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

We decided that the Plan does not have to pre-approve chiropractic services (CPT 97035 and 97140) for the
enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that
the Plan does not have to pre-approve chiropractic services (CPT 97035 and 97140) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the ophthalmology services provided on July 3, 2019 by an out of network (OON) provider.You asked the Plan to pay for the OON services. You say that the service was provided as part of an ongoing treatment of a pre-existing condition.The Plan denied your request. The Plan says the services could have been provided by a contract provider.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 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 for the ophthalmology services provided on July 3, 2019 by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ER visit provided on January 16, 2020.
You asked the Plan to waive the copayment for an ER visit. You say that you were taken against your request and 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 January 16, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit on January 10, 2020.
You asked the Plan to waive the copayment for the emergency room visit. You say that the copayment should be waived. 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 $50 copayment for Emergency Care. You have been asked to pay a $50 copayment for the emergency room visit. The emergency room 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 emergency room visit on January 10, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sodium chloride 3% vial (J3490).You asked the Plan to pre-approve sodium chloride 3% vial. You say that the requested medication is necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 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 sodium chloride 3% vial. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the enrollee was prescribed sodium chloride for nebulizer treatment every 4 hours as needed for cough. Review of guidelines and Medicare approved compendia does not support this use. 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 sodium chloride 3% vial have no been met.Therefore, we decided that the Plan does not have to pre-approve sodium chloride 3% vial (J3490).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence garments.
You asked the Plan to pre-approve incontinence garments. You say that you need this because of your
incontinence. The Plan denied your request. The Plan says that incontinence supplies are not covered because
they are hygienic items that are non-reusable.
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 pre-approve incontinence garments.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray and resin-based composite provided on January 30, 2020 by an OON provider.You asked the Plan to pay for the first intraoral periapical x-ray and resin-based composite. You say that you did not realize the network had changed. You also say that you believed the dentist would automatically be enrolled in the new dental plan.The Plan denied your request. The Plan says these services were rendered by an OON 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, the requested items or services are not covered when they are received OON.Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray and resin-based composite provided on January 30, 2020 by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that you did not have any choice but to call for the ambulance. You say that you called the ambulance because your blood sugar was low. You stated that you were told by the EMS responders that you would not be charged. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on January 15, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for assembly and operation of pump with oxygenator or heat
exchanger (with or without ECG and/or pressure monitoring) (99190) provided November 26, 2019.
You asked the Plan to pay for assembly and operation of heart lung machine. You say that the perfusionist is
required to be in the operating room during the length of the procedure. The Plan denied your request. The Plan
says payment for this service is the responsibility of the facility to any vendor.
The plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other
than the facility for services furnished to a beneficiary. The facility or hospital must furnish all necessary
covered services to the beneficiary either directly or under arrangements made with outside providers. You
provided perfusionist services while the enrollee was in inpatient status. Payment for this service would have
been included under the facility claim for observation. Payment to you for this service is the responsibility of
the facility or hospital. Therefore, the plan is not required to pay you separately for this claim. Therefore, we
decided that the Plan does not have to pay for assembly and operation of pump with oxygenator or heat
exchanger (with or without ECG and/or pressure monitoring) (99190) provided November 26, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on January 13, 2020.
You asked the Plan to pay for the laboratory services. 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 supported by the documentation.
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 the laboratory services are not supported in the medical record. Specifically, the documentation submitted did not include laboratory results for the testing provided. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on January 13, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four testing (95999) provided on July 30, 2019.
You asked the Plan to pay for train of four testing. You say that this was medically necessary. The Plan denied your request. The Plan says payment of this service is bundled into other 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. We find that CPT code 95999 is not supported in the medical record. Specifically, the use of unlisted CPT code 95999 to report train of four testing is not supported. According to CPT coding rules, train of four testing is not a separately reportable procedure and is included in the other intraoperative neuromonitoring procedures. Based on this information, we decided that Medicare rules for coverage of train of four testing have not been met. Therefore, we decided that the Plan does not have to pay for train of four testing (95999) provided on July 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on December 3, 2019.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 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 for laboratory services provided on December 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 4, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the enrollee must receive care from in-network providers with the exception of emergency or urgent care, or if the care cannot be provided with an in-network provider, which requires prior authorization from 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 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 for physician's services provided on November 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on August 29,
2019.
You asked the Plan to waive the copayment for the office visit. You say that you had a wellness visit and that
you disagree with 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 $0
copayment for an annual physical by your primary care physician (PCP). If, during the physical exam, you also
receive services to treat a medical condition, you will be expected to pay a $20 copayment for the additional
Medicare-covered services.
You have been asked to pay a $20 copayment for the office visit. The office visit falls within the "Physician/
Practitioner services, including doctor's office visits" benefit category. The record shows, in addition to the
annual wellness visit, diagnoses codes of dermatophytosis, female genital prolapse, and hypothyroidism which
makes the visit medical in nature.
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 office visit provided on August 29, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ER visit provided on October 6, 2019.
You asked the Plan to waive the copayment for an ER visit. You say that you have insurance and should not be
responsible for 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 October
6, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 16, 2018 by an out of network (OON) provider.You asked the Plan to pay for Mammaprint test. You say that this test is covered by Medicare and prior authorization is not required.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and prior authorization was not obtained.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 November 16, 2018 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the thoracentesis services coded 32555 provided on December 24, 2019.
You asked the Plan to pay for the thoracentesis services. 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 supported by the documentation.
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 32555 is thoracentesis, needle or catheter, aspiration of the pleural space; with imaging guidance. We find that CPT code 32555 is not supported in the medical record. Specifically, the documentation submitted did not include a detailed procedure note to support that thoracentesis, needle or catheter, aspiration of the pleural space; with imaging guidance was performed. Based on this information, we decided that Medicare rules for coverage of the thoracentesis services have not been met. Therefore, we decided that the Plan does not have to pay for the thoracentesis services coded 32555 provided on December 24, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on December 19, 2019.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 did not pre-approve the laboratory services. 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 for laboratory services provided on December 19, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the new patient office visit (99204) and the nasal/sinus endoscopy surgery (31238) provided by the out of network (OON) provider on December 11, 2019. You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment as the services provided were emergent. The Plan denied your request. The Plan says that the services were provided by an out of network provider, without prior authorization.
The Plan must follow Medicare rules. The rules say that an emergency exists based on a prudent layperson standard, not a retrospective medical review. For symptoms to be considered emergent in nature, they must be such that a prudent layperson with an average knowledge of medicine would reasonably expect the absence of immediate medical attention would result in serious jeopardy to their health. We decided that this case does meet the prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine would reasonably expect the absence of immediate medical care to seriously jeopardize their health in this case. Therefore, we decided that the Plan has to pay for the new patient office visit (99204) and the nasal/sinus endoscopy surgery (31238) provided by the out of network (OON) provider on December 11, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the unlisted neurological or neuromuscular diagnostic procedure coded 95999 provided on November 14, 2019.
You asked the Plan to pay for the unlisted neurological or neuromuscular diagnostic procedure. 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 supported by the documentation.
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 95999 is unlisted neurological or neuromuscular diagnostic procedure. We find that CPT code 95999 is not supported in the medical record. Specifically, the records show that the services provided were train of four testing. This testing is considered a bundled procedure and the cost is included in the cost of the primary procedure. Based on this information, we decided that Medicare rules for coverage of the unlisted neurological or neuromuscular diagnostic procedure have not been met. Therefore, we decided that the Plan does not have to pay for the unlisted neurological or neuromuscular diagnostic procedure coded 95999 provided on November 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an eye examination provided on December
20, 2019.
You asked the Plan to waive the copayment for eye exam. You say that you believe this visit should be covered
with $0 copayment. The Plan denied your request. The Plan says the copayment amount you are being charged
is correct.
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 $25
copayment for diagnostic eye exam. This eye exam was provided due to non-routine diagnoses; therefore, the
diagnostic exam copayment applies to this claim.
You have been asked to pay $25 copayment for eye exam. Eye exam falls within the Vision 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 eye examination provided on December 20,
2019.