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

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on November 26, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 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 has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on November 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on November 26, 2019 by an out-of-network provider.You asked the Plan to pay for the dental services. You say that you were under the impression that the coverage would be $1000 once the $100 deductible was paid.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC 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.Review of the file show that you received the dental services on November 26, 2019 from an out-of-network provider. Your EOC states, you'll save more when you receive care from one of the Plan's in-network dental providers. You can get care from an out-of-network dental provider but you may pay more.Therefore, we decided that the Plan does not have to pay for the dental services provided on November 26, 2019 by an out-of-network provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER visit provided on October 8, 2019.You asked the Plan to waive the copayment for the ER visit. You say that you went to the ER within 24 hours of the urgent care visit. You say that the copayment should be waived.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 $90 copayment for Medicare-covered emergency room visits.You have been asked to pay a $90 copayment for the ER visit. The ER visit falls within the "Emergency care" benefit category. The records do not support that you were admitted to the hospital. 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 October 8, 2019
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low dose CT scan for lung cancer screening.
You asked the Plan to pre-approve a low dose CT scan. The Plan denied your request. The Plan says the coverage criteria are not met.
The Plan must follow Medicare rules. Medicare rules say that a low dose CT scan for lung cancer screening is covered when all of the above criteria are met. We looked at the file and Medicare rules. The records show that the enrollee quit smoking 23 years ago. Based on this information, we decided that Medicare rules for coverage of a low dose CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a low dose CT scan for lung cancer screening.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a depression screening provided on January 24, 2020.You asked the Plan to pay for the depression screening. You say that you would like reconsideration because you informed the provider that you had already received this service.The Plan denied your request. The Plan says one screening for depression is covered per year and you had already received a depression screening.The Plan must follow Medicare rules. Medicare rules say that a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles and coinsurance).We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the depression screening have not been met. Specifically, the record indicates that you received a depression screening on December 17, 2019 and again on January 24, 2020. This exceeds the frequency limit for this benefit.Therefore, we decided that the Plan does not have to pay fora depression screening provided on January 24, 2020.Please note, you may not be liable for the payment for this service. Your complaint about the provider requesting you receive this service twice is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for screening testing provided on January 24, 2020.
You asked the Plan to pay for screening tests. You say that you are appealing with supporting documents. The
Plan denied your request. The Plan says the denial of payment for these services is correct, because these
services are not covered for the diagnoses listed and were performed for screening purposes.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
The test at issue in this appeal, screening tests, was requested solely for screening purposes. Medicare does not
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for
screening testing provided on January 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance, application of desensitizing resin for cervical and/or root surface, and gingivectomy or gingivoplasty provided on January 28, 2020 and February 3, 2020.
You asked the Plan to pay for the periodontal maintenance, application of desensitizing resin for cervical and/or root surface, and gingivectomy or gingivoplasty. You say that this claim has been processed multiple times and denied due to the treating dentist was out-of-network. You also say that a website plan provider search for the treating provider confirms that he is in network, and all previous claims received from this provider have been processed as in network. 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. 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 maintenance, application of desensitizing resin for cervical and/or root surface, and gingivectomy or gingivoplasty provided on January 28, 2020 and February 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on December 24, 2019.
You asked the Plan to pay for the pump assembly and operation. You say that you would like reconsideration because it takes at least 30 minutes to set up the machine and the perfusionist is required to remain in the operating room through the length of the procedure. The Plan denied your request. The Plan says payment for this service is the responsibility of the facility to any vendor.
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pump assembly and operation have not been met. Specifically, payment for this service is included in the DRG payment to the facility and is the responsibility of the facility to any vendor. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on December 24, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve longterm acute care hospital (LTACH) services.You asked the Plan to pre-approve the LTACH services. You say that a LTACH admission is medically necessary for the enrollee.The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of a LTACH admission.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee was admitted to the acute care hospital with a diagnosis of Covid-19 and later required intubation. A tracheostomy and PEG tube were subsequently placed on July 2, 2020. The enrollee was then taken off the ventilator on July 9, 2020. Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where she is currently receiving care. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on September 16, 2019.You asked the Plan to pay for drug test. You say that you are appealing with supporting documentation.The Plan denied your request. The Plan says the denial of payment for this service is correct, because the documentation submitted does not include a valid physician order, laboratory requisition, or medical records to support the test billed.The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a valid physician order or clear intent to order the specific lab service billed on this claim. Namely, the order submitted lists a date of service after this testing was performed. Based on this information, we decided that Medicare rules for coverage of drug test have not been met.Therefore, we decided that the Plan does not have to pay for drug testing provided on September 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the office visit provided on February 28, 2020.You asked the Plan to waive the coinsurance for the office visit. You say that the doctor is your primary care physician. You say that you should only be charged a $10 copayment.The Plan denied your request. The Plan says the coinsurance 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 50% coinsurance for provider and professional services at an out-of-network primary care physician's office.You have been asked to pay $52.53, which is 50% of the allowed amount for the office visit. The allowed amount is $105.07 (50% x $105.07 = $52.53). The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show the provider is out-of-network. 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 the office visit provided on February 28, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray of the fingers (73140) provided March 1, 2020.
You asked the Plan to pay for the x-ray. You say that the service was medically necessary. The Plan denied your request. The Plan says the claim did not include a correct modifier.
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 73140 is for a radiologic examination, finger(s). We find that CPT code 73140 is not supported in the medical record. Specifically, no anatomical modifier was included to denote which finger(s) were x-rayed. Based on this information, we decided that Medicare rules for coverage of the x-ray have not been met. Therefore, we decided that the Plan does not have to pay for an x-ray of the fingers (73140) provided March 1, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ultrasounds provided on February 11, 2020.
You asked the Plan to waive the copayment for ultrasounds. You say that you feel that the ultrasounds should
be included in your yearly mammogram screening. 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 $125
copayment for each radiological diagnostic service.
The medical records show that you received ultrasounds on February 11, 2020. Ultrasounds are not considered
mammogram screenings. Therefore, you are responsible to pay $60, which is less than the $125 copayment.
You have been asked to pay $60 for ultrasounds. Ultrasounds 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 copayment for
ultrasounds provided on February 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital services rendered on January 7,
2020.
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.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service
exceeds the MUE value for the HCPCS/CPT code will be denied.
In this case, the MUE for CPT code 99233 is one. You billed six units of this code, exceeding the MUE. 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 subsequent hospital services rendered on
January 7, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on February 6, 2020.
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.
The Plan must follow Medicare rules. The rules say that the PC for code 85060 is only paid if the services are
performed at an inpatient hospital.
We looked at the file and Medicare rules. The file shows that code 85060 was billed with a place of service
code 22 for outpatient hospital. 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 laboratory services
rendered on February 6, 2020.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pay for the services (CPT 31259) provided on November 13, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the billed code cannot be verified. 
 
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 31259 is "Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including sphenoidotomy, with removal of tissue from the sphenoid sinus". 
 
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 reviewers says that the use of CPT code 31259 is supported by the records provided. Our physician reviewer found that the documentation supports that a total ethoidectomy and sphenoidotomy, with removal of tissue from the sphenoid sinus, were performed. 
 
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 been met. Therefore, we decided that the Plan has to pay for the services (CPT 31259) provided on November 13, 2019.  
 
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the perfusionist services provided on March 26, 2020. 
 
You asked the Plan to pay for the services provided. You say that the charges are for the perfusionist that setup and operated the heart-lung machine for the enrollee's surgery. The Plan denied your request. The Plan says the services are included in the facility payment. 
 
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility for services furnished to a beneficiary. 
 
We looked at the file and Medicare rules. The facility must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. This service was provided via arrangement of the facility. Payment for this service would have been included under the facility claim. Payment to you for this service is the responsibility of the facility. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the perfusionist services provided on March 26, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the special pump services rendered on March 14, 2020. 
 
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 separately payable. 
 
The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are statutorily excluded.  
 
The provider submitted a claim for procedure code 99190 (special pump services). This code has a status indicator of X and no separate Medicare payment. Payment is included in the payment to the facility. Therefore, we decided that the Plan does not have to pay for the special pump services rendered on March 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve house cleaning services. 
 
You asked the Plan to pre-approve the house cleaning services. You say that you would like reconsideration because the member is an excellent candidate to receive this service. The Plan denied your request. The Plan says this service is a non-covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that custodial care is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the house cleaning services have not been met. Specifically, the service at issue is a homemaker service and is not covered under any condition. Therefore, we decided that the Plan does not have to preapprove house cleaning services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hydroxyzine HCl. 
 
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 self-administered drugs are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Hydroxyzine HCl.  
 
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on September 5, 2019 through November 26, 2019.
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says S codes are not payable by Original 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. We find that CPT code S9328 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code S9328 has a status code 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 September 5, 2019 through November 26, 2019.