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

We decided that the Plan does not have to waive the copayments for the therapeutic injections you received at an outpatient hospital facility on March 29, 2020 and March 30, 2020.
You asked the Plan to waive the copayments for the therapeutic injections. You say that you are not responsible for this amount. The Plan denied your request. The Plan says you were charged these copayments correctly. The Plan says that because the allowed amount for each date is less than your copayment, you are responsible for the full allowed 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 $150 copayment for services at an outpatient hospital facility. You have been asked to pay a $150 copayment for each date of service for the therapeutic injections. The therapeutic injections fall within the services at an outpatient hospital facility 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 therapeutic injections you received at an outpatient hospital facility on March 29, 2020 and March 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the established patient office or other outpatient visit and related services (20610, J1040, 73562, 99213) provided on May 20, 2020, by an out of network (OON) provider.
You asked the Plan to pay for the office visit and related services. You say that you received conflicting information regarding prior authorization requirements. The Plan denied your request. The Plan says prior authorization was not obtained by the facility or the provider; therefore, payment has been correctly denied.
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 established patient office or other outpatient visit and related services (20610, J1040, 73562, 99213) provided on May 20, 2020, by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a garment belt (A4467).
You asked the Plan to pre-approve a garment belt. You say that you need this to help you move around and
bend over. The Plan denied your request. The Plan says that this is not a covered item.
The Plan must follow Medicare rules. The rules say elastic or other fabric support garments with or without
stays or panels do not meet the statutory definition of a brace because they are not rigid or semi -rigid devices
and are denied as non-covered. Therefore, we decided that the Plan does not have to pre-approve a garment belt
(A4467).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approvegenetic testing thyroid including CPT codes 81210, 81479, 81401, and 81275You asked the Plan to pre-approvegenetic testing thyroid. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are not medically necessary.The Plan follows Medicare rules. Medicare rules say that genetic testing thyroid 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 pre-approve genetic testing thyroid. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found you have had a thyroid nodule aspirated. The pathology showed atypia of undetermined significance/follicular lesion of undetermined significance. LCD L35396 states that ThyraMIR, ThyGenX and Afirma services will be considered reasonable and necessary when there is indeterminate pathology on fine needle aspiration. Therefore, you do not meet criteria for the requested services.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genetic testing thyroid have not been met.Therefore, we decided that the Plan does not have to pre-approvegenetic testing thyroid including CPT codes 81210, 81479, 81401, and 81275
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital stay provided on December 23, 2019 to December 27, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the inpatient hospital stay. You say that you are attaching notes for the medical justification of your treatments. Please review and consider your claims for payment for services rendered in good faith. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 inpatient hospital stay provided on December 23, 2019 to December 27, 2019 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided by you on May 25, 2020.
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive
order for treatment in place. 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 May 25, 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 for the ambulance services provided by you on May
25, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on May 14, 2020.
You asked the Plan to pay for drug tests. You say that you are appealing with records. The Plan denied your
request. The Plan says the denial of payment for these services is correct, because the documentation submitted
does not include a valid physician order, lab requisition, or medical records stating exactly which tests were to
be performed.
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 services billed on this claim. Based on this information, we
decided that Medicare rules for coverage of drug tests have not been met. Therefore, we decided that the Plan
does not have to pay for drug testing provided on May 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on July 7, 2020.
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says
non-emergent, non-urgent services with out-of-network providers require prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan 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 subsequent nursing facility care provided on July 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the connector bar (D6920) provided on July 29, 2020.
You asked the Plan to pay for the dental item. You say that the dentist advised that this dental item was necessary for your oral health. The Plan denied your request. The Plan says prosthodontic services are specifically not covered. The Plan says that the connector bar is considered to be a prosthodontic service and therefore is not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the connector bar not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the connector bar (D6920) provided on July 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown re-cement (D2920) provided on June 3, 2020.
You asked the Plan to pay for the dental services. You say that you understand what the Evidence of Coverage says. You also say that you disagree with it. The Plan denied your request. The Plan says the crown re-cement is 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 crown re-cement is not among those covered under this benefit. The Evidence of Coverage specifically states that the only crown repair code that is covered is D2980. Therefore, we decided that the Plan does not have to pay for the crown re-cement (D2920) provided on June 3, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for wound debridement provided on June 26, 2020.
You asked the Plan to waive the copayment for wound debridement. You say that you were treated for an infected wound and did not receive a surgery. 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 $335 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. You have been asked to pay the allowed amount of $295.36, which is less than the $335 copayment for wound debridement. Wound debridement falls within the outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for wound debridement provided on June 26, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient therapy provided by an out-of-network provider on July 1, 2020.
You asked the Plan to pay for outpatient therapy. You say that you submitted medical records and necessity documents to consider this claim for payment. You say that the claim should be reprocessed for payment. The Plan denied your request. The Plan says the provider is not a network provider with the Plan.
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 outpatient therapy provided by an out-of-network provider on July 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the electroencephalogram (EEG) services coded 95822, the nerve conduction studies services coded 95909, the unlisted neurological or neuromuscular diagnostic procedure services coded 95999, and the needle electromyography services coded 95886 provided on February 18, 2020.
You asked the Plan to pay for the electroencephalogram (EEG) services, the nerve conduction studies services, the unlisted neurological or neuromuscular diagnostic procedure services, and the needle electromyography services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 codes 95822, 95909, 95999, and 95886 are not supported in the medical record. Specifically, the documentation submitted does not support that code 95822 was performed. The documentation indicates that intraoperative monitoring was performed. there is a more appropriate CPT that should be used to
bill for the service provided. The documentation submitted does not support that that code 95909 was performed. The documentation indicates that electromyography for monitoring of pedicle screw placement was performed. there is a more appropriate CPT that should be used to bill for the service provided. The documentation submitted does not support that this code was performed. The documentation indicates that Train of Four Testing/Monitoring was performed which does not meet the CMS guidelines of CPT code 95999. Therefore, it is inappropriate to bill the code for neuromuscular junction testing for Train of Four Monitoring.
The submitted medical records do not support that code 95886 was repeated. Therefore, the service, number of units and submitted modifiers cannot be verified.
Based on this information, we decided that Medicare rules for coverage of the electroencephalogram (EEG) services, the nerve conduction studies services, the unlisted neurological or neuromuscular diagnostic procedure services, and the needle electromyography services have not been met. Therefore, we decided that the Plan does not have to pay for the electroencephalogram (EEG) services coded 95822, the nerve conduction studies services coded 95909, the unlisted neurological or neuromuscular diagnostic procedure services coded 95999, and the needle electromyography services coded 95886 provided on February 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe enteral feeding supplies provided from March 18, 2020 to April 16, 2020.You asked the Plan to pay forthe enteral feeding supplies. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the items billed are not supported by the documentation.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid proof of delivery for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay forthe enteral feeding supplies provided from March 18, 2020 to April 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the surgical extraction (D7210), the initial 15 minutes of deep sedation (D9222) and the additional 15 minutes of deep sedation (D9223) provided on February 26, 2020.
You asked the Plan to reimburse you for the surgical extraction and deep sedation. You say that you have ongoing sinus infections. You say that you have been in a lot of pain. You say that you were advised you have cellulitis in your face. You also say that these services should be covered under your medical plan. The Plan denied your request. The Plan says the services that you received are dental in nature. The Plan says surgical extractions are not listed as a covered service. The Plan says that the deep sedation is 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 services you received are not among those covered under this benefit. Additionally, the services you are asking the Plan to reimburse you for involve 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. Therefore, we decided that the Plan does not have to reimburse you for the surgical extraction (D7210), the initial 15 minutes of deep sedation (D9222) and the additional 15 minutes of deep sedation (D9223) provided on February 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection services coded 62324 and 64450 provided on June 19, 2019.
You asked the Plan to pay for the injection services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 codes 62324 and 64450 are not supported in the medical record. Specifically, the documentation submitted did not include documentation for the billed date of service. Based on this information, we decided that Medicare rules for coverage of the injection services have not been met. Therefore, we decided that the Plan does not have to pay for the injection services coded 62324 and 64450 provided on June 19, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approvean MRI of the upper extremity joint.You asked the Plan to pre-approvean MRI of the upper extremity joint. You say that the requested MRI of the upper extremity joint is medically necessary.The Plan denied your request. The Plan says that the requested MRI of the upper extremity joint is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only whenthey are medically necessary. 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 an MRI of the upper extremity joint. Our reviewer says that the requested MRI of the upper extremity joint is medically necessary. Our physician reviewer found this enrollee presents with an approximate 3-month history of right shoulder pain with significant functional limitations in activities of daily living. Pain interrupts sleep. Clinical exam findings are consistent with rotator cuff and biceps tendon pathology, and radiographic evidence of subacromial space narrowing and acromioclavicular joint arthritis. Conservative treatment has included on-going activity modification, NSAIDs, subacromial cortisone injection, and home exercise program without significant improvement. Under consideration is a request for right shoulder MRI. Current evidence based medical guidelines support MRI as the next imaging study. There is evidence of more than 6-weeks of physician directed treatment with follow-up documenting failure of conservative treatment. Therefore, this request for right shoulder MRI is medically reasonable and necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI of the upper extremity joint have been met.Therefore, we decided that the Plan has to pre-approvean MRI of the upper extremityjoint.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services and an influenza vaccine provided on February 25, 2020.
You asked the Plan to pay for the laboratory services and an influenza vaccine. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the serviced 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 laboratory services and an influenza vaccine provided on February 25, 2020.