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

We decided that the Plan does not have to pay fora prosthetic eye provided on February 6, 2019.You asked the Plan to pay for the services. You say that the enrollee's current prosthesis was no longer adequate in size.The Plan denied your request. The Plan says the enrollee has no 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.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 a prosthetic eye provided on February 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe assistant surgeon services provided to "the beneficiary" March 5, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says assistant surgeon services are not payable for this type of provider.The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS.In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners.Therefore, we decided that the Plan does not have to pay forthe assistant surgeon services provided to "the beneficiary" on March 5, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran inpatient mental health stay provided by the providerl on August 14, 2019 to August 20, 2019.You asked the Plan to waive the copayment foran inpatient mental health stay. You say that you thought you were covered fully for this stay.The Plan denied your request. The Plan says the correct copayment has been applied for the service that was provided.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 $395 copayment per day for days 1-4. There is a $0 copayment for days 5-90 for inpatient mental health care. You have been asked to pay a $395 copayment per day for days 1-4. There is a $0 copayment for days 5-6 for an inpatient mental health stay. The total amount you are being asked to pay is $1,580 ($395 x 4 days = $1,580). An inpatient mental health stay falls within the inpatient mental health 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 foran inpatient mental health stay provided by on August 14, 2019 to August 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forchiropractic services provided to the enrollee on May 29, 2019.You asked the Plan to pay forthe services. You say that this should be paid for.The Plan denied your request. The Plan saysthis is not medically necessary.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. Despite multiple attempts by the plan, records were not received for this case. It cannot be determined if the enrollee had a subluxation of the spine.Therefore, we decided that the Plan does not have to pay forchiropractic services provided to the enrollee on May 29, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay forlab services provided to the enrollee on March 15, 2019.You asked the Planto pay forthe services. You say that the denied codes remain not supported.The Plandenied your request. The Plansaysthe documentation submitted did not include a valid physician order/lab requisition or medical records (signed by the ordering physician) for the billed date of service.The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be covered. The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were to be performed. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pay forlab services provided on March 15, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services provided from February 6, 2019 to February 10, 2019.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 Current Procedural Terminology (CPT) code 99291 (1 Unit) remains not supported.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 99291 is "Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 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 coded correctly. Our coding reviewer found CPT code 99291 is not supported for the dates in question. The medical record does not contain the amount of time spent providing critical care services. It cannot be verified that the CPT coding criteria for reporting 99291 has been met.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 critical care services provided from February 6, 2019 to February 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible forCPAP supplies provided on March 27, 2019.You asked the Plan to waive the deductible forCPAP supplies. You say that you were promised it would be covered by the Plan.The Plan denied your request. The Plan says the deductible applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that your deductible is $500. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost of your covered services. Out-of-network services are not excluded from the deductible.The item or service you asked the Plan to waive the deductible for falls within the "Durable medical equipment (DME) and related supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $500 deductible applies to out-of-network services. This cost sharing is a contractual obligation that had not been met at the time CPAP supplies were received from an out-of-network provider on March 27, 2019. Therefore, we decided that the Plan does not have to waive the deductible forCPAP supplies provided on March 27, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe discharge services (CPT 99239) provided to the enrollee on April 13, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says there is insufficient documentation to corroborate the services.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 99239 is "Hospital discharge day management; more than 30 minutes".We find that CPT code 99239 is not supported in the medical record. Specifically, the records provided do not document that more than 30 minutes of discharge day management services were provided on the date of service in question. 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 forthe discharge services (CPT 99239) provided on April 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora wrist-hand orthosis (L3916) provided to the enrollee on February 27, 2019.You asked the Plan to pay forthe orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This meansthat the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the non-covered visit are likewise non-covered.Therefore, we decided that the Plan does not have to pay fora wrist-hand orthosis (L3916) provided to the enrollee on February 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not have to pay forthe chiropractic services (97012, 97140, and 97032) provided to "the beneficiary" on July 2, 2019.You asked the Plan to pay forthe chiropractic services. The Plan denied your request. The Plan says these services are not covered when provided by a chiropractor.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services at issue are not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay forthe chiropractic services (97012, 97140, and 97032) provided to "the beneficiary" on July 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided to the enrollee on January 10, 2019 and billed under code 99239.You asked the Plan to pay for code 99239. You say that this claim should be paid.The Plan denied your request. The Plan says while a portion of this claim was paid, code 99239 is not supported by the medical records provided. The discharge summary does not support hospital discharge day management of more than 30 minutes was performed.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.The records provided must support the services billed. Code 99239 is a timed code. In this case, the records provided do not support the services billed. Based on this information, we decided that Medicare rules for coverage of codes 99239 have not been met.Therefore, we decided that the Plan does not have to pay for physician's services provided to the enrollee on January 10, 2019 and billed under codes 99239.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on August 14, 2019.You asked the Plan to pay for the services. You say that the services were medically necessary.The Plan denied your request. The Plan says the services were not authorized.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on August 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941) rendered by out of network provider from July 22, 2019 to August 9, 2019.You asked the Plan to pay for these services. You say that you have gone to a chiropractor many times since having this insurance and you have never needed prior authorization; nor were you aware that prior authorization was necessary.The Plan denied your request. The Plan says the services were rendered by an out of network provider without prior approval. The services were not urgent or emergent in nature and could have been provided by an in-network plan provider.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 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 or make arrangements for 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 chiropractic manipulative treatment (98941) rendered by out of network provider from July 22, 2019 to August 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for podiatry services (CPT 11056) provided on August 12, 2019.You asked the Plan to pay for the services. You say that payment should be made, based on the records.The Plan denied your request. The Plan says the documentation received does not support CPT 11056.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 11056 is "Paring or cutting of benign hyperkeratotic lesion (e.g., corn or callus)."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 coded correctly. Our coding reviewer found the medical records provided do not contain documentation supporting pairing or cutting of benign hyperkeratotic lesion (e.g.corn or callus) 2 to 4 lesions, therefore, CPT 11056 is not eligible for reimbursement consideration.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 podiatry services(CPT 11056) provided on August 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for limited oral evaluation - problem focused (D0140) provided on August 20, 2019.
You asked the Plan to pay for the dental services. You say that the follow up visits were related directly to the original crown work and not a routine visit. The Plan denied your request. The Plan says you exhausted your benefit frequency limit.
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. You exhausted your benefit frequency limit, because you had a periodic oral evaluation (D0120) on August 12, 2019. Your EOC clearly states, oral exam: one (1) every six (6) months. Therefore, we decided that the Plan does not have to pay for limited oral evaluation - problem focused (D0140) provided on August 20, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the hernia repair provided on July 11, 2019 by an out of network (OON) provider. 
You asked the Plan to pay for the OON surgery. You say that this was medically necessary and should be covered. The Plan denied your request. The Plan says this non-emergency procedure was provided without authorization from an OON provider. There were many network providers who were able to provide this care.
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 hernia repair provided on July 11, 2019 by the out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the charges for the knee injections provided on June 4, 2019, August 22, 2019, and September 26, 2019.
You asked the Plan to reduce the charges for the knee injections. You say that you do not feel that you should have to pay a $100 copayment as this is not really a surgery and it was not done at a hospital. You believe that you should only owe the $20 specialist copayment. The Plan denied your request. The Plan says these knee injections are surgical procedures which are subject to the $100 copayment whether done in a hospital or outpatient surgery center.
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 outpatient surgical procedures in an ambulatory surgery center. You have been asked to pay a $100 copayment for each of the knee injections. The knee injections fall within the outpatient surgical procedures in an ambulatory surgery center 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 reduce the charges for the knee injections provided on June 4, 2019, August 22, 2019, and September 26, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for genetic testing provided on August 28, 2019.
You asked the Plan to waive the coinsurance for genetic testing. You say that you disagree with the charges and cannot afford them. 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 20% coinsurance for genetic testing. You received genetic testing on August 28, 2019. Therefore, you are responsible to pay your share of the cost-sharing charges.
The total amount you owe is: $318.39. You have been asked to pay the total coinsurance amount of $318.39 for genetic testing. Genetic testing falls within the outpatient diagnostic tests and therapeutic services and supplies 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 coinsurance for genetic testing provided on August 28, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the crutch substitute rendered to you on July 9, 2019.
You asked the Plan to waive the deductible for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the deductible was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $1,000 yearly deductible for your covered medical services. The item or service you asked the Plan to waive the deductible for falls within the durable medical equipment and related supplies benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $1,000 yearly deductible for your covered medical services. This cost sharing is a contractual obligation that had not been met at the time these services were received on July 9, 2019. Therefore, we decided that the Plan does not have to waive the deductible for the crutch substitute rendered to you on July 9, 2019.