Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pay for the x-ray. We decided that the Plan does not have to pay for the injections.
You asked the Plan to pay for the x-ray and injections. You say that you would like reconsideration based on the records submitted. The Plan says that these services were billed incorrectly.
We decided that the Plan has to pay for the x-ray (72100). The Plan follows Medicare rules. The rules say that Medicare plans must make reasonable and diligent efforts to gather and forward information to the IRE.
The Plan has not forwarded sufficient documentation to substantiate the denial of CPT code 72100. Therefore, we decided that the Plan has to pay for the x-ray.
We also decided that the Plan does not have to pay for the injections (96374, 96375, J1170 and J1885). The Plan follows Medicare rules. Medicare rules say that providers must report services correctly.
The file does not support the services billed. Specifically, it is inappropriate to bill CPT codes 96374 and 96375 in a facility setting. Additionally, CPT codes J1170 and J1885 have a status code of N. This means that these codes are packaged services and payment is packaged into APC rates. Therefore, we decided that the Plan does not have to pay for the injections.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the spinal injection provided on February 18, 2020.
You asked the Plan to waive the copayment for the spinal injection. You say that you would not have gone to the facility if you had known the surgery would not be covered with financial assistance. 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 $325 copayment for outpatient surgery, including services at hospital outpatient facilities and ambulatory surgical centers. You have been asked to pay a $325 copayment for the spinal injection. the spinal injection falls within the "Outpatient surgery, including services 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 the spinal injection provided on February 18, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for high intensity focused ultrasound ablation (C9717) provided on July 24, 2019.
You asked the Plan to pay for high intensity focused ultrasound ablation. You say that you were told this would be covered. The Plan denied your request. The Plan says that this is not covered by Medicare.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. The high intensity focused ultrasound ablation at issue was provided by a contract provider. The file does not show that the Plan provided notice that high intensity focused ultrasound ablation would not be covered. Under Medicare rules, this means high intensity focused ultrasound ablation is considered approved by the Plan. Therefore, we decided that the Plan has to pay for high intensity focused ultrasound ablation (C9717) provided on July 24, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical extractions (D7250) inhalation of nitrous oxide/analgesia (D9230) unspecified preventive procedure (D1999) to be provided by an out of network
You asked the Plan to pre-approve the dental services. You say that you are in a lot of pain and needs this procedure before you get your dentures. The Plan denied your request. The Plan says enrollee's must receive their dental services from 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. The health plan contract specifically says that services must be performed by a participating general dentist. Prior authorization may be required and must be received by the plan's dental vendor from a participating dental provider. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve surgical extractions (D7250) inhalation of nitrous oxide/analgesia (D9230) unspecified preventive procedure (D1999) to be provided by an out of network
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 17, 2019 by an out
of network (OON) provider.
You asked the Plan to pay for the OON services. You say that the documentation supports the evaluation and
management of the enrollee. The Plan denied your request. The Plan says there is no record of a request for
authorization prior to offering the services.
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 OON services. Therefore, we decided
that the Plan does not have to pay for the medical services provided on October 17, 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 panel rendered on March 24, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was not billed correctly.
The Plan must follow Medicare rules. The rules say that the panel must be billed with procedure code 81479. The file shows that the panel was not billed with code 81479 but as a panel of codes. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the panel rendered on March 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 20, 2020 by an out of network (OON) provider.You asked the Plan to pay for the OON services. You say that the physician documentation supports treatment at the level of care billed.The Plan denied your request. The Plan says prior authorization was not obtained prior to rendering services.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 on January 20, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on August 14, 2019.You asked the Plan to pay for these services. You say that you disagree with the denial.The Plan denied your request. The Plan says there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay for the drug testing rendered on August 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 28, 2019, by an out-of-network provider.
You asked the Plan to pay for the out-of-network services. You say that the treatment received was medically necessary given the enrollee's history and treatment options. The Plan denied your request. The Plan says outpatient psychiatric visits are available in plan.
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan. The services at issue in this appeal were not provided in an emergency or urgent care situation. These services were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not have to pay for the medical services provided on August 28, 2019, by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 70549, CPT 70553) provided on February 13, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says one unit of each of these services has already been paid for.
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 additional units of CPT code 70549 and 70553 is not supported in the medical record. Specifically, the records show that one MRI and one MRA were provided on the date of service in question. The plan has paid for one MRI and one MRI. The additional units billed for these services are not supported by the records provided. 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 services (CPT 70549, CPT 70553) provided on February 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on October 29, 2019 by an out-of-network provider.You asked the Plan to pay for the dental services. You say that you were under the impression that dental services are like medical coverage and that you were able to go outside of network if conditions were warranted.The Plan denied your request. The Plan says you do not have out-of-network benefits.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.Review of the file show that you received dental services on October 29, 2019 from an out-of-network provider. Your EOC states, exclusions and limitations: services performed by an out-of-network dentist if your plan does not have out-of-network coverage. 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 dental services provided on October 29, 2019 by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on December 12, 2018.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid physician order.

The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.

We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on December 12, 2018.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic imaging services rendered on July 24, 2019.You asked the Plan to pay for these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the provider has opted out of Medicare.The plan must follow Medicare rules. Medicare rules say that Medicare plans may not pay for services given by a physician or other practitioner who has opted out of Medicare. We looked at case file and the Medicare rules. We confirmed that the provider has opted out of Medicare. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay for the diagnostic imaging services rendered on July 24, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the three bone replacement grafts (D7953 x3).You asked the Plan to pre-approve the bone replacement grafts. You say that the enrollee was covered under the Dental Platinum Rider for the period of May 1, 2019 to March 31, 2020. You also say that all dental claims incurred during this period should be processed under the benefits of the rider.The Plan denied your request. The Plan says these services are not covered under your plan. The Plan also says that your dental rider could no longer cover these services because the rider has been terminated as of March 31, 2020.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approve the three bone replacement grafts (D7953 x3).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on March 17, 2020 by an out
of network (OON) provider.
You asked the Plan to pay for laboratory tests. You say that most in-network providers cannot perform such
complex testing. The Plan denied your request. The Plan says the denial of payment for these services is
correct, because this provider is out-of-network with the Plan and the ordering provider is also out-of-network
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 the medical services provided on March 17, 2020
by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.You asked the Plan to pre-approve the LTACH services. You say that a LTACH admission is medically necessary for the enrollee.The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of a LTACH admission.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no certainty that the enrollee will require an inpatient hospital stay of more than 25 days. The enrollee will not require weaning. Additionally, the enrollee does not need the level of support of a LTACH and can reasonably receive services at lower level of care.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist device.
You asked the Plan to pre-approve the motion assist device. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the services are not supported by the records received.
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 motion assist device. Our reviewer says that the requested device is not reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member. Our physician reviewer found at this time the requested robotic orthosis is not proven to be more beneficial for treatment of the member's 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 motion assist device have not been met. Therefore, we decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist device.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on January 13, 2020.
You asked the Plan to waive the copayment for the ambulance transport. You say that The Plan denied your request. The Plan says that the cost sharing applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 copayment for per one-way ambulance trip. You have been asked to pay a $200 copayment for the ambulance transport. the ambulance transport falls within the per one-way ambulance trip 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 ambulance transport provided on January 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal maintenance.
You asked the Plan to pre-approve the periodontal maintenance. You say that you are at risk for heart disease and a stroke if you do not have regular periodontal maintenance cleanings, as required by your dentist. You also say that you need a periodontal maintenance cleaning every 3 months. The Plan denied your request. The Plan says this service is not covered under the benefit plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve periodontal maintenance.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the special pump services rendered on March 4, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services are not separately payable.
The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are
statutorily excluded.
The provider submitted a claim for procedure code 99190 (special pump services). This code has a status
indicator of X and no separate Medicare payment. Payment is included in the payment to the facility.
Therefore, we decided that the Plan does not have to pay for the special pump services rendered on March 4,
2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing rendered on December 11, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the definitive drug testing rendered on December 11, 2019.