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

We decided that the Plan does not have to pay for pathology services provided on May 29, 2019.
You asked the Plan to pay for the pathology services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
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 pathology services provided on May 29, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two additional extractions and immediate mandibular denture provided on November 8, 2019.You asked the Plan to pay for the two additional extractions and immediate mandibular denture. The Plan denied your request. The Plan says the benefits for extractions have been satisfied and the frequency limitation has been exceeded. The Plan also says that you are responsible for a 70% coinsurance for the immediate mandibular denture, and the service was processed correctly.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, extractions are limited to two procedures per calendar year. The record shows that you received extractions on October 25, 2019 and November 8, 2019, two of which were covered by the Plan, and your extractions benefit was then exhausted. The contract also clearly states that you are responsible for a 70% copay for immediate dentures when the service is received by an in-network provider. The record shows that the service was processed correctly according to your plan benefits.Therefore, we decided that the Plan does not have to pay for the two additional extractions and immediate mandibular denture provided on November 8, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit and urinalysis provided on January 10, 2020.
You asked the Plan to waive the copayment for the office visit and urinalysis. You say that your insurance card states a $45 copayment for a specialist visit. You say that no exam was done. 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 $45 for each Medicare-covered visit with an in-network specialist and $10 per day, per in-network provider, for Medicare-covered lab services. You have been asked to pay a $45 copayment for the office visit. You have also been asked to pay $2.25, which is less than the standard $10 copayment for the urinalysis. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The urinalysis 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 pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the office visit and urinalysis provided on January 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for dialysis provided from January 1, 2020 to February 29, 2020.You asked the Plan to waive the coinsurance for dialysis. You say that you disagree with the charges.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that Medicare plan name members must pay 20% coinsurance for services to treat kidney disease. You received dialysis from January 1, 2020 to February 29, 2020. The total allowed amount is $15,913.80 and 20% of that is $3,183.You have been asked to pay the total coinsurance amount of $3,183 for dialysis. Dialysis 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 fordialysis provided from January 1, 2020 to February 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from October 9, 2019 to October 16, 2019.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you disagree with the additional 3 day 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 $345 copayment per day for days 1-5 for inpatient hospital care. The medical records show that you had an inpatient hospital stay from October 9, 2019 to October 16, 2019. Therefore, you are responsible to pay a $345 copayment for days 1-5 (October 9, 2019 to October 13, 2019). $345 (copayment) x 5 (inpatient days) = $1,725. You have been asked to pay the total copayment amount of $1,725 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital 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 inpatient hospital stay provided from October 9, 2019 to October 16, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for initial hospital care (99221) provided December 29, 2019.You asked the Plan to pay for the hospital care. You say that the services were medically necessary.The Plan denied your request. The Plan says the claim was submitted with an invalid modifier.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 99221 is not supported in the medical record. Specifically, per the National Physician Fee Schedule Relative Value File, Code 99221 does not include a professional/technical component. Application of such a modifier is invalid. Based on this information, we decided that Medicare rules for coverage of the hospital care have not been met.Therefore, we decided that the Plan does not have to pay for initial hospital care (99221) provided December 29, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for arthroscopy (29824) provided on November 26, 2019.You asked the Plan to pay for the arthroscopy. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the documentation submitted does not support the billed 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.In this case, the CPT Code Manual definition of code 29824 is arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface (Mumford procedure). 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 arthroscopy. Our reviewer says that CPT code 29824 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not include enough documentation to corroborate that an Arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface (Mumford procedure) being performed on November 26, 2019, therefore this service cannot be verified.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 arthroscopy have not been met.Therefore, we decided that the Plan does not have to pay for arthroscopy (29824) provided on November 26, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids purchased on October 30, 2019.You asked the Plan to pay for the hearing aids. You say that this should be processed and paid.The Plan denied your request. The Plan says that the hearing aid must be purchased through Epic Hearing to be covered.Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when received from a network provider. We looked at the file and the Plan's rules. The file indicates you received the hearing aids from an out-of-network provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met.Therefore, we decided that the Plan does not have to pay for the hearing aids purchased on October 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit rendered by a chiropractor on January 6, 2020.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 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. The file shows that the provider submitted a claim for procedure code 99213 (office visit).Therefore, we decided that the Plan does not have to pay for the office visit rendered by a chiropractor on January 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on June 22, 2019.
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 payable.
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 noncovered visit are
likewise noncovered. Therefore, we decided that the Plan does not have to pay for the laboratory services
provided on June 22, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for an inpatient hospital stay from December 18, 2019 to December 23, 2019.
You asked the Plan to waive the copayments for an inpatient hospital stay. You say that you disagree with the charges because you were in the hospital longer due to waiting on approval. 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 $295 copayment per day for days 1-5 for inpatient hospital care. You had an inpatient hospital stay from December 18, 2019 to December 23, 2019. Therefore, you are responsible to pay the $295 (copayment) for days 1-5 (December 18, 2019 to December 22, 2019). $295 (copayment) x 5 (inpatient days) = $1,475.00. You have been asked to pay the total copayment amount of $1,475.00 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital 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 copayments for an inpatient hospital stay from December 18, 2019 to December 23, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on January 9, 2020 through January 16, 2020.
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration because CPT code S9328 is payable per CMS. The Plan denied your request. The Plan says CPT code S9328 has a status code of I which is not valid for Medicare purposes.
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 S9328 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code S9328 has a status code of I. This means that CPT code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) provided on January 9, 2020 through January 16, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from July 15, 2019 to August 19, 2019.
You asked the Plan to pay for home health services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the claim was submitted with inappropriate home health data to process and pay claims.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the claim submitted does not include a valid type of bill code, revenue code, Q code or treatment authorization code. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from July 15, 2019 to August 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wrist hand orthosis provided on January 14, 2020.You asked the Plan to pay for the wrist hand orthosis (L3916). You say that the Plan should pay this claim.The Plan denied your request. The Plan says the documentation submitted did not indicate the provider discussed the need for the billed supply codes, therefore the billed supply codes cannot be verified. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The medical records do not mention or support medical necessity for the orthoses. Based on this information, we decided that Medicare rules for coverage of the wrist hand orthosis (L3916) have not been met.Therefore, we decided that the Plan does not have to pay for the wrist hand orthosis provided on January 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services provided from January 13, 2020 to January 22, 2020.
You asked the Plan to pay for the infusion services. The Plan denied your request. The Plan says the code is not valid for Medicare purposes.
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 S9500 is Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 24 hours; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment.
We find that CPT code S9500 is not valid for Medicare purposes. Medicare uses another code for the reporting of, and payment for, these services. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy services provided from January 13, 2020 to January 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown provided on December 9, 2019.
You asked the Plan to pay for the crown. You say that you called prior to the appointment asking for the crown to be approved, and were told the crown was not needed. The Plan denied your request. The Plan says the tooth does not appear to have significant breakdown due to decay or trauma.
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 crown provided on December 9, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a vertebral corpectomy (63090 and 63091) and device insertion (22854) provided on October 3, 2019.
You asked the Plan to pay for the vertebral corpectomy and device insertion. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the services billed.
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 63090 is vertebral corpectomy (vertebral body resection), partial or complete, transperitoneal or retroperitoneal approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic, lumbar, or sacral; single segment. The CPT Code Manual definition of code 63091 is vertebral corpectomy (vertebral body resection), partial or complete, transperitoneal or retroperitoneal approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic, lumbar, or sacral; each additional segment (List separately in addition to code for primary procedure). The CPT Code Manual definition of code 22854 is insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to vertebral corpectomy(ies) (vertebral body resection, partial or complete) defect, in conjunction with interbody arthrodesis, each contiguous defect (List separately in addition to code for primary procedure). 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 vertebral corpectomy and device insertion. Our reviewer says that CPT codes 63090 and 63091 do not meet criteria for billing or reimbursement consideration. The medical records do not include documentation of vertebral corpectomy. Our reviewer found CPT code 22854 does not meet criteria for billing or reimbursement consideration. The medical records provided do not include documentation of an insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to vertebral corpectomy(ies) (vertebral body resection, partial or complete) defect, in conjunction with interbody arthrodesis, each contiguous defect (List separately in addition to code for primary procedure) being performed on October 3, 2019, therefore this service cannot be verified. 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 vertebral corpectomy and device insertion have not been met. Therefore, we decided that the Plan does not have to pay for a vertebral corpectomy (63090 and 63091) and device insertion (22854) provided on October 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient clinic visit provided on November 12, 2019 by an out of network (OON) provider.You asked the Plan to pay for outpatient clinic visit. You say that these services were medically necessary. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that there are in-network providers available within a reasonable distance to the member.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 outpatient clinic visit provided on November 12, 2019 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 moderate sedation services rendered on September 30,
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 Plan must follow Medicare rules. The rules say that a professional
component (PC)/technical component (TC) indicator of 3 represents TC only codes.
We looked at the file and Medicare rules. The provider submitted a claim for procedure code 99153. This code
has a PC/TC indicator of 3 and no payable professional component. 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 moderate sedation services rendered on September 30, 2019.