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

We decided that the Plan does not have to waive the copayment for the emergency room visit provided from May 19, 2019 to May 21, 2019.
You asked the Plan to waive the copayment for the emergency room visit. You say that you cannot afford to pay anymore copayments. You say you thought the nursing home would be responsible for the copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copayment for each emergency room visit. You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. The record shows you received services in the emergency department.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency room visit provided from May 19, 2019 to May 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99153) provided to the enrollee on May 14, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for this service is included in payment to the facility.
The Plan must follow Medicare rules. Medicare rules say that the OPPS recognizes that CPT code 99153 is a practice expense (PE) only code and is not paid in the facility setting. The Outpatient Prospective Payment System (OPPS) applies to all hospital outpatient departments. We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment for CPT code 99153 under the OPPS when performed in the facility setting. Therefore, we decided that the Plan does not have to pay for the services (CPT 99153) provided to the enrollee on May 14, 2019.
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 May 14, 2019 to May 15, 2019.
You asked the Plan to reduce the copayment for the inpatient hospital stay. You say that you never left the emergency room and should not be responsible for the inpatient hospital care 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 $360 copayment for each day for days 1 to 5 for Medicare-covered hospital care. You have been asked to pay a $360 copayment for the inpatient hospital stay. The inpatient hospital stay falls within the "Inpatient hospital care" benefit category. The medical record shows you were admitted to inpatient care.
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 May 14, 2019 to May 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to "the provider" by an out-of-network provider on June 25, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says there is no network deficiency for these services.Medicare rules say that plans can require enrollees to get care from network providers. The contract withthe 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 services 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 medical services provided to"the provider" by an out-of-network provider on June 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee on March 13, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the primary carrier's Explanation of Benefits was not received.
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 identified the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the services provided to the enrollee on March 13, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for reconstruction of the mandible (21245) provided on February 26, 2019.You asked the Plan to pay for the surgery. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the operative report did not include documentation of a partial reconstruction of mandible or maxilla, subperiosteal implant 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 21245 is Reconstruction of mandible or maxilla, subperiosteal implant; partial.We asked our coder 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 surgery. Our reviewer says that CPT code 21245 is not supported by the medical record. The record states that a mandible reconstruction with bone graft and reconstruction bar was performed. According to CPT rules, there is a more specific code for this procedure. Ourcoder found according to CPT rules, there is a more specific code for this procedure.We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the surgery have not been met.Therefore, we decided that the Plan does not have to pay for reconstruction of the mandible (21245) provided on February 26, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe selective catheter placement, and angiography provided on August 2, 2019 by the out of network provider.You asked the Plan to pay forthe radiology services. You say that the office verified online July 2, 2019 and were advised that no authorization was required for the services. You also say that the office called on July 23, 2019 and was advised by a Plan representative that no authorization was required.The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan says the enrollee's primary care physician did not refer them for the services. The Plan also says the services were not urgent or emergent.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plansays that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The provider in this case is not a network provider with the Plan. The 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 selective catheter placement, and angiography provided on August 2, 2019 by the out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe limited oral evaluation and intraoral x-rays provided on April 9, 2019.You asked the Plan to pay forthe limited oral evaluation and intraoral x-rays. You say that you were informed the dentist accepted your coverage. You say that you should not be responsible since you were not properly informed of coverage.The Plan denied your request. The Plan says dental servicesmust be received from an in-network provider.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, out-of-network services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe limited oral evaluation and intraoral x-rays provided on April 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on June 28, 2019 by out of network provider, "the provider"..You asked the Plan to pay forspecialist services. You say that you were unaware that you were out-of-network with the patient's specific plan.The Plan denied your request. The Plan says no prior authorization was obtained for the service in question.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 carefrom 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 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 June 28, 2019 by out of network provider, "the provider"..
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing rendered to the enrollee on June 13, 2019.
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 testing is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the genetic testing rendered to the enrollee on June 13, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered to the enrollee on June 3, 2019.
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 are not covered.
The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes. The rules say that laboratories must have a CLIA certificate in order to receive reimbursement from Federal programs. The provider billed procedure codes S1015 and S8301. These codes have a status indicator of I and are not valid for Medicare purposes. Code 82948 is not covered because the CLIA certification level is not met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered to the enrollee on June 3, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodontal evaluation provided on June 3, 2019 and the fluoride varnish application provided on June 18, 2019. You asked the Plan to pay forthe periodontal evaluation and fluoride varnish application. You say that you were referred by an in-network dentist. You say that the in-network provider could not help you.The Plan denied your request. The Plan says these are not covered 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.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 forthe periodontal evaluation provided on June 3, 2019 and the fluoride varnish application provided on June 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe somatosensory testing (95938), transcranial motor stimulation in the upper and lower limbs (95939), continuous intra-operative neurophysiology monitoring (G0453), and the needle electromyography (95861) provided on April 19, 2019.You asked the Plan to pay forthese services.You say that you are requesting this claim be processed under the patient's in-network benefits. The facility and the surgeon are in-network and you believe you fall under that umbrella as there were no in-network Neuro-monitoring professionals available within a 50-mile radius of Tucson, AZ at the time of surgery.The Plan denied your request. The Plan says the services provided are not a covered benefit under the member's policy.The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the case file and Medicare rules. Based on this information, we decided that Medicare rules for coverage ofthese serviceshave not been met.Specifically, there are no medical records provided for review in this case to corroborate the services provided. Therefore, we decided that the Plan does not have to pay forthe somatosensory testing (95938), transcranial motor stimulation in the upper and lower limbs (95939), continuous intra-operative neurophysiology monitoring (G0453), and theneedle electromyography (95861) provided on April 19, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services rendered to the enrollee.
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 not medically necessary.
The Plan follows Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare rules say that for procedures with an assistant surgery indicator of 0, the payment restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to establish medical necessity. In this case, you billed assistant surgery services for CPT code 15002. The Medicare Fee Schedule Database contains a surgical indicator of 0 for this procedure.
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 these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee underwent a right leg scar revision with adjacent tissue transfers and complex repair of hypertrophic scar. The use of a surgical assistant is not required or standard for code 15002. There was nothing noted in the operative report to support additional complexity or complication that required the use of an assistant surgeon. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met.
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT codes 13160 and 12042. The Medicare Fee Schedule Database contains a surgical indicator of 1 for these procedures. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for these services have not been met.
Therefore, we decided that the Plan does not have to pay for the assistant surgeon services rendered to the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forincontinence supplies.You asked the Plan to pay forincontinence supplies. You say that you cannot afford the supplies.The Plan denied your request. The Plan says the items are not covered under Medicare or the Health Plan.The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items.Therefore, we decided that the Plan does not have to pay forincontinence supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of area office visit provided on August 8, 2018 by the out
of network provider.
You asked the Plan to pay for the physician service. You say that your primary care physician (PCP) gave you
a prescription refill slip when you went to Hawaii. You say that the pharmacy would not refill the medication.
You say that they sent you to the emergency room to get the prescription refilled. You say that the emergency
room advised you needed to see a doctor on the island for a refill of narcotic analgesics. You also say that you
made an appointment for the prescription refill. The Plan denied your request. The Plan says the services you received were not urgent or emergent in nature.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and
pre-approved care.
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 physician service. Our reviewer says that
the service was not medically necessary. Our physician reviewer found the documentation does not support the
enrollee was in distress as the enrollee's pain was reported as a 2 out of 10. The visit was not urgent or
emergent. The documentation does not support prior authorization was attempted. Without the support of the
documentation, medical necessity cannot be determined.
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 physician service have not been met. Therefore, we decided that the Plan
does not have to pay for out of area office visit provided on August 8, 2018 by the out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for psychiatric diagnostic evaluation with medical services (CPT Code 90792) provided to the enrollee by an out-of-network provider on April 17, 2019.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the provider is not in-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. The claim denied correctly as a duplicate of 2019042400409412. Also, claim 2019042400409412 was denied due to no prior authorization for non-par provider services being obtained and there is no prior authorization is on file for these services. Therefore, we decided that the Plan does not have to pay for psychiatric diagnostic evaluation with medical services (CPT Code 90792) provided to the enrollee by an out-of-network provider on April 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waivethe copayment for the specialist visit you had on July 25, 2019.You asked the Plan to waivethe copayment. The Plan denied your request. The Plan says 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 $20 copayment for each specialist visit. Review of the file shows that you had a specialist office visit on July 25, 2019. You have been asked to pay a $20 copayment for the visit. The visit falls within the physician services benefit category. This means that you have been asked to pay the correctamount 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 waivethe copayment for the specialist visit you had on July 25, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe laboratory work on June 7, 2019.You asked the Plan to waive the copayment forthe laboratory work. You say that you should not be responsible for the copayment because the lab services were a part of your annual visit. The Plandenied 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 $20 copayment for in-network Medicare-covered non-preventive lab services. You have been asked to pay a $20 copayment for the laboratory work. The laboratory work falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows the rubella test is considered a diagnostic lab test.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 laboratory work provided by "the medical center" on June 7, 2019.