty, emergency medicine. The documentation does not support that the services billed were distinguished as separate, distinct services. Based on this information, we decided that Medicare rules for coverage of the emergency department visit have not been met. Therefore, we decided that the Plan does not have to pay for the emergency department visit provided on July 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe breast localization device placement provided on September 17, 2020.You asked the Plan to waive the copayment forthe breast localization device placement. You say that this was a light insertion that was required to help your later surgery. You say that it's not fair to be charged for this service.The Plan denied your request. The Plan says the copayment applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 copayment per date of service at an outpatient hospital facility.You have been asked to pay a $350 copayment for the breast localization device placement. The breast localization device placement falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The breast localization device placement is considered a surgical service. This meansthat 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 breast localization device placement provided on September 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate for the limited oral evaluation (D0140) and the extraction (D7140) provided on August 10, 2020.
You asked the Plan to pay the in network rate for the dental services. You say that the dental office advised that they accepted your plan. You say that you received a bill where the insurance only paid a small portion due to the dentist being out of network. You also say that you did not receive any kind of exam even though you were billed for one. The Plan denied your request. The Plan says the limited oral evaluation is not listed as a covered service. The Plan says the provider in this case is out of network. The Plan says if you see an out of network dentist, the coinsurance level will apply to the average negotiated in network fee schedule (INFS) in your area. The Plan also says you are responsible for the difference between the INFS and dentists' charged fees when visiting an out of network dentist.
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 limited oral evaluation is not among those covered under this benefit. Extractions that you receive out of network have a 55% coinsurance. This is a contractual obligation you agreed to when you enrolled in the Plan's dental coverage. Additionally, out of network providers are able to bill the difference between the in network fee schedule and the dentist's charged fees. Therefore, we decided that the Plan does not have to pay the in network rate for the limited oral evaluation (D0140) and the extraction (D7140) provided on August 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 23, 2020, by an OON provider.
You asked the Plan to pay for a health center visit. You say that, per Medicare rules, Medicare Advantage organizations are required to pay at least the original Medicare rate to OON providers. The Plan denied your request. The Plan says rules for payment have not been met.
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 23, 2020, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a periodontal scaling and root planing (D4342).
You asked the Plan to pre-approve the scaling and planing. The Plan denied your request. The Plan says this service is not covered under the enrollee's benefit 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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a periodontal scaling and root planing (D4342).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from May 8,
2020, through June 6, 2020.
You asked the Plan to pay for SNF care. You say that the service is medically necessary. The Plan denied your
request. The Plan says given the member has no skilled therapy or skilled nursing service needs, the member
does not meet the Medicare coverage guidelines outlined in the Medicare Benefit Policy Manual for admission
to SNF.
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 that there are no identifiable skilled therapy
service needs and the beneficiary does not require skilled nursing or therapy services on a daily basis.
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. Specifically, the beneficiary does not meet the
severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.
Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from
May 8, 2020, through June 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forhome health services (G0493, G0299) provided July 31, 2020 to August 4, 2020.You asked the Plan to pay forthe home health services. You say that the services were medically necessary.The Plan denied your request. The Plan says a corrected claim is needed.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 G0493, & G0299 is not supported in the medical record. Specifically, home health claims must include HCPCS codes Q5001, Q5002, orQ5009. None of these codes were included. Based on this information, we decided that Medicare rules for coverage of the home health services have not been met.Therefore, we decided that the Plan does not have to pay forhome health services (G0493, G0299) provided July 31, 2020 to August 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvebone marrow aspiration for the enrollee.You asked the Plan to pre-approvethis service. You say that this treatment is medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria are not met.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve this service. Our reviewer says that Medicare coverage criteria are not met. Our physician reviewer says that bone marrow aspiration remains experimental in posterior cervical fusion surgery. More research is needed to show safety and efficacy.Medicare coverage criteria are not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met.Therefore, we decided that the Plan does not have to pre-approvebone marrow aspiration for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the osseous surgery (D4261) and bone replacement graft (D4263) provided on July 28, 2020.
You asked the Plan to pay for the osseous surgery and bone replacement graft. You say that you have a dental benefit limit of $2,000 for all covered services. You also say that you have received treatment from this provider in the past, and some coverage was provided. The Plan denied your request. The Plan says these services are not covered benefits under your dental 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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the osseous surgery (D4261) and bone replacement graft (D4263) provided on July 28, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on September 10, 2020 byan out of network (OON) provider.You asked the Plan to pay forthe services provided. The Plan denied your request. The Plan says the services were not urgent, emergent, or approved in advance.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 file shows that the enrollee received a bone density test. The provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the servicesat issue. We foundno exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forthe medical services provided on September 10, 2020 by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe observation stay provided from August 7, 2020 through August 8, 2020.You asked the Plan to waive the copayment forthe observation stay. You say that you were never told that you would be admitted or not covered under the emergency room copayment. You say that you shouldn't be responsible for $250.The Plan denied your request. The Plan says the copayment applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for outpatient hospital observation services.You have been asked to pay a $250 copayment for the observation stay. The observation stay falls within the "Outpatient hospital observation" 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 forthe observation stay provided from August 7, 2020 through August 8, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services provided on September 30, 2019 by an out of network (OON) provider.You asked the Plan to pay forphysician services. You say that you would like this claim reprocessed and paid.The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the rendering facility is also out-of-network.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forphysician services provided on September 30, 2019 by an out of network (OON) provider
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran electrocardiogram (93000) performed on August 27, 2020.You asked the Plan to waive the copayment foran electrocardiogram. You say that this service was part of your annual wellness check-up and you have never before had a copayment.The Plan denied your request. The Plan says the correct copayment was 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). Your contract with the Plan clearly says that you must pay a $20 copayment for Medicare-covered non-radiological diagnostic services and that providers may ask you for more than one cost share payment if you get more than one service at an appointment. You have been asked to pay a $20 copayment for an electrocardiogram. An electrocardiogram falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" 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 paywhen you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment foran electrocardiogram (93000) performed on August 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ophthalmology visit you had on September 29, 2020.You asked the Plan to waive the copayment forthe ophthalmology visit. You say that because this visit was so close in time to when the Plan enacted its copayment waiver program, this copayment should be waived as well.The Plan denied your request. The Plan says their copayment waiver program did not go into effect until October 1, 2020. Therefore, the copayment was applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for vision care visits. You have been asked to pay a $40 copayment for the ophthalmology visit. The Plan's copayment waiver program was not in effect at the time of these services. 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 ophthalmology visit you had on September 29, 2020
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the after hour services provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service (99053) provided October 27, 2020.
You asked the Plan to pay for the after hour services. You say that the records should support the necessity of the services in dispute. The Plan denied your request. The Plan says payment for the services provided is already included in the approved emergency department services.
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 99503 has a bundled relationship with code 99285 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 the after hour services provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service (99053) provided October 27, 2020.