Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on February 3,
2020.
You asked the Plan to waive the copayment for an office visit. You say that this was an annual wellness visit
and you should not be responsible for 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 a $10
copayment for primary care provider visits.
The medical records show that you received services beyond an annual wellness visit on February 3, 2020.
Therefore, you are responsible to pay the $10 copayment.
You have been asked to pay a $10 copayment for an office visit. An office visit falls 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 copayment for an office visit provided on February 3, 2020.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to pay for physician services (99283) provided December 20, 2019. You asked the Plan to pay for the physician services. You say that the services were correctly billed. The Plan denied your request. The Plan says that the records do not support the code 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, the CPT Code Manual definition of code 99283 is Emergency department visit for the evaluation and management of a patient. We find that CPT code 99283 is supported in the medical record. Specifically, the medical records provided support the code billed. Based on this information, we decided that Medicare rules for coverage of the physician services have been met. Therefore, we decided that the Plan has to pay for physician services (99283) provided December 20, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe molecular genetic hereditary testing provided on December 11, 2019.You asked the Plan to pay forthe molecular genetic hereditary testing. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services rendered are not a covered benefit.The Plan follows Medicare rules. The rules explicitlysay that screening tests, with the exception of the few tests listed above, are not covered.The molecular genetic hereditary testing at issue in this appeal 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 forthe molecular genetic hereditary testing provided on December 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on March 26, 2020 by an out of network (OON) provider.
You asked the Plan to pay for skilled nursing services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the member's primary care physician did not refer these services. The Plan says that the referring facility is out-of-network.
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 skilled nursing services provided on March 26, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on January 28, 2020.
You asked the Plan to pay for the knee orthosis (L1833) and suspension sleeve (L2397). You say that the orthoses were medically necessary. The Plan denied your request. The Plan says the documentation submitted did not indicate the provider discussed the need for the billed supply codes, therefore the billed supply codes cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. The current medical records from the ordering physician do not mention or support medical necessity for the orthoses. Based on this information, we decided that Medicare rules for coverage of the knee orthosis (L1833) and suspension sleeve (L2397) have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on January 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation (D7953), complete series of intraoral x-rays (D0210), comprehensive oral evaluation (D0150), and extraction (D7210) provided by an OON provider on October 17, 2019.
You asked the Plan to pay for the bone replacement graft, intraoral x-rays, comprehensive oral evaluation, and extraction. You say that you trust this provider and other dental offices would charge you a lot of money. The Plan denied your request. The Plan says the dentist that provided this treatment is not part of the Plan's network. The Plan also says that services done by an out-of-network dentist are 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 covered when they are received out-of-network. Therefore, we decided that the Plan does not have to pay for the bone replacement graft for ridge preservation (D7953), complete series of intraoral x-rays (D0210), comprehensive oral evaluation (D0150), and extraction (D7210) provided by an OON provider on October 17, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional rhinoplasty procedures (30430, 14060).
You asked the Plan to pre-approve additional rhinoplasty procedures. You say that this should be covered because you were approved for a reconstructive rhinoplasty. The Plan denied your request. The Plan says the requested procedures are cosmetic.
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are coverable. We looked at the file and Medicare rules. The medical records submitted indicate that these procedures are being requested for cosmetic purposes and may worsen the conditions the approved rhinoplasty was ordered to treat. Based on this information, we decided that Medicare rules for coverage of additional rhinoplasty procedures have not been met. Therefore, we decided that the Plan does not have to pre-approve additional rhinoplasty procedures (30430, 14060).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the services provided from January 29, 2019 through January 30, 2019 by an out-of-network provider.You asked the Plan to waive the coinsurance for the services. You say that you are appealing your cost-share responsibility for the services you received.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received the services provided from January 29, 2019 through January 30, 2019 by an out-of-network provider. You are asked to pay 40% coinsurance for the services. 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 services provided from January 29, 2019 through January 30, 2019 by an out-of-network provider.
Appeal type: Practitioner Services
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 January 8, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 January 8, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MAYZENT.You asked the Plan to pre-approve this drug. The Plan denied your request. The Plan says that this is not covered under Part B.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered 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 MAYZENT.Benefits for this drug 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forEmergency Room Services (99285, 93010) provided January 16, 2020.You asked the Plan to pay forthe Emergency Room Services. You say that the services were medically necessary.The Plan denied your request. The Plan says the claim was not submitted with a valid primary diagnosis.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 99285, 93010 is not supported in the medical record. Specifically, a secondary diagnosis code was listed as the primary diagnosis code. There was no valid primary diagnosis code on the claim provided. Based on this information, we decided that Medicare rules for coverage of the Emergency Room Services have not been met.Therefore, we decided that the Plan does not have to pay forEmergency Room Services (99285, 93010) provided January 16, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fortherapeutic exercises provided by a participating provider on August 1, 2019 to August 26, 2019.You asked the Plan to waive the copayment for therapeutic exercises. You say that you are on a fixed income and cannot afford these copayments. The Plan denied your request. The Plan says the correct copayment has been applied.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 Planclearly says that you must pay a $30 copayment for outpatient rehabilitation services/physical therapy. You have been asked to pay a $30 copayment for therapeutic exercises. The total amount you are being asked to pay is $210 ($30 x 7 visits = $210). The correct copayment has been applied to the services that were provided.Therapeutic exercises fall within the outpatient rehabilitation services/physical therapy 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 therapeutic exercises provided by a participating provider on August 1, 2019 to August 26, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Doxepin cream.You asked the Plan to pre-approve the Doxepin cream. You say that the enrollee needs a short term, non-steroidal alternative that is topical to treat their face and neck areas to relieve itching of the skin caused by eczema and hypersensitivity reaction.The Plan denied your request. The Plan says this drug is self-administered. The Plan also says that this drug is not covered for the enrollee's condition under Medicare Part B.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered 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 Doxepin cream.Benefits for the Doxepin cream 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: Hospice
Decision: Favorable

We decided that the Plan has to pay for the ED visit and ECG provided on November 9, 2019.
You asked the Plan to pay for the ED visit and ECG. You say that you believe these expenses should be covered because the enrollee had been discharged from hospice prior to her hospital stay. You also say that the enrollee was hospitalized and treated for a condition unrelated to her prior hospice diagnosis. The Plan denied your request. The Plan says that the enrollee had elected Hospice while in Hospice care. The Plan also says that because the enrollee elected Hospice care, this Hospice under terminal prognosis would be covered by Medicare.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not provide a copy of the enrollee's applicable hospice election information. Without this information we cannot determine that the Plan's coverage rules support the denial of payment in this case. Thus, the plan has not substantiated their denial of payment in this case. Therefore, we decided that the Plan has to pay for the ED visit and ECG provided on November 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gingival irrigation, per quadrant (D4921) provided on February 26, 2020.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 these services are not a covered benefit under your contractual policy.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 services provided are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay for the gingival irrigation, per quadrant (D4921) provided on February 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial periapical x-ray (D0220) and the additional periapical x-ray (D0230) provided on January 28, 2020.You asked the Plan to pay for the dental services. You say that you had an appointment for a cleaning and x-rays. You say that according to your insurance coverage, you are entitled to 2 annual cleanings and a set of x-rays. You also say that you have never had an issue with coverage.The Plan denied your request. The Plan says periapical x-rays are not listed as a covered service.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 the periapical x-rays are not among those covered under this benefit. The Evidence of Coverage clearly states that any services not listed are not covered.Therefore, we decided that the Plan does not have to pay for the initial periapical x-ray (D0220) and the additional periapical x-ray (D0230) provided on January 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (81518) provided on January 31, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. Medicare guidelines say that ICD-10-CM has a coding convention that requires the underlying condition to be sequenced first, followed by the manifestation. In this case, Z17.0 is a manifestation code and cannot be used as the primary or first-listed diagnosis code on the claim. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services (81518) provided on January 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206) provided on November 21, 2019.You asked the Plan to pay for the dental service. You say that you have been getting cleanings twice per year from this dentist. You say that while you are happy with the services you receive from this provider, their prices are not as low as your previous dentist. You say that you always refuse any services that you would have to pay for. You also say that you did not agree to pay for the topical application of fluoride varnish.The Plan denied your request. The Plan says the topical application of fluoride varnish is not listed as a covered service. The Plan also says that any services not specifically listed are 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 topical application of fluoride varnish is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206) provided on November 21, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for Computed Tomography (CT) of the head and brain (70450)
provided January 10, 2020.
You asked the Plan to pay for the CT scan. You say that the service was medically necessary. The Plan denied
your request. The Plan says the code billed shares a Column I / Column II relationship with another code 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, we have confirmed that code 70450
has a bundled relationship with code 70496 and cannot be paid as billed. This code cannot be paid as a separate
line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided
that the Plan does not have to pay for Computed Tomography (CT) of the head and brain (70450) provided
January 10, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (HCPCS S9328) provided to the enrollee from October 17, 2019 to December 5, 2019.You asked the Plan to pay for the services. You say that this is home infusion, not DME, and was received at the provider's office.The Plan denied your request. The Plan says this code is 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 code.In this case, the CPT Code Manual definition of HCPCS code S9328 is "Home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem."We find that CPT code S9328 is not supported in the medical record. Specifically, this code has a status indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay for home infusion therapy (HCPCS S9328) provided to the enrollee from October 17, 2019 to December 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the walker provided on October 6, 2019.
You asked the Plan to waive the coinsurance for the walker. You say that you are not paying for the walker. 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 20% coinsurance for durable medical equipment, oxygen/oxygen equipment and related supplies. You have been asked to pay $17.13 which is 20% of the allowed amount for the walker. The allowed amount is $85.69. ($85.69 x 20% = $17.13). The walker falls within the "Durable medical equipment (DME) and related 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 coinsurance for the walker provided on October 6, 2019.