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

We decided that the Plan does not have to pay forthe physician services (99309) provided on December 11, 2019.You asked the Plan to pay forthe physician services. You say that services were medically necessary.The Plan denied your request. The Plan says the services were not emergent or pre-authorized. There were network providers available.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 physician services (99309) provided on December 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fororal exam (D0140) intraoral periapical x-ray (D0220) and extraction of tooth 31 (D7210) provided December 3, 2019.You asked the Plan to waive the copayment forthe dental services. You say that you said the provider did not do it right. Please send a letter to the dentist and tell him what he did wrong. You have already paid the provider $352.The Plandenied your request. The Plan says this claim was processed correctly at the out of network level of 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). Your contract with the Plan clearly says that you must pay 50% of the allowable for the oral exam and the x-ray and 45% of the allowable for the extraction. If you go to an out of network provider your cost share may be higher.You have been asked to pay 387.90 for the dental services. The services fall within the dental 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 obligationyou agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment fororal exam (D0140) intraoral periapical x-ray (D0220) and extraction of tooth 31 (D7210) provided December 3, 2019
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transthoracic echocardiogram (TTE) for the enrollee.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has no new symptoms since a prior echocardiogram less than one year ago. He is stable on guideline-directed medical therapy. He has no evidence of an intercurrent myocardial infarction or ventricular rhythm disturbances on the interrogation of the automated implantable cardioverter defibrillator (AICD). He has no new murmurs or signs of congestive heart failure on physical exam. He has had two successive echocardiograms in the past three years that are unchanged and show preserved left ventricular function and no significant valvular heart disease. The requested TTE is therefore not reasonable or medically necessary at this time. We looked at this physician's review, the file, and Medicare rules. 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 pre-approve a transthoracic echocardiogram (TTE) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forinitial hospital care(CPT Code 99222) provided to the enrollee from September 11, 2019 through September 13, 2019.You asked the Plan to pay forthe services. You say that the claim should be paid.The Plan denied your request. The Plan says the patient was not in an inpatient status for this date of service.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 patient was not in an inpatient status for this date of service, per CMS Policy. Hospital observation services are outpatient hospital services performed to evaluate whether the patient should be admitted as an inpatient or can be discharged from the outpatient hospital. It is not appropriate for providers to report inpatient Evaluation and Management services while the patient is in an observation status. This patient's claim history shows that the patient was in an outpatient hospital observation status for this date of service; therefore the inpatient Evaluation and Management service has been denied.Therefore, we decided that the Plan does not have to pay forinitial hospital care (CPT Code 99222) provided to the enrollee from September 11, 2019 through September 13, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to hold you harmless for dental services (D2950, D5110, D7210, D6240)
provided January 16, 2019 to January 17, 2019
You asked the Plan to hold you harmless for the dental services. You say that the services should be covered.
The Plan denied your request. The Plan says that the correct copayments were applied.
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 the dental
services when the services are medically necessary and reasonable.
We looked at the file, and Medicare rules. The Evidence of Coverage does not clearly explain what Dental
services are covered and what the copayments may be. The plan failed to furnish a copy of their Dental
Handbook to our adjudicators for review. Based on this information. Therefore, we decided that the Plan has to
hold you harmless for dental services (D2950, D5110, D7210, D6240) provided January 16, 2019 to January
17, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for add tooth to existing partial denture (D5650 x 2) and repair resin denture base (D5610) provided on October 17, 2019.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says the services are 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. The services are not listed in your EOC as a covered benefit; therefore, the services are not covered. Therefore, we decided that the Plan does not have to pay for add tooth to existing partial denture (D5650 x 2) and repair resin denture base (D5610) provided on October 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941), the office visit (99213), and the supplies and materials (99070) rendered by out of network (OON) provider from January 10, 2019 to November 8, 2019.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were provided by an 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 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 chiropractic manipulative treatment (98941), the office visit (99213), and the supplies and materials (99070) rendered by the out of network (OON) provider from January 10, 2019 to November 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an office visit and evaluation provided on August 21, 2019.
You asked the Plan to waive the coinsurance for primary care services. You say that you were told several times that this doctor was covered by Medicare. The Plan denied your request. The Plan says the coinsurance amount you are being charged is correct.
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 primary care provider services. The allowed amount of this claim is $285.85, resulting in a coinsurance obligation of $142.93. You have been asked to pay 50% coinsurance for primary care services. Primary care services fall within the Physician/Practitioner Services, Including Doctor's Office Visits 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 an office visit and evaluation provided on August 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the specialist office visits provided on November 26, 2019 and December 18, 2019. You asked the Plan to waive the copayments for the specialist office visits. You say that you do not feel like you should have to pay a copayment every time you see a specialist for the same issue. 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 per in-network specialist office visit. You have been asked to pay a $40 copayment for each of the specialist office visits. The specialist office visits fall within the "Physician/Practitioner services, including doctor's office visits" 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 for the specialist office visits provided on November 26, 2019 and December 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecrowns (D2740) on teeth 30 and 31.You asked the Plan to pre-approvecrowns. You say that this is medically necessary.The Plan denied your request. The Plan says the enrollee does not have bone loss that necessitates these crowns.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 crowns when the services are medically necessary andreasonable. 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 crowns. Our reviewer says that the requested crowns are not medically necessary. Our physician reviewer found teeth 30 and 31 have existing restorations. There does not appear to be significant coronal breakdown of either tooth. Routine restorative material would be adequate to restore these teeth to normal function.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 crowns have not been met.Therefore, we decided that the Plan does not have to pre-approvecrowns (D2740) on teeth 30 and 31.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER visit provided on November 7, 2019.
You asked the Plan to waive the copayment for the ER visit. You say that you only went back to the ER to get the balloon removed. 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 $60 copayment for each emergency room visit. You have been asked to pay a $60 copayment for the ER visit. The ER visit falls within the "Emergency 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 the ER visit provided on November 7, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF care provided to the enrollee from July 23, 2019 through August 22, 2019.You asked the Plan to pay forSNF care. You say that the stay was medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.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 pay for SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are noidentifiable skilled therapy service needs. The beneficiary does not require skilled nursing or therapy services on a daily basis. This beneficiary 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 pay forSNF care provided to the enrollee from July 23, 2019 through August 22, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from December 2, 2019 through December 4, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found based on the documentation provided this hospitalization does not qualify for inpatient payment under the two-midnight rule. At the time of admission, it was not reasonable to expect that two midnights in the hospital would be required. The emergency department (ED) evaluation showed no life/limb threatening condition(s). The enrollee could have been safely placed on observation status pending further evaluation and monitoring. As is, no acute issues were identified.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from December 2, 2019 through December 4, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the FoundationOne CDx next generation sequencing (NGS) testing rendered to the enrollee on November 6, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that NGS is covered when specific criteria are met. 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 these services. Our reviewer says that the
services were not medically necessary. Our physician reviewer found a surgical pathology report contains a pathologic diagnosis of a high grade serous carcinoma of the left ovary and fallopian tube, paracolic nodule, and omentum for the enrollee. The documentation does not indicate whether the enrollee has had previous testing using the same NGS test for the same primary diagnosis of cancer, and it is not documented that the enrollee has decided to seek further cancer treatment. The testing was not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pay for the FoundationOne CDx next generation sequencing (NGS) testing rendered to the enrollee on November 6, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on October 14,
2019 through October 21, 2019.
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration because
per CMS, CPT code S9328 is valid. The Plan denied your request. The Plan says CPT code S9328 has a status
code of I which is not valid for Medicare purposes.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT code S9328 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT
code S9328 has a status indicator of I. This means the CPT code S9328 is not valid for Medicare purposes.
Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not
been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328)
provided on October 14, 2019 through October 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tdap vaccine you received on November 14, 2019.
You asked the Plan to pay for the Tdap vaccine. You say that you need to take precautions since you are at a high risk for infections. The Plan denied your request. The Plan says this is not a covered service.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Tdap vaccine. The Plan follows the same rules. The records do not show that you have been injured or directly exposed to any illness related to the Tdap vaccine. Therefore, we decided that the Plan does not have to pay for the Tdap vaccine you received on November 14, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided to the enrollee on February 27, 2019.
You asked the Plan to pay for the ambulance services. You say that stretcher transportation was deemed required to move the enrollee to their destination safely without causing any more discomfort for the enrollee. The Plan denied your request. The Plan says that ambulance transport to or from an outpatient office is not a Medicare covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when they meet certain origin and destination requirements. A doctor's office is not a covered destination. The services you have asked the Plan to pay for are ambulance transport services to a doctor's office. Therefore, we decided that the Plan does not have to pay for the ambulance services provided to the enrollee on February 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 12, 2019 by an out of network (OON) provider.You asked the Plan to pay for office visit. You say that this is the only provider in your area and you had no choice but to go there.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and this service could have been obtained from an 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 forthe medical services provided on December 12, 2019 by an out of network (OON) provider.