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

We decided that the Plan does not have to pre-approve an interstitial continuous glucose monitor (A9278, A9277, A9276). You asked the Plan to pre-approve an interstitial continuous glucose monitor (A9278, A9277, A9276). You say that you need a CGM to help you live safer.The Plan denied your request. The Plan says they will approve a CGM but these codes are not used to bill for supplies used with a covered therapeutic continuous glucose monitor.The Plan must follow Medicare rules. Medicare rules say providers must report services correctly. Procedures should be reported with the CPT code that describes the services performed. You can find this rule in the Medicare National Correct Coding Initiative Manual, Chapter I(A).We looked at review the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an interstitial continuous glucose monitor (A9278, A9277, A9276) have not been met.While the Plan is approving the CGM (K0554, K0553)we decided that the Plan does not have to pre-approve an interstitial continuous glucose monitor (A9278, A9277, A9276).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for eye surgery provided on January 28, 2020.
You asked the Plan to waive the copayment for eye surgery. You submitted your bill for review. You say that you don't understand why you are responsible to pay the copayment. 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 $75 copayment for each Medicare-covered ambulatory surgical center visit. You have been asked to pay a $75 copayment for eye surgery. The eye surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 eye surgery provided on January 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on January 2, 2020.
You asked the Plan to pay for drug test. You say that you have submitted a valid physician laboratory requisition form. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the documentation submitted does not include a valid physician order, lab requisition, or medical records stating exactly which tests were to be performed.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a valid physician order or clear intent to order the specific lab service billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug test have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on January 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital discharge day management; more than 30 minutes (CPT Code 99239) inpatient hospital care on December 26, 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 services are not supported by the records.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Current Procedural Terminology (CPT) code 99239 (1 Unit) remains not supported. The submitted discharge summary does not support hospital discharge day management of more than 30 minutes was performed. A documented duration of time of 31 minutes or more is required to support this code. Therefore, the billed service cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information. We have insufficient documentation to corroborate the services so we can confirm Medicare coverage has been met.Therefore, we decided that the Plan does not have to pay for hospital discharge day management; more than 30 minutes (CPT Code99239) inpatient hospital care on December 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) knee orthosis, LT, (L1833) suspension sleeve, LT (L2397) provided December 10, 2019. You asked the Plan to pay for the orthoses. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says there is no evidence of an established relationship between the enrollee and the ordering physician, there was no claims submitted for an evaluation and management service and there is no evidence of a prior telehealth service with the ordering physician as required per CMS guidelines.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the non-covered visit are likewise non-covered. Therefore, we decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) knee orthosis, LT, (L1833) suspension sleeve, LT (L2397) provided December 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for hemodialysis provided from January 3, 2020 through February 3, 2020. You asked the Plan to waive the coinsurance for hemodialysis. You say that you cannot afford the cost. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for Medicare-covered dialysis services within the service area when ordered by your PCP. You have been asked to pay $55.20, which is 20% of the allowed amount for each hemodialysis visit. The allowed amount is $276 ($20% x $276 = $55.20). The total amount you owe is $717.60 ($55.20/visit x 13 visits = $717.60). Hemodialysis falls within the "Services to treat kidney disease" 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 coinsurance for hemodialysis provided from January 3, 2020 through February 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on August 28, 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 procedure code G0482 is not supported.
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 G0482 is definitive drug testing, 15-21 drug classes.
We find that CPT code G0482 is not supported in the medical record. Specifically, there is no documentation
of testing of 15-21 drug classes. Based on this information, we decided that Medicare rules for coverage of
these services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing
rendered on August 28, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound provided on March 4, 2020.
You asked the Plan to waive the copayment for the ultrasound. You say that you were told that all pre- and post- services would be covered in full. 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 $55 copayment for each Medicare-covered standard x-ray and ultrasound. You have been asked to pay a $55 copayment for the ultrasound. The ultrasound falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. Please note, there is no provision in the contract which indicates a copayment would be waived if performed as a pre-operative or post-operative service to a surgical procedure.
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 ultrasound provided on March 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for initial hospital care (99222) provided on November 21, 2019. You asked the Plan to pay for the initial hospital care. You say that you would like reconsideration because this service was billed with the correct place of service code.The Plan denied your request. The Plan says the member was no in an inpatient status for this date of service.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 99222 is not supported in the record. Specifically, the record indicates that the member was not in an inpatient stay on this date of service.  The member's claim history indicates that they were in an outpatient hospital observation status on this date of service. Based on this information, we decided that Medicare rules for coverage of the initial hospital care have not been met.Therefore, we decided that the Plan does not have to pay for initial hospital care (99222) provided on November 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on January 17, 2020 by an out-of-
network provider.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the
denied charges. The Plan denied your request. The Plan says you do not have out-of-network benefits.
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 January 17, 2020 from an out-of-network
provider. Your EOC states, to be covered in-network, you need to use a provider that is contracted with the
Plan's dental vendor to provide supplemental dental services. Care rendered by a provider that is not part of the
Plan's supplemental dental network is not covered. 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 dental
services provided on January 17, 2020 by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient consultation provided on January 18, 2020.You asked the Plan to pay for the inpatient consultation. You say that the plan is required to reimburse 90% of the billed charges according to Federal and State law. This doctor has no contract and is not obligated to accept reduced rates.The Plan denied your request. The Plan says it is only required to cover what Medicare covers. The billed code is not payable by Medicare.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.CPT code 99254 has a status indicator of "I" in the Medicare Physician Fee Schedule, meaning that it is invalid for Medicare billing purposes. Based on this information, we decided that Medicare rules for coverage of the inpatient consultation have not been met.Therefore, we decided that the Plan does not have to pay for the inpatient consultation provided on January 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided to the enrollee from September 7, 2019 through September 10, 2019.You asked the Plan to waive the copayment for inpatient hospital care. You say that you did not know there was a copayment for a hospital stay.The Plan denied your request. The Plan says the claim was processed accordingly with the member's 2019 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 shows that the enrollee was admitted on September 7, 2019 and discharged on September 10, 2019. You were asked to pay a $250 copayment per day from September 7, 2019 through September 9, 2019, days 1-3 of your inpatient hospital care. You were discharged on September 10, 2019 and there was no copayment charge for the day of discharge. Per your contract there is a $250 copayment per day required for days 1-4. 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 for inpatient hospital care provided to the enrollee from September 7, 2019 through September 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for dermatology services provided on May 9, 2019 by an out of network (OON) provider.You asked the Plan to pay for dermatology services. You say that you called and asked if they took your insurance. You say that you were told that your insurance was accepted.The Plan denied your request. The Plan says no prior authorization was 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 dermatology services provided on May 9, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan partially has to pay forgingival irrigation -per quadrant (D4921 x 4) and drugs or medicaments dispensed in the office for home use (D9630 x 2)provided on October 23, 2019 and October 30, 2019 by an in-network 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 services are not a covered benefit under the 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.We decided that the Planhas to pay fordrugs or medicaments dispensed in the office for home use (D9630 x 2).Your EOC shows that you have coverage for anesthesia; therefore, drugs or medicaments dispensed in the office for home use (D9630 x 2 should be approved. Your EOC states, Anesthesia -Frequency/Limitations -As needed with covered procedures (Necessary anesthesia with covered service).Therefore, we decided that the Plan has to pay fordrugs or medicaments dispensed in the office for home use (D9630 x 2)provided on October 23, 2019 and October 30, 2019 by an in-network provider. We also decided that the Plandoes not have to pay forgingival irrigation -per quadrant (D4921 x 4).Review of the file show that gingival irrigation -per quadrant (D4921 x 4) is not listed in your EOC as a covered benefit; therefore, it is not covered.Therefore, we decided that the Plan does not have to pay forgingival irrigation -per quadrant (D4921 x 4) provided on October 23, 2019 and October 30, 2019 by an in-network provider.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/orsend us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction services (92015) provided December 3,
2019.
You asked the Plan to pay for the refraction services. You say that refractory exams have never been used to
obtain glasses and was never a routine exam. You will still require eye exams that include refractory tests in
order for the doctor to know the best way to treat your problem. The Plan denied your request. The Plan says
this service is not covered under the plan 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. The Plan does not cover refraction services.
We looked at the file and the Plan's rules. Refraction services are not covered under the plan benefits. Based on
this information, we decided that the Plan's rules for coverage of the refraction services have not been met.
Therefore, we decided that the Plan does not have to pay for the eye refraction services (92015) provided
December 3, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a chest x-ray (71046) provided February 14, 2020.You asked the Plan to waive the copayment for the chest x-ray. You say that the copayment should be waived.The Plan denied your request. The Plan says the correct cost-sharing 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 X-rays. You have been asked to pay a $20 copayment for the chest x-ray. The chest x-ray falls within the X-rays 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 a chest x-ray (71046) provided February 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the new patient office visit (99203) provided on February 24, 2020.You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says this service is not a covered benefit under your contractual policy.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 pay for the new patient office visit (99203) provided on February 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for deep sedation/general anesthesia - 1st 15 minutes (D9222)
and deep sedation/general anesthesia each subsequent 15 minute (D9223) provided August 28, 2019 to
September 24, 2019.
You asked the Plan to pay for the sedation services. You say that the requirement for general anesthesia is
verified by an M.D. The need for dental work is verified by a respected DDS. I think we can dispense with the
idea that general anesthesia is a routine dental practice. The Plan denied your request. The Plan says seep
sedation/general anesthesia given for a dental procedure performed in an outpatient setting is not a covered
under the plan benefits.
Medicare generally does not cover dental services. The Plan follows the same rule.
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid
for by Medicare. Therefore, we decided that the Plan does not have to pay for deep sedation/general anesthesia
- 1st 15 minutes (D9222) and deep sedation/general anesthesia each subsequent 15 minute (D9223) provided
August 28, 2019 to September 24, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary.The Plan denied your request. The Plan says the enrollee's needs can be met at a different level of care.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does require skilled physical therapy and occupational therapy but based on the medical records provided the enrollee does not require treatment in an intensive rehabilitation therapy program.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.