Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care services coded 99233 provided on June 18, 2020
You asked the Plan to pay for the subsequent hospital care 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 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, the CPT Code Manual definition of code 99233 is subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, 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 unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are spent at the bedside and on the patient's hospital floor or unit. We find that CPT code 99233 is not supported in the medical record. Specifically, this service was billed with code 99291 (critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) for the same date of service. Based on this information, we decided that Medicare rules for coverage of the subsequent hospital care services have not been met. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care services coded 99233 provided on June 18, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of intraoral x-rays provided on August
10, 2020.
You asked the Plan to pay for the complete series of intraoral x-rays. You say that the last x-ray you had was
taken was not paid for by the Plan. The Plan denied your request. The Plan says benefits for this service have
been satisfied and the frequency limitation has been exceeded.
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, full mouth or panoramic x-rays are
limited to one procedure every three years. The record shows that you received a panoramic x-ray on February
7, 2019, and your full mouth or panoramic x-rays benefit has been exhausted. Therefore, we decided that the
Plan does not have to pay for the complete series of intraoral x-rays provided on August 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the treatment of post-surgical complications (D9930) provided on July 16, 2020.
You asked the Plan to pay for the dental service. You say that you had a tooth extracted. You say that the next day you had additional problems called dry socket. You say that the dentist advised you to come in to get additional medication for the pain. The Plan denied your request. The Plan says the treatment of post-surgical complications 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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the treatment of post-surgical complications (D9930) provided on July 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

The rules say that plans must pay for a medical service or item ifregular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.The rules say that plans may choose the networks of providers available to enrollees and may require enrollees to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in the Medicare Managed Care Manual, Chapter 1, Section 20.2.If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that, with limited exceptions, members of the Plan must use network providers to get medical care and services. The only exceptions are emergencies, urgently needed care when the network is not available (generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan authorizes the use of out-of-network providers. You can find this information on page 14 of the Plan's 2020 Evidence of Coverage.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to hold you harmless for the lower limb prostheses provided on February 27, 2019.
You asked the Plan to hold you harmless for the prostheses. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that the comparison code is not given, and the reason why the comparable code cannot be used is not given.
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. You were referred for the prostheses by a contract provider. The file does not show that the Plan provided notice that the prostheses would not be covered. Under Medicare rules, this means the prostheses is considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for the lower limb prostheses provided on February 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe specialist office visit provided on October 10, 2018.You asked the Plan to waive the copayment forthe specialist office visit. You say that you should not be responsible for the $35 copayment. 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 $35 copayment for each in-network specialist visit for Medicare-covered services. You have been asked to pay a $35 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office 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, wedecided that the Plan does not have to waive the copayment forthe specialist office visit provided on October 10, 2018.Your complaint about the provider's services is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the neck/spine.
You asked the Plan to pre-approve MRI. You say that you are requesting that the Plan review the necessary
documents for this testing. The Plan denied your request. The Plan says the denial of authorization for this MRI
is correct, because this test is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they 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 MRI. Our reviewer says that you do not
meet the Medicare criteria for the requested MRI. Our physician reviewer found there is no documentation of
adequate conservative measures for neck pain including a six-week trial of physical therapy. There are no red
flags for MRI at this time.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of MRI have not been met. Therefore, we decided that the Plan does not have to
pre-approve MRI of the neck/spine.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromonitoring services provided on April 30, 2019.
You asked the Plan to pay for the neuromonitoring services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the claim was billed untimely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the neuromonitoring services was not filed until August 3, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the neuromonitoring services provided on April 30, 2019.
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 the enrollee requires daily physician visits, rehab therapy, and wound care management. The Plan denied your request. The Plan says the enrollee's needs are being met in the current acute setting.
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 physician reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) for weakness and kidney failure, in the setting of an EC fistula and colostomy. The enrollee is receiving TPN and hemodialysis. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory work provided on September
29, 2020.
You asked the Plan to waive the copayment for the laboratory work. You say that you went for your annual
wellness visit and should not have to pay a copayment. 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 $5
copayment for diagnostic laboratory services and diagnostic procedures and tests (per day, per facility).
You have been asked to pay a $5 copayment for the laboratory work. The laboratory work falls within the
"Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows you
received diagnostic laboratory services in addition to the annual wellness 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 laboratory work provided on September 29, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe Vertiflex device for the enrollee.You asked the Plan to pre-approvethe Vertiflex device. You say that this device is medically necessary.The Plan denied your request. The Plan says this device is not covered by Medicare.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 Vertiflex device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental for spinal stenosis treatment. More research is needed to show safety and efficacy. The records do not show hardware is needed and no spinal instability clearly documented. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of theVertiflex device have not been met.Therefore, we decided that the Plan does not have to pre-approvethe Vertiflex device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forOffice or other outpatient visit for the evaluation and management of an established patient (99213) provided on January 25, 2019.You asked the Plan to pay foroffice visit. You say that you should not be responsible for the cost share.The Plan denied your request. The Plan says the cost share was 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 $35 copayment for Physician/Practitioner services, including doctor's office visits. You have been asked to pay a $35 copayment for office visit. This service falls within the Physician/Practitioner services, including doctor's office 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 pay forOffice or other outpatient visit for the evaluation and management of an established patient (99213) provided on January 25, 2019
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an ultrasound (76642) provided on January 16, 2020 by an out of network provider.
You asked the Plan to pay for the ultrasound. You say that the service should be covered. The Plan denied your request. The Plan says the service was non-emergent and there were network providers available that could provide the service.
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 service 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 an ultrasound (76642) provided on January 16, 2020 by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora diagnosticeye exam (92004) performed on September 18, 2020.You asked the Plan to waive the copayment fora diagnosticeye exam. You say that a representative of the Plan quoted a $0 copayment to you for these services.The Plan denied your request. The Plan says the correct copayment was applied.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 $40 copayment for each Medicare-covered eye exam. You have been asked to pay a $40 copayment for adiagnostic eye exam.A diagnostic eye exam which results in medical findings is distinct from a routine annual eye exam. A diagnosticeye exam falls within the "Vision 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 fora diagnostic eye exam (92004) performed on September 18, 2020.Your complaint about receiving erroneous or misleading information about your cost-sharing responsibility from a representative of the Planis not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on March 23, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe laboratory services. You say that you would like reconsideration because this testing was performed per the request of the referring in-network physician.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 forthe medical services provided on March 23, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay fortrain of four testing, unlisted neurological or neuromuscular diagnostic procedure provided March 10, 2020.You asked the Plan to pay forthe train of four testing. You say that you have attached all applicable information so that your claim can be processed appropriately. Please review enclosed documentation and remit payment accordingly.The Plan denied your request. The Plan says this service is included in the cost of the primary procedure.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 the train of four testing has a bundled relationship with code other neuromonitoring services 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 fortrain of four testing, unlisted neurological or neuromuscular diagnostic procedure provided March 10, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from June 2,
2020, to June 19, 2020.
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 the type of bill code on the claim was submitted incorrectly. The Plan states a corrected
claim would be reviewed.
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 type of bill code reported on the
claim is incorrect. Medicare rules for coverage of this service have not been met. Therefore, we decided that
the Plan does not have to pay for home health services provided to the enrollee from June 2, 2020, to June 19,
2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the electrocardiogram provided on August 24, 2020.
You asked the Plan to waive the copay for the testing services. You say that the test was done in conjunction with your annual physical. The Plan denied your request. The Plan says the copay was 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 copay per day for Medicare-covered outpatient diagnostic tests. You have been asked to pay $18.75 for the testing services. Because the amount is less than the $30 copay, you were charged the lesser amount. The services fall within the outpatient diagnostic tests benefit category. The services at issue are not included in your annual 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 copay for the electrocardiogram provided on August 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlab work provided on March 3, 2020 by an out of network (OON) provider.You asked the Plan to pay forlab work. You say that you do not agree with this. You say you had no control over where this was sent.The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that prior authorization was not obtained.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 forlab work provided on March 3, 2020 by an out of network (OON) provider