Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on January 22, 2020.
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says there
was no authorization in place for the enrollee to receive services from a non-contracted 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 did not pre-approve the
psychotherapy services. 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 psychotherapy services provided on January 22,
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the colonoscopy through stoma (44388) Injection, ketorolac
tromethamine (J1885) injection, acetaminophen (J0131) provided on May 27, 2020, by an out-of-network
(OON) provider.
You asked the Plan to pay for the colonoscopy services. You say that please review this case again or you will
be left paying for this procedure which you cannot afford. The Plan denied your request. The Plan says
enrollee's must receive their medical services from an in-network provider with the exception being urgent or
emergent services. Non-emergent services with non-contracted providers require prior authorization before
services being rendered.
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 had network providers
available who could have provided 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 colonoscopy through stoma (44388) Injection,
ketorolac tromethamine (J1885) injection, acetaminophen (J0131) provided on May 27, 2020, by an out-ofnetwork (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug injection provided
on July 16, 2020.
You asked the Plan to waive the coinsurance for a Medicare Part B drug injection. You say that you cannot
afford the charges. The Plan denied your request. The Plan says the claims were processed correctly and you
are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20%
coinsurance for Medicare Part B prescription drugs.
You received a Medicare Part B drug injection on July 16, 2020. The total allowed amount is $2,344.36 and
20% of that is $468.95.
You have been asked to pay the total coinsurance amount of $468.95 for a Medicare Part B drug injection. A
Medicare Part B drug falls within the Medicare Part B prescription drugs 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 a Medicare Part B drug injection provided on July 16, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services (S9500 and S9501)
provided from March 26, 2020, to April 1, 2020.
You asked the Plan to pay for the home infusion therapy services. You say that these services were medically
necessary. The Plan denied your request. The Plan says these codes are not payable under Medicare.
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 S9500 and S9501 is home infusion therapy, antibiotic,
antiviral, or antifungal therapy.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the home infusion therapy services have not been met. Specifically, the code billed (S9500 and
S9501) is not covered by Medicare or the Plan. Medicare uses another code for reporting of, and payment for,
these services. Based on this information, we decided that Medicare rules for coverage of the home infusion
therapy services have not been met. Therefore, we decided that the Plan does not have to pay for the home
infusion therapy services (S9500 and S9501) provided from March 26, 2020, to April 1, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee.

You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the FIPS value needs to be 5 digits. Therefore, the claim cannot be paid as billed.

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, this claim cannot be paid as billed due to an issue with the FIPS code. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for home health services provided to the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the fluoride treatment (D1206) and the fillings (D2335)
for teeth # 23 and 25 provided on August 6, 2020.
You asked the Plan to pay more for the dental services. You say that you went in for a cleaning and 1 filling.
You say that they ended up doing another filling that you were not aware of. You also say that the provider
should have made sure the services were covered or at least let you know before they did them so you could
make the decision. The Plan denied your request. The Plan says the fluoride treatment is not listed as a covered
service. The Plan says that there is a $200 allowance for fillings and simple extractions per year. The Plan also
says that the $200 allowance has been exhausted.
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 fluoride treatment is not among
those covered under this benefit. Additionally, the $200 allowance for fillings and simple extractions has been
exhausted. The record shows that the Plan paid $200 towards the filling for tooth # 23, thus exhausting the
allowance. Therefore, we decided that the Plan does not have to pay more for the fluoride treatment (D1206)
and the fillings (D2335) for teeth # 23 and 25 provided on August 6, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on April 3, 2020.
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says the Plan
requires utilization of network providers when possible and available, and requires authorization for certain
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has
been documented.
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
psychotherapy services. 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 psychotherapy services provided on April 3, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal scaling and root planing provided on July 9,
2020.
You asked the Plan to pay for the scaling and planing. You say that you told the Plan representative that you
have been going to a periodontal dentist. You also say that you were told that was alright, and that the service
would be covered. The Plan denied your request. The Plan says this service is 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 pay for the
periodontal scaling and root planing provided on July 9, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 12, 2019 by a non-network provider.
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 rendered by a non-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 had network providers available who could have provided 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 provided on November 12, 2019 by a non-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care provided on August 1, 2020 by an
out of network (OON) provider.
You asked the Plan to pay for OON nursing facility care. You say that these were medically necessary services
provided in good faith. The Plan denied your request. The Plan says these services were not authorized and
were provided in connection to a non-covered nursing facility stay.
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 had network providers
available who could have provided 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 nursing facility care provided on August 1,
2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional extractions provided on August 17, 2020 and August 31, 2020.
You asked the Plan to pay for the additional extractions. You say that you received a letter stating all your teeth were approved to be removed. You say that now you have another letter denying approval and the dentist hasn't gotten paid. The Plan denied your request. The Plan says your extraction benefit has been exhausted.
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 Plan also has a maximum benefit of 6 extractions per calendar year. The Plan paid for 4 extractions provided on August 6, 2020 and 2 extractions on August 17, 2020, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the additional extractions provided on August 17, 2020 and August 31, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient hospital care from July 26, 2020, through July 30, 2020.
You asked the Plan to pay for inpatient hospital care. You say that the service was medically necessary. The Plan denied your request. The Plan says that the readmission was for a continuation or recurrence of the reason for the initial admission. Based on the documentation provided, it appears that the readmission was preventable.
The Plan follows Medicare rules. Medicare rules say that when a care provider takes an action that results in unnecessary admissions, premature discharges and readmissions, multiple readmissions or other inappropriate medical or other practices with respect to beneficiaries or billing for services, CMS authorizes QIOs to take certain actions, including denial of payment. 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 inpatient hospital care. Our reviewer says that the service was medically necessary. Our physician reviewer found that the readmission did not result from a premature discharge of the prior hospital stay. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient hospital care have been met. Specifically, the readmission was not a result of a premature discharge and was found medically necessary. Therefore, we decided that the Plan has to pay for inpatient hospital care from July 26, 2020, through July 30, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on May 14, 2020, through September 23, 2020.
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration because this infusion code is not durable medical equipment and was not delivered to the member's home. The Plan denied your request. The Plan says CPT code S9328 has a status indicator of I and 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 that 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 May 14, 2020, through September 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for passive joint motion device (E1806) on August 4, 2020.
You asked the Plan to pay for passive joint motion device. You say that this device should be covered. The
Plan denied your request. The Plan says the NCD says this is not a covered service.
The rules say this device is not a Medicare covered benefit for any use other than directly after knee joint
replacement surgery. As a non-covered service, it is not a benefit when ordered by either a contracted or a noncontracted
provider. The documentation does not show recent knee joint replacement surgery. Therefore, we
decided that the Plan does not have to pay for passive joint motion device (E1806) on August 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for DME provided on September 15, 2020.
You asked the Plan to pay for the DME. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.
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 DME. We found no exception that would require the Plan to pay for this item. Therefore, we decided that the Plan does not have to pay for DME provided on September 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the removal of a malignant growth provided on July 13, 2020.
You asked the Plan to waive the copayment for the removal of a malignant growth. You say that you were not aware that the procedure would be billed as a surgery. You state that you were not put under anesthesia and should not owe a such a high 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 $250 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You received the removal of a malignant growth on July 13, 2020, at an outpatient hospital facility. The removal of a malignant growth is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $250 copayment. You have been asked to pay a $250 copayment for the removal of a malignant growth. The removal of a malignant growth 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 the removal of a malignant growth provided on July 13, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services provided to the enrollee on July 19, 2020.You asked the Plan to pay forthis service. You say that this claim should bepaid.The Plan denied your request. The Plan says due to the enrollee's hospice election at the time of service, this claim should be submitted to Original Medicare.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay forphysician services provided to the enrollee on July 19, 2020.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the air ambulance services provided on July 17, 2020.
You asked the Plan to pay for the air ambulance services. You say that you would like the Plan to reconsider their denial of payment. You say that this service is payable at the ground ambulance rate. The Plan denied your request. The Plan says that the air ambulance services are not payable.
The Plan follows Medicare rules. Medicare rules say that if air ambulance services were ordered, but ground ambulance transport would have sufficed, payment for the transport is based on the amount payable for ground ambulance transport. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the air ambulance services. have been met. Specifically, you are requesting payment at the ground ambulance rate. This is a covered benefit per Medicare. Therefore, we decided that the Plan has to pay the ground ambulance rate for the air ambulance services provided on July 17, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forpsychotherapy visits provided on September 9, 2019, to December 30, 2019 by an out of network (OON) provider.You asked the Plan to pay forpsychotherapy visits. You say that you were told that this provider was in-network.The Plan denied your request. The Plan says 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 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 had network providers available who could have provided 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 forpsychotherapy visits provided on September 9, 2019, to December 30, 2019 by an out of network (OON) provider.We note your complaint about being told this provider was in-network. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve psychotherapy services (90837) provided June 3, 2019 to August 29, 2019.
You asked the Plan to pre-approve the psychotherapy services. You say that these services were medically necessary. The Plan denied your request. The Plan says medical records were not provided to support the services billed.
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. No medical records were provided to support the services billed. Based on this information, we decided that Medicare rules for coverage of the psychotherapy services have not been met. Therefore, we decided that the Plan does not have to pre-approve psychotherapy services (90837) provided June 3, 2019 to August 29, 2019.