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

We decided that the Plan does not have to waive the copayment for a SNF stay provided from December 30, 2019 to January 22, 2020.
You asked the Plan to waive the copayment for a SNF stay. You say that you were not informed that you would owe a copayment and would have left sooner if you had known. 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 $0 copayment for days 1-20 and a $172 copayment for days 21-100 for SNF care. You had a SNF stay from December 30, 2019 to January 22, 2020. You are not being charged a copayment for days 1-20 (December 30, 2019 to January 18, 2020). You are responsible to pay a $172 copayment for days 21-23 (January 19, 2020 to January 21, 2020). $172 (copayment) x 3 (SNF days) = $516. You have been asked to pay the total copayment amount of $516 for a SNF stay. A SNF stay falls within the SNF 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 a SNF stay provided from December 30, 2019 to January 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora physician visit provided on October 13, 2018.You asked the Plan to pay forphysician visit. You say that you sent this claim in a timely manner.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this claim was not submitted within the timely filing limit.The Plan follows Medicare rules. The rulessay 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 physician visit was not filed until February 18, 2020. This means that more thanone 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 fora physician visit provided on October 13, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider
You asked the Plan to pay for the services. The Plan denied your request. The Plan says out-of-network services are not covered.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services provided to the enrollee on October 14, 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 per the Outpatient Hospital Services MUE value of 1 for CPT code 19125 and the MUE Adjudication Indicator value is 2 for date of service edit, we find the Medicare rule for payment of two (2) units of CPT code 19125 has not been met.
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 19125 is "Excision of breast lesion identified by preoperative placement of radiological marker, open; single lesion." 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 19125 was not billed appropriately per the Medically Unlikely Edits rule associated with the code. An MUE for a HCPCS/CPT code is the maximum number of units of service (UOS) under most circumstances allowable by the same provider for the same beneficiary on the same date of service. The ideal MUE value for a HCPCS/CPT code is the unit of service that allows the vast majority of appropriately coded claims to pass the MUE. CPT 19125 has an MUE allowable of 1 unit. The provider billed 2 units of 19125, therefore the Medicare rule for payment of MUE allowable units has not been met. 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 outpatient hospital services provided to the enrollee on October 14, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a problem focused detailed and extensive oral evaluation.
You asked the Plan to pre-approve the problem focused detailed and extensive oral evaluation. You say that the medicine you took that cracked your tooth did not have an expiration date. You also say that you are not asking Medicare to pay for this service. 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. Though the Plan offers a dental benefit in excess of Medicare coverage, problem focused detailed and extensive oral evaluation is not among those covered under this benefit. The contract clearly states that routine preventive dental care and periodic oral or comprehensive exams are the only exams that are covered by the Plan. Therefore, we decided that the Plan does not have to pre-approve a problem focused detailed and extensive oral evaluation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for urgently needed services.
You asked the Plan to waive the copayment for urgently needed services. You say that you should not owe a copayment for urgent care services. 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 $40 copayment for out-of-network urgently needed services provided by a specialist. You received urgently needed services from an out-of-network specialist. Therefore, you are responsible to pay the $40 copayment. You have been asked to pay a $40 copayment for urgently needed services. Urgently needed services fall within the urgently needed 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 urgently needed services.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Prolia. You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says that the use of the drug requires that the enrollee does not have uncorrected pre-existing hypocalcemia.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Prolia. Our physician reviewer found that the enrollee has a past medical history of osteoporosis and a stress fracture of the metatarsal as documented in medical records. Laboratory data showed a calcium level of 10.5 mg/dL. Laboratory documentation shows no evidence of hypocalcemia. The documentation does support that Prolia is safe and effective for the enrollee. The documentation does support that Prolia is medically reasonable and necessary for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have been met. Therefore, we decided that the Plan has to pre-approve Prolia.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (36415, 80053, 82306, 83036, 84439, 84443, and 84480) provided on December 9, 2019 by an out of network (OON) provider.
You asked the Plan to pay for OON laboratory services. You say that you did not know these services required a referral. The Plan denied your request. The Plan says these services were not authorized.
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 laboratory services (36415, 80053, 82306, 83036, 84439, 84443, and 84480) provided on December 9, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for nuclear imaging provided by on December
27, 2019.
You asked the Plan to waive the copayment for nuclear imaging. You say that you should only owe a $50
copayment. 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 $225
copayment for each advanced imaging service.
You have been asked to pay a $225 copayment for nuclear imaging. Nuclear 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 nuclear imaging provided by on December 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services.
You asked the Plan to pay for the office visit. You say that you would like reconsideration because the member has been seen by this provider since 2017. The Plan denied your request. The Plan says services for the enrollee's diagnosis can be provided by a contracted, in network provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy services provided.
You asked the Plan to pay for home infusion therapy services. You say that you believe that you are in-network with the Plan. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the code billed is not valid for Medicare purposes and is not payable.
The Plan must follow Medicare rules. Medicare rules say that procedure code S9348 is not valid for Medicare purposes and is not payable. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home infusion therapy services have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy services provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia provided on October 23, 2018.
You asked the Plan to pay for anesthesia. You say that the claim should have been submitted to the Plan first. You say that the decision should be reversed. The Plan denied your request. The Plan says you must submit your claim to us within one year of the date you received the service, item, or drug.
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 anesthesia was not filed until December 19, 2019. 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 anesthesia provided on October 23, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says nonemergent,
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 physician's services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and garment
(E0667).
You asked the Plan to pre-approve a pneumatic compression device and garment. You say that you ask for
reversal of the denial after review of the enclosed documents as this enrollee has demonstrated a medical need
and unique clinical condition which meets the criteria of the provider. The Plan denied your request. The Plan
says the enrollee does not meet the LCD criteria for an advanced lymphedema pump as there is no failed four
week trial of a basic pneumatic compression device of either E0650 or E0651.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily,
multiple-hour home usage of the E0650 or E0651 is required.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting,
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device
(E0652) and garment (E0667).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve retreatment of previous root canal therapy (D3348), surgical procedure for isolation of tooth with rubber dam (D3910), canal preparation and fitting of preformed dowel or post (D3950), and drugs or medicaments dispensed in the office for home use (D9630).You asked the Plan to pre-approve the retreatment of previous root canal therapy, surgical procedure for isolation of tooth, canal preparation and fitting of preformed dowel or post, and drugs or medicaments dispensed in the office. You say that the Plan's dental benefit documents say these services are covered. These services need to be provided as soon as possible.The Plan denied your request. The Plan says these services are not covered.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 pre-approveretreatment of previous root canal therapy (D3348), surgical procedure for isolation of tooth with rubber dam (D3910), canal preparation and fitting of preformed dowel or post (D3950), and drugs or medicaments dispensed in the office for home use (D9630).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for more than 30 minutes of hospital discharge day management services (99239) provided on September 10, 2019.
You asked the Plan to pay for the hospital discharge day management services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted discharge summary does not support hospital discharge day management of more than 30 minutes was performed.
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 99239 is hospital discharge day management; more than 30 minutes. We find that CPT code 99239 is not supported in the medical record. Specifically, the record does not indicate that more than 30 minutes of hospital discharge day services were rendered. Based on this information, we decided that Medicare rules for coverage of the hospital discharge day management services have not been met. Therefore, we decided that the Plan does not have to pay for more than 30 minutes of hospital discharge day management services (99239) provided on September 10, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the services (CPT 69220) you received on October 29, 2019.You asked the Plan to waive the copayment. You say that you should only have a $50 copayment.The Plan denied your request. The Plan says the claim processed 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 $300 copayment for each outpatient surgery procedure. Review of the file shows that you were provided services on October 29, 2019. The services in question are considered surgical services according to the American Medical Association (AMA). Per your contract with plan name, there is a $300 copayment for outpatient surgery. This cost sharing is a contractual obligation that you agreed to pay when you enrolled in plan name. However, the Medicare allowed amount for these services was $189.62. Given that the allowed amount was less than the $300 copayment, you have been asked to pay $189.62 for these services. This means that you have been asked to pay the correct amount based on your contract with the Plan.Therefore, we decided that the Plan does not have to waive the copayment for the services (CPT 69220) you received on October 29, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hereditary cancer panel provided on August 16, 2019.
You asked the Plan to pay for the testing services. You say that test results can help people make informed decisions about managing their health care. The Plan denied your request. The Plan says the services are not a Medicare benefit for the diagnoses listed on the claim.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The testing at issue in this appeal was requested for screening purposes. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the hereditary cancer panel provided on August 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have does not have to pay for 30 of the 60 minutes of acupuncture treatment provided on each date of service (the 2 additional units of 97811) from June 5, 2019 to June 26, 2019.
You asked the Plan to pay for 30 of the 60 minutes of acupuncture treatment provided on each date of service (the 2 additional units of 97811). You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the record does not support the billed services.
The rules say that acupuncture services are not covered by Medicare. However, the Plan offers an acupuncture benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
We looked at the case file and the Plan's rules for coverage. Based on this information, we decided that the Plan's rules for coverage of these services have not been met. Specifically, the acupuncture treatment at issue is not covered by the Plan as it was not provided on the same date of surgery. Therefore, we decided that the Plan does not have does not have to pay for 30 of the 60 minutes of acupuncture treatment provided on each date of service (the 2 additional units of 97811) from June 5, 2019 to June 26, 2019.