Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for oral exam (D0120) cleaning (D1110) topical application of fluoride (D1208) intraoral-periapical first x-ray (D0220) and intra-periapical each additional x-rays (D0230) and bitewing x-rays (D0274) provided December 19, 2019.
You asked the Plan to pay for the dental services. You say that please review this claim again. The services were provided to the enrollee as an out of network provider and the services were preventive works. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to services being rendered.
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 when rendered by an out of network provider. Therefore, we decided that the Plan does not have to pay for oral exam (D0120) cleaning (D1110) topical application of fluoride (D1208) intraoral-periapical first x-ray (D0220) and intra-periapical each additional x-rays (D0230) and bitewing x-rays (D0274) provided December 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on October 15, 2019.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are not covered.
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 lab services at issue in this appeal were requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on October 15, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forhome health services provided to the enrollee from December 2, 2019 to December 8, 2019.You asked the Plan to pay forhome health services provided to the enrollee. You say that this claim should be paid. The Plan denied your request. The Plan says claim record shows the claim form does not have the appropriate home health data to process and pay claim. The final claim must have the appropriate Type of Bill 329. In this case, the claim submitted has errors preventing payment. The Plan states a corrected claim would be reviewed if submitted. Medicare rules for coverage of the services billed have not been met.Therefore, we decided that the Plan does not have to pay forhome health services provided to the enrollee from December 2, 2019 to December 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit (99203) and echocardiography (93306) provided on December 10, 2019.
You asked the Plan to waive the copayment for an office visit and echocardiography. You say that you should not have to pay for these services. The Plan denied your request. The Plan says these services 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 $45 copayment for specialist office visits and a $50 copayment for diagnostic procedures and tests. You have been asked to pay $45 for s specialist office visit and $50 for echocardiography, which is a diagnostic procedure. 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 (99203) and echocardiography (93306) provided on December 10, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forassistant surgeon services provided during a knee arthroscopy provided on May 8, 2019.You asked the Plan to pay forassistant surgeon services provided with the knee arthroscopy procedure. You say that the records provided support the medical necessity of the service in dispute.The Plan denied your request. The Plan says the services of an assistant surgeon, co-surgeon, or surgical team are not covered for this procedure.The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT code 29873. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for assistant surgeon services provided with the knee arthroscopy procedure have not been met.Therefore, we decided that the Plan does not have to pay forassistant surgeon services provided during a knee arthroscopy provided on May 8, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from November 9, 2019 to November 16, 2019 and billed under code S9328.
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 this code has a status indicator not payable on Medicare claims. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, the code billed has a status code indicator of "I" which that does not allow payment on Medicare claims. Therefore, we decided that the Plan does not have to pay for home health services provided to the enrollee from November 9, 2019 to November 16, 2019 and billed under code S9328.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on April 26, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the outpatient clinic visit (G0463) and chest x-ray (71046) provided on April 26, 2019.. You say that you would like reconsideration because pre-authorization for these services has not been required in the past. The Plan denied your request. The Plan says utilization of network providers is required when possible and available.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on April 26, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on November 19, 2019.
You asked the Plan to pay for the genetic testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that genetic testing is only covered for certain indications. 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 genetic testing. Our reviewer says that the documentation does not support that the services provided are medically reasonable or necessary. Our physician reviewer found the enrollee has a diagnosis of malignant neoplasm of stomach. Because of the large number of mutations contained in expanded panels, it is not possible to determine clinical validity for the panels as a whole. The use of expanded cancer mutation panels for selecting targeted cancer treatment is not proven. The documentation does not support that the enrollee has Non-Small Cell Lung Cancer (NSCLC). The enrollee did not meet criteria for the Guardant360 Tumor Sequence Assay provided. 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 genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on November 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waivethe copayment for the office visit you had on November 12, 2019.You asked the Plan to waivethe copayment. The Plandenied your request. The Plan says you are responsible for the cost share.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 $50 copayment for each specialist office visit. Review of the file shows that you had a specialist visit on November 12, 2019. You have been asked to pay a $50 copayment for the visit. The visit falls within the physician services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waivethe copayment for the office visit you had on November 12, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the emergency room visit or the central venous catheter insertion procedure provided on December 7, 2019 and December 9, 2019.You asked the Plan to waive the copayments for the emergency room visit and the catheter insertion procedure. You say that you do not believe you should be responsible for the copayments. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $120 copayment for emergency care and a $250 copayment for each outpatient surgery and/or services at an ambulatory surgical center. You have been asked to pay a $115.76 copayment for the emergency room visit, which is less than the standard copayment amount. You have also been asked to pay a $250 copayment for the catheter insertion procedure. The emergency room visit falls within the "Emergency care" benefit category. The catheter insertion procedure falls within the "Outpatient hospital services" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the emergency room visit or the central venous catheter insertion procedure provided on December 7, 2019 and December 9, 2019.
Appeal type: Imaging
Decision: Partially Favorable

We decided that the Plan has to pay forthe diagnostic mammogram. We decided that the Plan does not have to pay forthe mammogram. You asked the Plan to pay forthe diagnostic mammogram. You say that this was a follow-up scan after an abnormality on your screening mammogram.The Plan says that the cost share was applied based on your plan benefits.We decided that the Planhas to reduce the copayforthe diagnostic mammogram.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles, and coinsurance).The diagnostic mammogram is considered a diagnostic radiological service. Your contract with the plan says that you must pay a $40 copay for Medicare-covered diagnostic radiological services. Based on the plan contract, youcannot be asked to pay more than $40 for the service provided. Therefore, we decided that the Plan has to reduce the copayforthe diagnostic mammogramyoureceived on November 18, 2019. 
We also decided that the Plandoes not have to completely waive the cost shareforthe mammogram.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles, and coinsurance). The service you received falls under the outpatient diagnostic tests benefit category. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.Therefore, we decided that the Plan does not have to completely waive the cost shareforthe mammogramyou received on November 18, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tertiary level referral.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your
request. The Plan says the records do not show a need for a higher level of care.
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 referral. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found in this case a request for a tertiary consult would largely be for your convenience at this point in
time. Given that you have not had any recurrence of symptoms that have necessitated acute treatment or further
work up, the tertiary level of would exceed your needs at this interval. In as much the requested vision would
not meet the Medicare definition of medical necessity.
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 referral have not been met. Therefore, we decided that the Plan does not
have to pre-approve a tertiary level referral.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 12, 2019 by an out of network (OON) provider.You asked the Plan to pay for the out of network medical services. You say that the enrollee needed surgery and the doctor was the only one who could do the surgery.The Plan denied your request. The Plan says the non-urgent services provided out of network 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 did not pre-approve the services being provided out of network. We found no exception that would require the Plan to pay for the out of network care in dispute.Therefore, we decided that the Plan does not have to pay for the medical services provided on September 12, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecotton tipped applicators.You asked the Plan to pre-approvecotton tipped applicators. You say that you need cotton tipped applicators for wound care.The Plan denied your request. The Plan says cotton tipped applicators are non-reusable,disposable,supply items available in stores without a prescription.The Plan covers all items that Medicare covers. Medicare rules state that cotton tipped applicators are not covered because they are hygienic items that are non-reusableand not considered wound dressing. While cotton tipped applicatorsmay be appropriate in this case, neither the Plan nor Medicare offers coverage of these items.Therefore, we decided that the Plan does not have to pre-approvecotton tipped applicators.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for RestoreX Penile Traction Therapy Device provided on October 23, 2019 by an out of network (OON) provider.You asked the Plan to pay for the RestoreX Penile Traction Therapy Device. You say that if you did not purchase this device then it might have led to another surgery in the future. This is a new device that should improve results so you do not have to go through the injections again.The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to services being rendered. This device is also not a covered benefit.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 RestoreX Penile Traction Therapy Device provided on October 23, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe chest x-ray rendered on October 16, 2019.You asked the Plan topay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 71045 is not separately payable.The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.The provider submitted a claim for procedure codes 71045 and 74022. Code 71045 is a column II code with a modifier indicator of 1 when billed with column I code 74022. Code 710453 was not billed with an appropriate modifier to allow for separate payment.Therefore, we decided that the Plan does not have to pay forthe chest x-ray rendered on October 16, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from November 26, 2019 to November 29, 2019.
You asked the Plan to waive the copayment for the inpatient hospital care. You say that the copayment should be waived because you were released too soon. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 copayment per day for days 1-5 each time you are admitted to an acute care hospital. You have been asked to pay a $350 copayment for each day of the inpatient hospital care. ($350 x 3 days = $1,050). The inpatient hospital care falls within the "Inpatient hospital care" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from November 26, 2019 to November 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on September 16, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the laboratory services. 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.
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 the laboratory services provided on September 16, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider on December 4, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are available in-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 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 you by an out-of-network provider on December 4, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic testing and outpatient surgery provided on November 27, 2019 to December 6, 2019 by an out of network (OON) provider.You asked the Plan to pay for diagnostic testing. You say that you would like this bill paid. You say that you may as well not even have insurance.The Plan denied your request. The Plan says these services could have been provided in-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 diagnostic testing and outpatient surgery provided on November 27, 2019 to December 6, 2019 by an out of network (OON) provider