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

We decided that the Plan does not have to pay for an outpatient surgery provided on January 10, 2020 by an out of network (OON) provider.
You asked the Plan to pay for an outpatient surgery. 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 the member's primary care physician did not refer these services.
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 an outpatient surgery provided on January 10, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Simvastatin tablets.
You asked the Plan to pre-approve self-administered drugs. You say that you are appealing. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Simvastatin tablets.
Benefits for self-administered drugs 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 fordrug testing services provided to the enrollee on December 3, 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 Current Procedural Terminology (CPT) code 80307 and Healthcare Common Procedure Coding System (HCPCS) G0482 remain 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 the denied codes is:CPT 80307:Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry analyzers (e.g., utilizing immunoassay [e.g., EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (e.g., GC, HPLC), and mass spectrometry either with or without chromatography, (e.g., DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service,HCPCS G0482:Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed 
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 inthis case were not coded correctly. Our coding reviewer found the medical records provided does not include and evaluation and management note from the ordering physician the help establish a relationship between the enrollee and the ordering physician ofthe lab service to validate the physician is treating the patient for a specific medical problem warranting the ordering of tests. As a result, these services 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 services have not been met.Therefore, we decided that the Plan does not have to pay fordrug testing services provided to the enrollee on December 3, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for personal care services (T1019) and supplies (A9270) provided from March 23, 2019 to July 22, 2019.
You asked the Plan to pay for personal care services and supplies. You say that you were told this would be covered. The Plan denied your request. The Plan says this was non-covered custodial care.
The Plan must follow Medicare rules. Medicare rules say that custodial care is not covered. We looked at the file and Medicare rules. The services at issue are custodial in nature. Based on this information, we decided that Medicare rules for coverage of personal care services and supplies have not been met. Therefore, we decided that the Plan does not have to pay for personal care services (T1019) and supplies (A9270) provided from March 23, 2019 to July 22, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the ostomy supplies provided from January 23, 2020 to March 2, 2020. You asked the Plan to waive the coinsurance for the ostomy supplies. You say that you were never told you would have to start paying for your ostomy supplies after 22 years of not having to pay for the supplies. 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 20% coinsurance for prosthetic devices and medical supplies. You have been asked to pay a total of $119.92 for the ostomy supplies. The ostomy supplies fall within the "Prosthetic devices and related 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 coinsurance for the ostomy supplies provided from January 23, 2020 to March 2, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for myocardial perfusion imaging provided on
January 6, 2020.
You asked the Plan to waive the copayment for myocardial perfusion imaging. You say that you thought that
you were only receiving a stress test. 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 diagnostic radiology services.
You have been asked to pay a $250 copayment for myocardial perfusion imaging. Myocardial perfusion
imaging 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 myocardial perfusion imaging provided on January 6, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient skilled nursing facility (SNF) care.
You asked the Plan to pre-approve continued SNF care. You say that you are requesting a reconsideration of
the Plan's denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage
of continued inpatient skilled nursing facility care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is not covered.
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 continued SNF care. Our reviewer says
continued inpatient skilled nursing facility care is not medically necessary. Our physician reviewer found that
the enrollee does not require skilled nursing or skilled therapy services on a daily basis. Additionally, the
enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled
nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve continued inpatient skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foradvance careplanning services (CPT 99497) provided to the enrollee on June 6, 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 Current Procedural Terminology (CPT) code 99497 remains 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 99497 is "Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate."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 the medical records provided do not include documentation of the time spent providing advance care planning, 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 services have not been met.Therefore, we decided that the Plan does not have to pay foradvance care planning services (CPT99497) provided to the enrollee on June 6, 2019..
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis, bitewings, and periodic oral evaluation provided on February 4, 2020 by an OON provider.
You asked the Plan to pay for the prophylaxis, bitewings, and periodic oral evaluation. You say that in-network and out-of-network preventive services are listed as the same coverage. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that the total enrollee liability was applied 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, you are responsible for the difference between the billed amount and allowed amount when the services are received OON. Therefore, we decided that the Plan does not have to pay for the prophylaxis, bitewings, and periodic oral evaluation provided on February 4, 2020 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora knee orthosis provided to the enrollee on January 15, 2020.You asked the Plan to pay for the orthosis. You say that this should be paid for.The Plan denied your request. The Plan says the documentation submitted did not indicate the provider discussed the need for the billed supply code; therefore the billed supply code cannot be verified.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:HCPCS L1833:Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated, off-the shelf HCPCS L2397:Addition to lower extremity orthosis, suspension sleeve 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 orthosis. Our reviewer says that the services at issue in this case were not coded correctly. Our coding reviewer found the medical records provided does not include sufficient information to meet Medicare's criteria to substantiate/validate the necessity for the type of Durable Medical Equipment provided to ENROLLEE and billed to her health plan.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 orthosis have not been met.Therefore, we decided that the Plan does not have to pay fora knee orthosis provided to the enrollee on January 15, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean inpatient skilled nursing facility (SNF) care admission.You asked the Plan to pre-approveSNF care. You say that an inpatient skilled nursing facility care admission is medically necessary.The Plan denied your request. The Plan says you do not meet criteria for coverage of an inpatient skilled nursing facility care admission.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.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 SNF care. Our reviewer says that an inpatient skilled nursing facility care admission is not medically necessary. Our physician reviewer found that you do not require skilled nursing or skilled therapy services on a daily basis. Additionally, you do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approvean inpatient skilled nursing facility (SNF) care admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the surgical removal of erupted tooth number 28 (D7210).
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says the records indicate that tooth number 28 has been previously extracted.
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 Plan covers dental extractions when medically necessary and reasonable. 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 this service. Our reviewer says the surgical removal of tooth number 28 is not medically necessary. Our physician reviewer found the documentation submitted appears to indicate that tooth number 28 is no longer present. We looked at this physician's review, the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pre-approve the surgical removal of erupted tooth number 28 (D7210).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing services provided on December 18, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the billed code cannot be verified.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering physician's intent that the tests 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 forthe drug testingservices provided on December 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office visit services provided to the enrollee on January 14, 2020. 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 the rendering provider is no longer credentialed or eligible for Medicare/Medicaid billing of services. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rendering provider is not eligible to bill Medicare. The Plan did not pre-approve the services. We found no exception that would require the Plan to pay for these items/services. 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 office visit services provided to the enrollee on January 14, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for observation care (99217) provided on January 4, 2018.You asked the Plan to pay for the observation care. You say that you would like reconsideration because you did not receive proper notice of the member's benefit determination.The Plan denied your request. The Plan says this claim was received past the 12 month timely filing time frame.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service.The record shows that a claim for the observation care was not filed until January 29, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay for observation care(99217) provided on January 4, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve quick release axles identified with code K0108.You asked the Plan to pre-approve quick release axles. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested items are not medically necessary.The Plan follows Medicare rules. Medicare rules say that items identified with code K0108 are only covered for certain indications. 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 quick release axles. Our reviewer says that the documentation does not support that the requested quick release axles are medically reasonable or necessary. Our physician reviewer found you are noted to need assistance with toileting, dressing, grooming, bathing, meal prep and are independent with eating. A vendor seating evaluation notes left and right shoulder mobility limitations, limited endurance, weakness or all extremities. The documentation does not support that the quick release axles are reasonable and necessary for the diagnosis or treatment or illness or injury or to improve the functioning of a malformed body member.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of quick release axles have not been met.Therefore, we decided that the Plan does not have to pre-approve quick release axles identified with code K0108.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Osphena 60mg tablets. You asked the Plan to pre-approve Osphena. You say that Osphena is medically necessary. The Plan denied your request. The Plan says this type of drug is not eligible for coverage under the Part B medical benefit. The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Osphena 60mg tablets.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe percutaneous transcatheter mitral valve repair (TMVR) rendered on November 7, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claim was not billed correctly.The Plan must follow Medicare rules. The rules say that TMVR is covered for a non-FDA approved indication when part of a clinical trial.We looked at the file and Medicare rules. The file shows that the services were rendered as part of a clinical trial but were not billed with the appropriate modifier to signify the clinical trial. 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 percutaneous transcatheter mitral valve repair (TMVR) rendered on November 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME and related supplies provided on August 29, 2019.
You asked the Plan to waive the coinsurance for DME and related supplies. You say that you already paid and disagree with the additional 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 20% coinsurance for DME and related supplies. You received DME and related supplies on August 29, 2019. The total allowed amount is $170 and 20% of that is $34. You have been asked to pay the total coinsurance amount of $34 for DME and related supplies. DME and related supplies fall within the DME and related 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 coinsurance for DME and related supplies provided on August 29, 2019.