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

We decided that the Plan does not have to waive the copayment for the ambulance services provided on July 15, 2019.You asked the Plan to waive the copayment for the ambulance services. The Plan denied your request. The Plan says that 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 $175 copayment for each non Medicare-covered ambulance stabilization when there is no transport. You have been asked to pay a $145 copayment for the ambulance services. The ambulance services fall within the non Medicare-covered ambulance stabilization when there is no transport benefit category. This means that you have been asked to pay less than the applicable copayment 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 ambulance services provided on July 15, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for four dental extractions provided on July 9, 2019.
You asked the Plan to pay for the dental extractions. You say that The Plan denied your request. The Plan says
that they covered up to the benefit maximum for extractions.
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 up to four
dental extractions per year.
We looked at the file and Medicare rules. The file indicates the plan has already covered and paid for four
dental extractions on this same date of service. The plan is not required to cover any additional extractions
beyond the plan limit. Based on this information, we decided that the Plan's rules for coverage of the dental
extractions have not been met. Therefore, we decided that the Plan does not have to pay for four dental
extractions provided on July 9, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forfinger surgery provided on August 21, 2019.You asked the Plan to waive the copayment forfinger surgery. You say that the report shows your share as $0. You say that you were erroneously charged $250.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 termsall cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for each ambulatory surgical center visit.You have been asked to pay a $250 copayment for finger surgery. Finger surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that you owe $0 for the doctorand the $250 copayment applies tothe facility. 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 forfinger surgery provided on August 21, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the CxBladder testing provided to the enrollee on June 19, 2019.
You asked the Plan to pay for the CxBladder testing. The Plan denied your request. The Plan says this is not a covered test.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 pay for the CxBladder testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that CxBladder is not a screening test for urothelial cancer. Cystoscopy and possible biopsy and upper tract imaging will still be necessary regardless of the results of CxBladder testing. Urinary biomarker tests such as CxBladder give significant false-negative results in patients with bladder cancer and are subject to false-positive results in others. Accuracy is poor for low-stage and low-grade tumors. To date, there are multiple urine markers that have improved sensitivity over cytology but there is lack of validation of clinical utility. Some of the recently developed markers aim to change the paradigm of urothelial diagnosis and follow-up by replacing or reducing the need of invasive investigations. Further prospective validations are needed to confirm these findings. 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 CxBladder testing have not been met. Therefore, we decided that the Plan does not have to pay for the CxBladder testing provided to the enrollee on June 19, 2019.
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 on June 4,
2019.
You asked the Plan to pay for home health services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the submitted claim is missing required information.
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 for this service has been billed incorrectly. The claim is missing required information regarding the
skilled services provided to the enrollee.. Therefore, we decided that the Plan does not have to pay for the home
health services provided to the enrollee on June 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse youfor the wheelchair ramp provided by "the provider" on June 11, 2019.You asked the Plan to reimburse youfor the wheelchair ramp. You say that the provider told you the wheelchair ramp would be covered by Medicare.The Plan denied your request. The Plan says wheelchair ramps do not primarily serve a medical purpose and are not covered by Medicare or the Plan.The Plan must follow Medicare rules.The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Medicare does not cover home modifications.Therefore, we decided that the Plan does not have to reimburse youfor the wheelchair ramp provided by "the provider" on June 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forrepair resin denture base (D5610) replace broken teeth (D5610) provided by "the doctor" September 20, 2018 to September 24, 2018.You asked the Plan to pay forthe denture repairs. You say that you assumed that you had $1,000 per year for dental. Dental issues can and does cause problems for your heart and health issues. You only have 3 teeth left.The Plan denied your request. The Plan says these services are not covered 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. Per the health plan contract the plan provided coverage for denture reline procedures, but does not cover for denture repairs.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 forrepair resin denture base (D5610) replace broken teeth (D5610) provided by "the doctor" September 20, 2018 to September 24, 2018
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee.
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 records do not indicate a clear provider intent to order the lab.
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, qualitative; any number of devices or procedures, by instrument chemistry and analyzers (e.g., utilizing immunoassay [EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (e.g., GC, HPLC), and mass spectrometry either with or without chromatography, (DAT, 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 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 (the lab test report and an unsigned lab requisition) there is no support for the coding of CPT 80307 and HCPCS G0482. There is no indication of a clear provider intent to order the lab collected. 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 for drug testing services provided to the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to the enrollee.
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 when performed by a chiropractor.
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 services were billed with codes 97012 (mechanical traction therapy), 97140-59 (manual therapy techniques), 97032 (electrical stimulation), and 99212-25 (office visit). Therefore, we decided that the Plan does not have to pay for the services rendered to the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor supplies provided.
You asked the Plan to pay for the continuous glucose monitor supplies. You say that the Plan should pay this claim. The Plan denied your request. The Plan says without the secondary qualifier ICD10 code medical necessity cannot be determined.
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. Medical records were requested but not received. Based on this information, we decided that Medicare rules for coverage of the continuous glucose monitor supplies have not been met. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor supplies provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for extraction (D7210) performed on October 8, 2019.
You asked the Plan to pay for the dental services. You say that your tooth could not be removed by your dentist as it was a partial tooth and the tooth had to be removed by a specialist piece by piece. The Plan denied your request. The Plan says the service is not a covered benefit under the plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 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. This service is not listed in your EOC as a covered benefit; therefore, it is not covered. Therefore, we decided that the Plan does not have to pay for extraction (D7210) performed on October 8, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for radiologic examination, abdomen; 2 views (CPT Code
74019) provided to the enrollee on March 25, 2019
You asked the Plan to pay for the services. You say that you are appealing for reconsideration of the denied
charges. The Plan denied your request. The Plan says this procedure code is not allowed because this service
was included in another service provided at the same time.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the services have not been met. The services were paid on date of service March 25, 2019. The plan received that claim on April 1, 2019 and paid
code 74022 on April 15, 2019. The services were also rendered by the doctor. Therefore, we
decided that the Plan does not have to pay for radiologic examination, abdomen; 2 views (CPT Code 74019)
provided to the enrollee on March 25, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on July 8, 2019.
You asked the Plan to pay for the physician's 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 physician's services provided on July 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for extracapsular cataract removal provided on August 19, 2019 and September 16, 2019.You asked the Plan to waive the coinsurance for extracapsular cataract removal. You say that you feel that the charges should be processed as in-network.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 50% coinsurance for out-of-network outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You received extracapsular cataract removal on August 19, 2019 and September 16, 2019.The provider is considered out-of-network. Therefore, you are responsible to pay 50% coinsurance per eachservice. The total amount you owe is: $895.28.You have been asked to pay the total coinsurance amount of $895.28 for extracapsular cataract removal. Extracapsular cataract removal 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 coinsurance forextracapsular cataract removal provided on August 19, 2019 and September 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary or rest home visit you provided on May 24, 2019.
You asked the Plan to pay for the domiciliary or rest home visit. 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. We looked at the file and the rules. You are 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 a domiciliary or rest home visit you provided on May 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate (E1390) and portable gaseous oxygen system, rental; home compressor used to fill portable oxygen cylinders; includes portable containers, regulator, flow meter, humidifier, cannula or mask, and tubing (K0738) provided by an out-of-network provider from June 19, 2019 through July 19, 2019.You asked the Plan to waive the coinsurance for the DME. You say that you are appealing your cost-share responsibility for the services you received.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received DME from an out-of-network provider, from June 19, 2019 through July 19, 2019. You are asked to pay 50% coinsurance for the DME. 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 foroxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate (E1390) and portable gaseous oxygen system, rental; home compressor used to fill portable oxygen cylinders; includes portable containers, regulator, flowmeter, humidifier, cannula or mask, and tubing (K0738) provided by an out-of-network provider from June 19, 2019 through July 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for patient lift, fixed system, includes all components/accessories (CPT E0640) provided to the enrollee from a non-contracted provider.
You asked the Plan to pay for the stair lift. You say that you are requesting reimbursement of services rendered. The Plan denied your request. The Plan says this request was for a stair lift, not a chair lift. The Plan states a stair lift (stairway elevator) is never covered by Medicare.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pay for patient lift, fixed system, includes all components/accessories (CPT E0640) provided to the enrollee from a non-contracted provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for assembly and operation of pump with oxygenator or heat exchanger (with or without ECG and/or pressure monitoring); each hour (CPT Code 99190) provided to the enrollee.
You asked the Plan to pay for the services. You say that these charges are for the perfusionist that set up and operated the heart lung machine for this patient's surgery. You state CPT code 99190 is for the set up and operation of the Heart Lung machine for the above patient's open heart surgery. You state it takes a half hour to an hour to set up Heart Lung Machine. You state the perfusionist is required to be in the operating room during the length of the procedure and per hospital protocol it is mandatory that the surgeon, anesthesiologist and perfusion transport the patient to the unit and be there until the patient is in stable condition. The Plan denied your request. The Plan says the Medicare rules have not been met.
The plan must follow Medicare rules. Medicare does not pay any provider or supplier other than the hospital for services furnished to the beneficiary while an inpatient in hospital, and this takes precedence over the claim system denial. These services and CPT codes are statutorily excluded by Medicare. The facility must furnish all necessary covered services to the beneficiary either directly or under arrangements made between the facility and outside vendors. The enrollee received the services in the facility during inpatient hospitalization, and payment for this service would be included in the part-A DRG payment to the facility. Payment for this service is the responsibility of the facility to any vendor. Any and all codes on this claim are denied, and in addition, previous payments to these providers for this member are subject to recoupment. Therefore, we decided that
the Plan does not have to pay for assembly and operation of pump with oxygenator or heat exchanger (with or without ECG and/or pressure monitoring); each hour (CPT Code 99190) provided to the enrollee.