Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursementfor the recliner chair with aseat lift mechanism purchased on July 8, 2020.You asked the Plan to issue reimbursementfor these items. You say that alift chair is medically necessary.The Plan denied your request. The Plan says you do not meet criteria for coverage of a lift chair.The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed above are met. Additionally, Medicare will pay for durable medical equipment that is mainly used to serve a medical purpose.We looked at the case fileand Medicare rules. Based on this information, we decided that Medicare rules for coverage of these items have not been met.Specifically, a recliner chair is not durable medical equipment that is mainly used to serve a medical purpose. Additionally, the medical records provided do not indicate that you have severe arthritis of the hip or knee or have a severe neuromuscular disease. Therefore, we decided that the Plan does not have to issue reimbursementfor the recliner chair with a seat lift mechanism purchased on July 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services (CPT 20103) provided on June 25, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not medically necessary.
The Plan follows Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare rules say that for procedures with an assistant surgery indicator of 0, the payment restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to establish medical necessity. In this case, you billed assistant surgery services for CPT code 20103. The Medicare Fee Schedule Database contains a surgical indicator of 0 for this procedure. 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 reviewer says that the requested assistant surgeon services are not medically reasonable and necessary. Our physician reviewer found that the enrollee is an 83-year-old woman who suffered extensive and complex wounds to her right ankle. The enrollee had previous reconstruction with Integra application. A procedure was performed on June 25, 2020, with debridement, local tissue rearrangement, and skin grafting. There is no clinical documentation of the need for the services of a surgical assistant. 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 not been met. Therefore, we decided that the Plan does not have to pay for the assistant surgeon services (CPT 20103) provided on June 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe evaluation and management service (99358) provided on June 17, 2020.You asked the Plan to pay forthis service. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says the procedure code billed is not supported in the medical record provided. 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 99358 is prolonged evaluation and management service before and/or after direct patient care; first hour.We find that CPT code 99358 is not supported in the medical record. Specifically, CPT code 99358 is used when a prolonged service is provided that is neither face-to face time in the office or outpatient setting, nor additional unit/floor time in the hospital or nursing facility setting during the same session of evaluation and management and is beyond the usual physician or other qualified health care professional service time. This code may be reported on a different date than the primary service to which it is related. Theprovider's documentation in the medical record indicates that the time was spent coordinating care with other providers after face to facetime with the patient.Based on this information, we decided that Medicare rules for coverage of this service have not been met.Therefore, we decided that the Plan does not have to pay forthe evaluation and management service (99358) provided on June 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay fordetermination of refractive state (90215) provided August 21, 2020.You asked the Plan to pay forthe vision services. You say that you were told since you do not have vision coverage you should go to your regular eye doctor, pay out of pocket and submit the receipts.The Plan denied your request. The Plan says this service is not covered under the plan benefits. Enrollee's must receive their vision services from an in-network provider.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when rendered by an in network provider.We looked at the file and the Plan's rules. enrollee's must receive their vision services from an in-network provider. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met.Therefore, we decided that the Plan does not have to pay fordetermination of refractive state (90215) provided August 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe bitewing x-rays(D0274) you received on September 29, 2020.You asked the Plan to pay forthe x-rays. The Plan denied your request. The Plan says the benefit limit has been reached.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 services are subject to a benefit limitation. The Plan covers bitewing x-rays once per year. The records show that you received covered bitewing x-rays on March 20, 2020. This means that the requested x-rays exceed the benefit limit, and are not covered.Therefore, we decided that the Plan does not have to pay forthe bitewing x-rays(D0274) you received on September 29, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe dental exam you received on August 31, 2020.You asked the Plan to pay forthe exam. The Plan denied your request. The Plan says this is not an in-network provider.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 services are not among those covered under this benefit when provided by an out-of-network provider. The dental exam you received was provided by a provider who is not contracted with the Plan's dental vendor.Therefore, we decided that the Plan does not have to pay forthe dental exam you received on August 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lead wires provided on September 15, 2020.You asked the Plan to pay forthe lead wires (A4557). You say that the Plan should pay this claim.The Plan denied your request. The Plan says a TENS device was purchased in the previous 12 months therefore the lead wires have been denied.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The record shows a TENS device was purchased on June 15, 2020 and records supporting the medical necessity of the additional lead wires were not submitted.Therefore, we decided that the Plan does not have to pay forthe lead wires provided on September 15, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forpost stabilization services provided from August 16, 2020, to August 18, 2020.You asked the Plan to pay forthe provided services. The Plan denied your request. The Plan says the enrollee was stable for transfer.The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 
The file shows that the Plan approved and paid for emergency care from August 15, 2020, to 10:26 am on August 16, 2020. 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 servicesat issue. Our physician reviewer found that the enrollee presented to the emergency room after a mechanical fall. He did not sustain any head trauma. The review indicates that all inpatient care provided after 10:27 am on August 16, 2020, to 10:04 pm on August 18, 2020,was not needed on an emergent basis. The enrollee was hemodynamicallystable for ambulance transport with monitoring to a Plan facility for continued observation/inpatient level of care services. The treating physician did not document (in the physician notes, on a form, or in an order) that the enrolleewas not stable for transfer on any dates of serviceat issue.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 provided services have not been met.Therefore, we decided that the Plan does not have to pay forpost stabilization services provided from August 16, 2020, to August 18, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on March 25, 2019.You asked the Plan to pay forthe services provided. You say that the services were provided to the enrollee in good faith.The Plan denied your request. The Plan says the claim was received past the allowed timeframe.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.The record shows that a valid claim for the services provided was not filed until August27, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay forthe medical services provided on March 25, 2019
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for outpatient mental health services (90791, 90792) provided on July 30, 2020.
You asked the Plan to waive the coinsurance for outpatient mental health services. You say that you should not be charged because the provider did not help you. The Plan denied your request. The Plan says this processed 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 20% coinsurance for outpatient mental health care. You have been asked to pay a $78.40 coinsurance for outpatient mental health services ($392 total allowed amount x 20% = $78.40). 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 outpatient mental health services (90791, 90792) provided on July 30, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the stay is 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 pre-approve 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 identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 pre-approve SNF care.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran ultrasound provided on August 11, 2020.You asked the Plan to waive the copayment foran ultrasound. You say that you request assistance with 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 $155 copayment for each radiological diagnostic service. You have been asked to pay the allowed amount of $145.07, which is less than the $155 copayment for an ultrasound. An ultrasound falls 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 foran ultrasound provided on August 11, 2020
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelumbar fusion -single level (low back surgery) (CPT Code 22612).You asked the Plan to pre-approvethe surgery. You say that you are in excruciating pain and need this surgery done as soon as possible.The Plan denied your request. The Plan says your doctor said you had back pain and did not give us any other information. The Plan states before they can approve the request, the Plan needs notes that show you have not used nicotine products for at least six (6) weeks.The Plan states they also need an imaging report that says you have an unstable spine.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found current evidence based medical literature would not support the medical necessity of fusion at this time. The provider imaging studies provided including magnetic resonance imaging (MRI) and computerized tomography (CT) scan do not demonstrate spondylolisthesis at the requested surgical level. Evidence of existing or inevitable intraoperative instability has not been documented. Furthermore, there is limited documentation supporting that smoking cessation has occurred for at least six (6) weeks. Therefore, in this reviewer's opinion, the request for L4-L5 fusion is not medically necessary for treatment of your medical condition.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 surgery have not been met.Therefore, we decided that the Plan does not have to pre-approvelumbar fusion -single level (low back surgery) (CPT Code 22612).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided from May 31, 2020, to June 3, 2020.
You asked the Plan to waive the copayment for emergency care. You say that you paid the $80 copayment and disagree with the additional 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 $120 copayment for emergency care. You have been asked to pay a $120 copayment for emergency care. Emergency care 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 emergency care provided from May 31, 2020, to June 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe limited oral evaluation (D0140), the periapical x-ray (D0220), crown (D2740), core build up (D2950), the extraction (D7210), bone graft (D6104), guided tissue regeneration (D4266), the implant (D6010), and the second stage implant surgery (D6011) provided from September 3, 2020, to September 22, 2020.You asked the Plan to reimburse you forthe dental services. You say that you were in an accident on September 2, 2020. You say that you returned to the dentist the following day due to pain and inability to chew. You say that you had another fractured tooth which needed to be extracted.The Plan denied your request. The Plan says the services you received are dental in nature. The Plan says dental services are not covered. The Plan also says that the services you received are not listed as covered supplemental dental services.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 services you are asking the Plan to reimburse you forinvolve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare.Additionally, though the Plan offers a dental benefit in excess of Medicare coverage, theservicesyou receivedare not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you forthe limited oral evaluation (D0140), the periapical x-ray (D0220), crown (D2740), core build up (D2950), the extraction (D7210), bone graft (D6104), guided tissue regeneration (D4266), the implant (D6010), and the second stage implant surgery (D6011) provided from September 3, 2020, to September 22, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forhome infusion therapy (S9342) provided from February 15, 2020, to March 15, 2020.You asked the Plan to pay forhome infusion therapy. You say that this is supported by the records.The Plan denied your request. The Plan says this was not billed with a valid code.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 S9342 is not supported in the medical record. Specifically, this code has a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage ofhome infusion therapy have not been met.Therefore, we decided that the Plan does not have to pay forhome infusion therapy (S9342) provided from February 15, 2020, to March 15, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided by THE Fire DEPT on March 6, 2020.You asked the Plan to pay forthe ambulance services. You say that you fell and needed assistance getting back up.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on March 6, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services provided by THE Fire DEPT on March 6, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided, by an out of network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. 
The Plan denied your request. The Plan says these services were not referred by a network provider. The plan 
says that these services were provided via telehealth at a non-participating facility. 
 
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 physician services provided by an out of network 
(OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe dental services (D0140, D0220, D2393) you received on July 13, 2020.You asked the Plan to pay forthe dental services. The Plan denied your request. The Plan says these services 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 services are not among those covered under this benefit. The Plan covers only those dental services for which the dental codes are listed in the Evidence of Coverage. Dental codes D0140, D0220, and D2393, are not listed, and therefore are not covered.Therefore, we decided that the Plan does not have to pay forthe dental services (D0140, D0220, D2393) you received on July 13, 2020