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

We decided that the Plan does not have to pay for CPT codes 14301 and 14302 provided on March 12, 2019.You asked the Plan to pay forCPT codes 14301 and 14302. You say that the medical records support the billing of CPT code 14301.The Plan denied your request. The Plan says the medical records do not support the billing of CPT code 14301.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 14301 is Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm.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 CPT code 14301. Our reviewer says that the medical records do not support the billing of CPT code 14301. Our physician reviewer found the documentation describes an incisional hernia repair involving the removal of scar tissue and the placement of mesh. Measurements note the size of the hernia defect and the mesh used to cover/close the defect. There is no evidence that adjacent tissue was transferred or rearranged to close the defects in question. Therefore, the billing of CPT 14301 is not supported.Medicare rules also say that CPT code 14302 is a Type 1 add-on code and must be reported with a proper Primary Code. As the Primary code was denied for payment, CPT code 14302 is not eligible for payment.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CPT codes 14301 and 14302 have not been met.Therefore, we decided that the Plan does not have to pay forCPT codes 14301 and 14302 provided on March 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe observation care discharge provided on December 20, 2019.You asked the Plan to waive the copayment forthe observation care discharge. You say that the provider did not provide any service other than reviewing your chart and discharging you from the hospital. 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 a $40 copayment for each in-network specialist visit for Medicare-covered benefits. You have been asked to pay a $40 copayment for the observation care discharge. The observation care discharge falls within the "Physician/Practitioner services, including doctor'soffice visits" benefit category. The medical record shows that discharge instructions were given.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 agreedto pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment forthe observation care discharge provided on December 20, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for eye surgery provided on August 8, 2019.
You asked the Plan to waive the copayment for eye surgery. You say that the first procedure was incorrectly done. You say that you shouldn't have to pay twice. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 copayment for each Medicare covered outpatient hospital facility or ambulatory surgical center visit for surgery. You have been asked to pay a $200 copayment for eye surgery. Eye surgery 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 eye surgery provided on August 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on November 18, 2019.
You asked the Plan to pay for the orthoses. 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. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on November 18, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home health services rendered to the enrollee on September 6, 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 the Type of Bill (TOB) code 032x is required for home health services under a plan of treatment. We looked at the file and Medicare rules. The claim was not billed with a valid TOB code. 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 home health services rendered to the enrollee on September 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) purchases on November 8, 2019.
You asked the Plan to pay for the CGM. You say that you were told this was replaceable for medical necessity. The Plan denied your request. The Plan says repair or replacement of equipment damaged due to patient neglect is ineligible for coverage.
The Plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime of equipment in no case can be less than five years. You received a CGM on August 28, 2019, which is less than five years ago. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor (CGM) purchases on November 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mandibular advancement device.You asked the Plan to pre-approvea mandibular advancement device. Yousay that you have no similar device.The Plan denied your request. The Plan says that Medicare considers this item and a CPAP to be similar devices used for the same function.The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.The file shows that you have a continuous positive airway pressure (CPAP) device. A continuous positive airway pressure (CPAP) device serves the same purpose as a mandibular advancement device.Therefore, we decided that the Plan does not have to pre-approvea mandibular advancement device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy on tooth #20 and #21 (D3320) provided on July 26, 2019.You asked the Plan to pay for the endodontic therapy on tooth #20 and #21 (D3320). You say that the procedure was done because of an infection. You say this was medically necessary. The Plan denied your request. The Plan says the 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, the endodontic therapy on tooth #20 and #21 (D3320) are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the endodontic therapy on tooth #20 and #21 (D3320) provided on July 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) with cast metal framework.
You asked the Plan to pre-approve a maxillary partial denture. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says that a maxillary partial denture is not medically necessary due to a poor periodontal prognosis and advanced bone loss.
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 a maxillary partial denture when the services are 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 the maxillary partial denture. Our reviewer says that the enrollee does not meet criteria for coverage of a maxillary partial denture. Our physician reviewer found that there are only three teeth remaining on the upper arch (#6, #11 and #15). With only three remaining teeth, it is important to determine if a tooth supported appliance is appropriate. Stability of these teeth is critical for the long term stability of the remaining teeth as well as the appliance. The provided records did not include x-rays but did include a periodontal charting. The pockets on the abutment teeth are sufficiently deep (up to 7 mm). It is imperative to evaluate the extent of resolution of the periodontal condition following scaling and root planing prior to finding necessity for the requested partial denture. Follow up charting would be necessary to review along with x-rays to determine reasonableness and necessity for the requested metal frame tooth supported appliance. At the present time there can be no finding of medical necessity for the requested procedure.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the maxillary partial denture have not been met. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) with cast metal framework.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on October 25, 2019 by an out
of network (OON) provider.
You asked the Plan to pay for physician services. You say that these services were medically necessary. The
Plan denied your request. The Plan says the referring provider is out-of-network therefore the referral is
invalid.
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 physician services provided on October 25, 2019
by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forlaboratory services provided on January 28, 2019 and September 23, 2019.You asked the Plan to waive the copayments forlaboratory services. You say that you disagree with the charges because you were never charged in the past.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 $10 copayment for laboratory tests. You received laboratory services on January 29, 2019 and September 23, 2019. Therefore, you are responsible to pay a $10 copayment per each laboratory service. The total amount you owe is: $20. You have been asked to pay the total copayment amount of $20 for laboratory services. Laboratory services fall 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 copayments forlaboratory services provided on January 28, 2019 and September 23, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary or rest home visit for the evaluation and management of an established patient (99335) provided on October 10, 2019 by an out of network (OON) provider.
You asked the Plan to pay for a domiciliary or rest home visit. You say that the services were provided and payment should be rendered. The Plan denied your request. The Plan says prior authorization was not requested or received and the services were not emergent in nature. Therefore, coverage criteria has not been met.
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 a domiciliary or rest home visit for the evaluation and management of an established patient (99335) provided on October 10, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay fora laparoscopy provided on September 12, 2019 by an out of network (OON) provider.You asked the Plan to pay fora laparoscopy. You say that these services were medically necessary for the patient.The Plan denied your request. The Plan says no prior authorization was obtained.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 andpre-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 fora laparoscopy provided on September 12, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on November 18, 2019 by an out of network (OON) provider.You asked the Plan to pay for the OON drug testing. You say that this testing was ordered by the treating physician and you have no direct contact with the patient to obtain authorization.The Plan denied your request. The Plan says this enrollee is seeing a non-participating provider for these services. Coverage for these visits were denied as there are network providers available. As such, no payment can be made for the services ordered by this physician.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 drug testing services provided on November 18, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an upper airway stimulation device.You asked the Plan to pre-approve the device. You say that this is medically necessary.The Plan denied your request. The Plan says neither Medicare nor the health plan covers this item.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 pre-approve the device. Our reviewer says that the requested device is not considered medically reasonable and necessary in this case. Our physician reviewer found the LCD for this procedure lists the patient characteristics which must be met. Among them are, BMI less than 35. The patient's BMI is 36.8. Another is "No other anatomical findings that would compromise performance of device (e.g., tonsil size 3 or 4 per standardized tonsillar hypertrophy grading scale). According to the findings on endoscopic exam, the patient has sufficient hypertrophy of the tonsils to cause complete lateral obstruction. In addition there is redness and swelling in several structures of the upper airway. It appears that these anatomical findings would interfere with the operation of the device. Therefore the hypoglossal nerve stimulator is considered not medically necessary. 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 device have not been met.Therefore, we decided that the Plan does not have to pre-approve an upper airway stimulation device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe bitewing x-rays (D0274) provided on December 2, 2019.You asked the Plan to pay forthe dental service. You say that the x-rays should be covered. You say that the provider's office advised that the 12 month waiting period had passed. You also say that the provider's office advised the x-rays would be covered.The Plan denied your request. The Plan says bitewing x-rays are covered once every 12 months. The Plan also says that the frequency limit has been exceeded.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 and bitewing x-rays are listed as a covered service, the frequency limit for bitewing x-rays has been exceeded. The record shows that the Plan paid for this service that you received on December 13, 2018.Therefore, we decided that the Plan does not have to pay forthe bitewing x-rays (D0274) provided on December 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam provided on October 21, 2019.
You asked the Plan to waive the copayment for the eye exam. You say that you believe you had an annual eye exam. You say that you shouldn't have to pay a copayment for the visit. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment per visit for Medicare-covered exams to diagnose and treat diseases of the eye. You have been asked to pay a $40 copayment for the eye exam. The eye exam falls within the "Vision care" benefit category. The records show that the visit was for diagnostic purposes. 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 eye exam provided on October 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on October 3, 2019 by an out of network (OON) provider.You asked the Plan to pay forsurgical services. You say that you are appealing based on medical necessity.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 prior authorization was not obtained.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has topay 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 forthe medical services provided on October 3, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on September 10, 2019 to enrollee by an out of network (OON) provider.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 services were rendered byan out-of-network provider without 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 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 forthe medical services provided on September 10, 2019 to enrollee by an out of network (OON) provider.