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

We decided that the Plan does not have to waive the copayment for the destruction of a benign lesion provided on August 29, 2019.
You asked the Plan to waive the copayment for the destruction of a benign lesion. You say that you did not receive a surgical procedure. 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 $250 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You received the destruction of a benign lesion on August 29, 2019. The destruction of a benign lesion is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $250 copayment. You have been asked to pay a $250 copayment for the destruction of a benign lesion. The destruction of a benign lesion 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 the destruction of a benign lesion provided on August 29, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodic oral exam (D0120) bitewing x-rays (D0274) intraoral periapical first x-rays (D0220) intraoral periapical each additional x-rays(D0230) and prophylaxis (D1110) provided on September 5, 2019.
You asked the Plan to pay for the dental services. You say that you are appealing because you broke a part of your tooth and need a crown on tooth #15 and needed a cleaning. The Plan denied your request. The Plan says these services are not covered under the plan 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 for periodic oral exam (D0120) bitewing x-rays (D0274) intraoral periapical first x-rays (D0220) intraoral periapical each additional x-rays(D0230) and prophylaxis (D1110) provided on September 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injection services (CPT 64445) provided on March 15, 2019.You asked the Plan to pay for the services. You say that this should be paid for.The Plan denied your request. The Plan says CPT 64445 is not supported in the medical records submitted.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 64445 is "Injection, anesthetic agent; sciatic nerve, single."We asked our coding 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 services. Our reviewer says that the services at issue in this case were not coded correctly. Our coding reviewer found CPT code 64445 is not supported. The medical record does not contain evidence that this procedure was performed during this episode of care.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 services have not been met.Therefore, we decided that the Plan does not have to pay for injection services (CPT 64445) provided on March 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forurology services provided on June 25, 2019.You asked the Plan to pay forthe services. You say that this should be paid for.The Plan denied your request. The Plan says the records do 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 the denied codes is:CPT 57265:Combined anteroposterior colporrhaphy, including cystourethroscopy with enterocele repairCPT 57282:Colpopexy, vaginal; extra-peritoneal approachCPT 57267:Insertion of mesh or other prosthesis for repair of pelvic floor defect, each site (anterior, posterior compartment), vaginal approach We asked our coding reviewer to carefully review the casefile and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported in the records. Our coding reviewer found the issue in this case is that the procedure report submitted is for a different date of service. It cannot be verified that the codes reported were performed on the date of service in question. There were no medical records for the date of service provided.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 services have not been met.Therefore, we decided that the Plan does not have to pay forurology services provided on June 25, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on July 10, 2019.You asked the Plan to pay for the services. You say that this should be paid for.The Plan denied your request. The Plan says there is a more appropriate code to use -HCPCS G0482.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.In this case, the definition of code G0483 is "drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers, including, but not limited to, GC/MS and LC/MS and excluding immunoassays and enzymatic methods; qualitative or quantitative, all sources(s), includes specimen validity testing, per day, 22 or more drug class (es), including metabolite(s) if performed."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 services. Our reviewer says that the services at issue in this case were not coded correctly. Our physician reviewer found based on the medical records provided, 22 or more classes of drugs were not tested for on the drug screen analysis in question.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 services have not been met.Therefore, we decided that the Plan does not have to pay fordrug testing services provided to the enrollee on July 10, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided on June 11, 2019.You asked the Plan to pay for the services. You say that this should be paid for.The Plan denied your request. The Plan says Healthcare Common Procedure Coding System (HCPCS) G0483 (1 Unit) remains not supported.The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be covered.The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were to be performed. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay for drug testing services provided on June 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 21, 2019 by out of
network provider.
You asked the Plan to pay for wound care. You say that you would like this reprocessed for payment. The Plan
denied your request. The Plan says prior authorization was not obtained. The Plan says that the referring doctor
is also out-of-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the medical services provided on August 21, 2019
by out of network provider.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services rendered to you by the provider on April 30, 2019.You asked the Plan to pay forthese services. You say that you needed the services after breast cancer and a double mastectomy.The Plan denied your request. The Plan says the provider is not Medicare certified.The Plan must follow Medicare rules. The rules say that Medicare pays for services only when they are furnished by a provider orsupplier enrolled in the Medicare program.The file shows that the provider was not Medicare-certified during the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay forthe services rendered to you on April 30, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered from July 26, 2019 to August 2, 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 that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies.We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe home infusion therapy rendered from July 26, 2019 to August 2, 2019.Benefits for these services may be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids provided by "the general provider" on May 31, 2018.You asked the Plan to reimburse you for the hearing aids. You say that the hearing aids that were approved by the Plan did not meet your medical needs. The Plan denied your request. The Plan says Hearing aids must be ordered directly from "plans direct provider" 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 ordered directly from the "plans direct provider".We looked at the file and the Plan's rules. "the general provider"  is not a network hearing aid provider with the Plan. 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 reimburse you for hearing aids provided by "the general provider", onMay 31, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection provided on July 11, 2019 by the out of network provider.
You asked the Plan to pay for the surgical service. 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 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 provider in this case is not a network provider with the Plan. The referring provider is not a network provider either. 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 injection provided on July 11, 2019 by the out of network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for debridement of subcutaneous tissue (11042) provided by the doctor.
You asked the Plan to waive the copayment for debridement of subcutaneous tissue. You say that you were treated for a wound on your left calf and you were in pain for the next couple of days. You say after the bandages were taken off that the same procedure was performed again however your wound had still not healed. You say that you went to another doctor who told you not to use ace bandages. The Plan denied your request. The Plan says outpatient surgery services have a $250 copayment.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for outpatient surgery services. You have been asked to pay a $250 copayment for debridement of subcutaneous tissue. This service falls within the outpatient surgery services 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 debridement of subcutaneous tissue (11042) provided by the doctor.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered to the enrollee from July 15, 2019 to July 22, 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 that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered to the enrollee from July 15, 2019 to July 22, 2019.
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
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 a lumbar-sacral orthosis (L0650) provided to the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental extraction of tooth #9 (D7210) provided by the doctor.
You asked the Plan to pay for dental services. You say that you do not understand why this was denied. You were on a cruise and fell and broke your tooth and the doctor was the oral surgeon who extracted the tooth and did a necessary bone graft. The Plan denied your request. The Plan says this service is not a covered benefit.
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. The health plan contract says any services not listed under the Description of Benefits is not covered by the plan. 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 dental extraction of tooth #9 (D7210) provided by the doctor.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for radiology services (93886) provided July 26, 2019.You asked the Plan to waive the copayment for the radiology services. You say that the copayment should only be $20.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 $100 copayment for Radiological diagnostic services, not including X-rays.You have been asked to pay a $100 copayment for a Transcranial Doppler study. These radiology services fall within the Radiological diagnostic services, not including 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 radiology services (93886) provided July 26, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered to the enrollee from September 12, 2019 to September 19, 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 that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered to the enrollee from September 12, 2019 to September 19, 2019.
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services rendered to the enrollee by the provider on May 6, 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 there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 forthe laboratory services rendered on May 6, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on May 1, 2019 to May 3, 2019 by an out of network provider.
You asked the Plan to pay for physical therapy. You say that you are appealing with the referral and medical records. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and the referring physicians are also out-of-network with 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 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 May 1, 2019 to May 3, 2019 by the out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion provided on July 10, 2019 through July 19, 2019.
You asked the Plan to pay for the home infusion. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says procedure code 99601 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 99601 is not supported in the medical record. Specifically, per the 2019 Physician Fee Schedule, 99601 has a status code of "I." This means that 99601 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion have not been met. Therefore, we decided that the Plan does not have to pay for home infusion provided on July 10, 2019 through July 19, 2019.