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

We decided that the Plan does not have to pay for office visit services provided to the enrollee from July 21, 2020 to July 23, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says a manifestation diagnosis code cannot be billed as first position on the claim.
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 the denied codes is: CPT 99222: initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of moderate severity. Physicians typically spend 50 minutes at the bedside and on the patient's hospital floor or unit. CPT 99232: subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of the 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Physicians typically spend 25 minutes at the bedside and on the patient's hospital floor or unit. CPT 99239: hospital discharge day management services, more than 30 minutes
We asked our coding 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 services at issue in this case were not supported by the medical records. Our coding reviewer found the claim submitted by provider has ICD 10 D63.1 Anemia in Chronic Kidney Disease. This diagnosis describes the manifestation of an underlying disease, and not the disease itself. An instructional note is listed under this code stating; "Code first underlying chronic kidney disease". This diagnosis code should not be reported as the primary diagnosis. We looked at this coder'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 office visit services provided to the enrollee from July 21, 2020 to July 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on April 1, 2020.
You asked the Plan to waive the copayment for the office visit. You say that you are entitled to see a specialist
not a nurse. You say that you are requesting a refund of your copayment. The Plan denied your request. The
Plan says the copayment 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 $30
copayment for each specialist visit for Medicare-covered benefits.
You have been asked to pay a $30 copayment for the office visit. The office visit falls within the
"Physician/Practitioner services, including doctor's office visits" benefit category. The records show that
services were provided during the visit. 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 office
visit provided on April 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe visit (CPT 99213) provided to the enrollee on June 23, 2020.You asked the Plan to pay forthe visit. The Plan denied your request. The Plan says this visit is included in the global surgical package.The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global surgery procedures includes payment for the above services related to the surgery when furnished by the physician who performs the surgery. We looked at the file and Medicare rules. The surgical procedure provided to the enrollee has a global period of 90 days. The visit in question was provided within 90 days of the surgery, which means the visit is included global surgery package and separate payment cannot be made. Based on this information, we decided that Medicare rules for coverage of the visit have not been met.Therefore, we decided that the Plan does not have to pay forthe visit (CPT 99213) provided to the enrollee on June 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two surgical extractions.

You asked the Plan to pre-approve the extractions. The Plan denied your request. The Plan says this service is not covered under the enrollee's benefit plan. The Plan also says that the enrollee has coverage for preventive services, which does not include extraction 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.

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 two surgical extractions.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to make additional payment forthe services described by code 77014 provided during a qualifying clinical trial from April 15, 2020 to April 23, 2020.You asked the Plan to make additional payment forthese clinical trial services. You say that these were incorrectly denied as duplicates since the second claim was filed after Original Medicare made payment for code 77014 for which additional payment is due from the Plan.The Plan denied your request. The Plan says that these were denied as duplicate correctly, and the original denial of 77014 was also correct because 77014 is a noncovered service.The Plan must follow Medicare rules. Medicare rules say that, while Original Medicare pays for the routine costs related to a clinical trial, MA plans are required to pay the difference between Original Medicare cost sharing and the Plan cost sharing for the same service category. The contract states that there is no copayment for radiation therapy provided in a freestanding radiology facility. In this case, we find that the Plan has incorrectly denied payment for the amount assessed as cost sharing for code 77014. The Original Medicare contractor covered this code in a subsequent remittance and assessed a cost share of $22.86. The Plan cannot decide to which items qualify for payment bythe Plan, when the service was covered by Original Medicare under the clinical trial. The Plan also incorrect applied the Plan cost sharing to the claims. For the dates 4/15 through 4/22, a $10 copayment was applied, and a $40 copayment was applied for 4/23. The contract, however, states that enrollees do not have a copayment for this service in a freestanding facility. Review of the NPI number of this facility shows that this facility is a radiation clinic, which a reasonable layperson would consider a freestanding facility. As such, the additional payment owed by the Plan for dates 4/15 through 4/22 would be $32.86, and the amount owed for 4/23 would be $62.86. Since there is no copayment according to the plan contract, the Plan must pay the entire amount which the Medicare contractor assessed as coinsurance.
Therefore, we decided that the Plan has to make additional payment forthe services described by code 77014 provided during a qualifying clinical trial from April 15, 2020 to April 23, 2020.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/orsend 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray (71045) provided July 31, 2020.
You asked the Plan to pay for the x-ray. You say that the x-ray was medically necessary. The Plan denied your
request. The Plan says the CPT code billed shares a column I / column II relationship with another code billed
and is not separately payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 71045
has a bundled relationship with code 32555 and cannot be paid as billed. This code cannot be paid as a separate
line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided
that the Plan does not have to pay for an x-ray (71045) provided July 31, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forhome infusion therapy (S9328) provided on January 27, 2020.You asked the Plan to pay forhome infusion therapy. You say that the enrollee was referred by an in-network provider for this service.The Plan denied your request. The Plan says this service 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 S9328 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 of home infusion therapy have not been met.Therefore, we decided that the Plan does not have to pay forhome infusion therapy (S9328) provided on January 27, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation of portable x-ray equipment and personnel and set-up of portable x-ray equipment provided on July 22, 2020 by an OON provider.
You asked the Plan to pay for the transportation and set-up of portable x-ray equipment. You say that the Plan is incorrect in their denial. The Plan denied your request. The Plan says the services were rendered by a non-network provider who does not work with the enrollee's health plan. The Plan also says that the enrollee was referred by a non-network provider.
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 transportation of portable x-ray equipment and personnel and set-up of portable x-ray equipment provided on July 22, 2020 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe medical items/services to be provided by an out-of-network (OON) provider.You asked the Plan to pre-approvethe medical items/services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested items/services can be provided by a network provider.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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide theitems/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvethe medical items/services to be provided by an out-of-network (OON) provider
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waivethe copayment for the ultrasound you had on June 25, 2020.You asked the Plan to waivethe copayment. The Plan denied 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 $100 copayment for each covered x-ray.Review of the file shows that you had an ultrasound on June 25, 2020. You have been asked to pay a $100 copayment for the ultrasound. The ultrasound falls within the outpatient diagnostic tests 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 ultrasound you had on June 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a routine ophthalmologist eye exam with refraction (S0621) provided on July 17, 2020.
You asked the Plan to pay for a routine ophthalmologist routine ophthalmologist eye exam with refraction. You say that the services should be covered. The Plan denied your request. The Plan says there is a $35 copayment for specialist's visits and refractions are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we decided that the Plan does not have to pay for a routine ophthalmologist eye exam with refraction (S0621) provided on July 17, 2020.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pre-approvethe porcelain fused crown. We decided that the Plan does not have to pre-approvethe core buildup and gingivectomy.You asked the Plan to pre-approvethese services. You say that you disagree with the denial. The Plan says that the services are not medically necessary.We decided that the Planhas to pre-approvethe porcelain fused crown.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 Plan covers these services when the services are medically necessary and reasonable. 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 these services. Our reviewer says that 
the crown is medically necessary and the core buildup is not medically necessary. Our physician reviewer found the enrollee has a prior endodontic filling and post and crown on tooth #31. It is noted that there is recurrent decay on the distal aspect of the tooth. It will be taken as fact that there is recurrent decay at the distal of the tooth, and as such the existing crown would no longer be serviceable.  It does not appear that a new core would be necessary as there is ample distal structure seen that would act as the new distal margin for a replacement crown. As the only appropriate method for replacing a crown with a defective margin in an inaccessible area is to replace that crown, the replacement crown would be considered medically necessary.  A core buildup does not appear to be necessary to retain a new crown and would not be considered medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the porcelain fused crown have been met. Therefore, we decided that the Plan has to pre-approvethe porcelain fused crown.We also decided that the Plandoes not have to pre-approvethe core buildup and gingivectomy.We looked at this physician's review, the file, and Medicare rules. The physician states that the core buildup is not medically necessary. The gingivectomy is not covered by the enrollee's supplemental dental benefit. Based on this information, we decided that the Plan's rules for coverage of the core buildup and gingivectomy have not been met. Therefore, we decided that the Plan does not have to pre-approvethe core buildup and gingivectomy.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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for telemedicine specialist office visits provided on June 8, 2020, and September 9, 2020. You asked the Plan to waive the copayment for the services. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claims were processed accordingly with your 2020 EOC benefits. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your EOC states for specialist office visit there will be a $45 copayment that applies per visit. In addition, the Plan states they sent out a written communication to all members explaining how the telemedicine service has expanded its availability to cover Covid-19 testing and treatment at no member cost share. That document states regular specialist cost sharing will apply to all expanded telemedicine services not related to COVID-19 testing. Review of the file shows that you received telemedicine specialist office visits provided on June 8, 2020, and September 9, 2020. You were assessed a $20.60 copayment per date of service. Therefore, you were asked to pay the correct amount. 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 telemedicine specialist office visits provided on June 8, 2020, and September 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the immediate upper denture (D5130) and the partial lower denture (D5212) provided on January 20, 2020.
You asked the Plan to pay for the dental items. You say that the dentures were approved on November 20, 2019. You say that they were then denied on May 29, 2020. The Plan denied your request. The Plan says dentures are not listed as a covered service. The Plan also says that you signed a treatment plan informing you that the dentures would not be covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. The record shows the record shows that your authorization letter states that payment for approved services depends on the plan's benefit limitations and eligibility at the time of service. Therefore, we decided that the Plan does not have to pay for the immediate upper denture (D5130) and the partial lower denture (D5212) provided on January 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe cardiology visit you had on June 8, 2020.You asked the Plan to waive the copayment forthe cardiology visit. You say that you were under the impression that all copayments were being waived.The Plan denied your request. The Plan says it is waiving copayments for screening, testing, and treatment of COVID-19 only.  Copayments for other services are not being waived.  Therefore, the Plan says you were charged this copayment correctly.Therules 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 copayment for specialist visits. You have been asked to pay a $20 copayment for the cardiology visit. The cardiology visit falls within the specialist visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe cardiology visit you had on June 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services you had on July 24, 2020.
You asked the Plan to waive the copayment for the lab services. You say that there should be no copayment for lab services with your annual physical The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that you were not charged a copayment for your annual physical. The Plan says that these lab services were performed by an outpatient hospital facility, not by your PCP.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 copayment for lab services. You have been asked to pay a $10 copayment for the lab services. According to your Evidence of Coverage, annual physical exams (for which there is no copayment), do not include lab services. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for lab services you had on July 24, 2020.