Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from October 4, 2019 to October 6, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that this was medically necessary. The Plan denied your request. The Plan says inpatient care was not warranted.
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 enrollee presented to the emergency department with abdominal pain and diarrhea. Evaluation in the emergency room did not identify an acute process on imaging or concerning laboratory results. She remained in the hospital with a diagnosis of abdominal pain. The enrollee was noted to have an increased stool burden and was prescribed oral magnesium citrate. She was noted to have an increased stool burden and was ordered magnesium citrate. Gastroenterology specialists were requested to provide a specialty consultation. Care provided to the enrollee was observation level. There were no advance interventions or complex medical conditions. She had stable vital signs and no complaints at the time of admission. Inpatient services were not supported by the documentation.
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 from October 4, 2019 to October 6, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the physician's initial observation services provided on March 8, 2019.
You asked the Plan to pay for the physician's initial observation services. The Plan denied your request. The Plan says that the provider is not in-network and/or there is no authorization on file.
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 Health Plan follows these rules. The physician's services were requested by and provided at a contract facility. The file does not show that the Plan provided notice that the physician's initial observation services would not be covered prior to the services being rendered. Under Medicare rules, this means the physician's initial observation services are considered approved the Plan. Therefore, we decided that the Plan has to pay for the physician's initial observation services provided on March 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve custom foot orthotics (L3010).
You asked the Plan to pre-approve custom foot orthotics. You say that you are requesting a reconsideration of
the Plan's denial as the patient has difficulty walking and standing without the support of custom foot orthotics.
The Plan denied your request. The Plan says this item is not a covered benefit for the enrollee's condition.
Medicare rules state that supportive devices for the feet (such as custom foot orthotics) are only covered for
patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace.
Although custom foot orthotics may be appropriate for her, neither Medicare nor the Plan provides coverage of
custom foot orthotics for her condition. Therefore, we decided that the Plan does not have to pre-approve
custom foot orthotics (L3010).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for topical application of fluoride varnish (placing fluoride on the teeth (D1206) provided on October 29, 2019.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says the service is not a covered benefit under the 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. This service is not listed in your EOC as a covered benefit; therefore, it is not covered. However, as an alternative, The provider will not be charging you for this service. Therefore, we decided that the Plan does not have to pay for topical application of fluoride varnish (placing fluoride on the teeth (D1206) provided on October 29, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for facial repair surgery (13152) provided on November 26, 2019.
You asked the Plan to pay for facial repair surgery. You say that this code is clearly documented. The Plan denied your request. The Plan says this code is not shown in the record.
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 13152 is repair, complex, eyelids, nose, ears and/or lips; 2.6 cm to 7.5 cm. 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 facial repair surgery. Our reviewer says that this code is not supported. Our physician reviewer found the submitted medical records do not specify wound size, therefore this code cannot be verified. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of facial repair surgery have not been met. Therefore, we decided that the Plan does not have to pay for facial repair surgery (13152) provided on November 26, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for flow cytometry testing provided on October 31, 2019.
You asked the Plan to pay for lab test. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the service was misrepresented.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a valid physician order or clear intent to order the specific lab service billed on this claim. Based on this information, we decided that Medicare rules for coverage of lab test have not been met. Therefore, we decided that the Plan does not have to pay for flow cytometry testing provided on October 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for (D7250), (D9239), (D7210), (D9243) and (D9612) provided on May 20, 2019, by an out-of-network provider.
You asked the Plan to pay for the dental services. You say that you needed to have these procedures but no one local was taking new patients. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
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 analgesia and extractions were paid and the therapeutic drugs were denied as not covered under the Plan. The services were paid out-of-network due to the provider not participating with the plan. Therefore, we decided that the Plan does not have to pay for (D7250), (D9239), (D7210), (D9243) and (D9612) provided on May 20, 2019, by an out-of-network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an EGD provided on September 9, 2019.
You asked the Plan to waive the copayment for an EGD. You say that you feel that you should not be responsible for the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct mount.
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 Medicare Preferred HMO Prime Rx members must pay a $100 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You received an EGD on September 9, 2019. An EGD is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $100 copayment. You have been asked to pay a $100 copayment for an EGD. An EGD falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an EGD provided on September 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-referral circle provider.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says this provider is not uniquely qualified to treat hip pain, and provide hip replacement surgery.
Medicare rules say that plans can require enrollees to get care from certain network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-referral circle providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a provider within your PCP's referral circle. The Plan has network providers available in the referral circle who can provide the items/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-approve a referral to an out-of-referral circle provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergency ambulance services provided on July 10, 2019 by an out of network provider.
You asked the Plan to pay for the ambulance service. You say that this transport was medically necessary as the care was reasonably expected to reduce or ameliorated the physical effects of presenting conditions. The Plan denied your request. The Plan says non-emergent services with non-contracted providers require prior-authorization prior to services being rendered.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the non-emergency ambulance services provided on July 10, 2019 by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the root canal provided on August 2, 2019.
You asked the Plan to pay for the root canal. You say that the x-ray and evaluation are covered with what is stated in the EOC. You also say that although there was no cleaning involved, the x-ray and evaluation should be covered. The Plan denied your request. The Plan says the root canal for the molar tooth is not a preventive dental service and is not a covered benefit under your 2019 Dental Allowance.
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 root canal provided on August 2, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services to be provided by an out-of-network
provider.
You asked the Plan to pre-approve the dental services. You say that you have found that this provider offers the
finest level of dental care you have ever experienced. You also say that you doubt any in-network providers
would be interested in cleaning, x-raying and examining your teeth only to discover that any follow up work
would not be performed by them. The Plan denied your request. The Plan says this provider is non-contracted
with your 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
covered when they are received out-of-network. Therefore, we decided that the Plan does not have to preapprove
dental services to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a removable unilateral partial denture (D5281).
You asked the Plan to pre-approve removable unilateral partial denture. You say that this should be covered since other types of dentures are covered. The Plan denied your request. The Plan says this is not a covered code under your dental 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 a removable unilateral partial denture (D5281).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ankle foot orthosis provided on January 14, 2020.
You asked the Plan to pay for the ankle foot orthosis (L1971). You say that the orthosis was medically necessary. The Plan denied your request. The Plan says the documentation submitted did not indicate the provider discussed the need for the billed supply codes, therefore the billed supply codes cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The medical records do not mention or support medical necessity for the orthoses. Based on this information, we decided that Medicare rules for coverage of the ankle foot orthosis (L1971) have not been met. Therefore, we decided that the Plan does not have to pay for the ankle foot orthosis provided on January 14, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for cataract surgery provided on December 17,
2019.
You asked the Plan to waive the copayment for cataract surgery. You say that you were told that you would
only owe a $350 copayment. The Plan denied your request. The Plan says the claims were processed correctly
and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $375
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory
surgical centers.
You have been asked to pay a $375 copayment for cataract surgery. Cataract surgery falls within the outpatient
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit
category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we
decided that the Plan does not have to waive the copayment for cataract surgery provided on December 17,
2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for endovenous ablation therapy provided by
an outpatient hospital facility on January 13, 2020 to January 16, 2020.
You asked the Plan to waive the copayment for an outpatient surgery. You say that this was not provided at a
hospital. You say that this was a performed in an office. The Plan denied your request. The Plan says the
correct copayment has been 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 $250
copayment for outpatient surgery/in-network/outpatient hospital facility.
You have been asked to pay a $250 copayment for each outpatient surgery. The total amount you are being
asked to pay is $500 ($250 x 2 = $500). Evidence was provided to verify the center these services were
provided at is owned by an outpatient hospital; therefore, the correct copayment has been applied. An
outpatient surgery falls within the outpatient surgery/in-network/outpatient hospital facility benefit category.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that
the Plan does not have to waive the copayment for endovenous ablation therapy provided by an outpatient
hospital facility on January 13, 2020 to January 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the mask, tubing, and filters provided on August 13, 2019.
You asked the Plan to pay for the home vent supplies. You say that the supplies are necessary. The Plan denied
your request. The Plan says the billed supplies cannot be verified.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.
The record shows that the Plan made several attempts to obtain the physician order and proof of delivery
documentation for the items at issue in this appeal. The record does not contain a valid physician order and
proof of delivery for the supplies provided in this case. The submitted physician order is for the home ventilator
only. Therefore, we decided that the Plan does not have to pay for the mask, tubing, and filters provided on
August 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services rendered on September 4, 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 procedure code 99291 is 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 find that CPT code 99291 is not supported in the medical record. Specifically, there is no documentation of
30-74 minutes of critical care services spent on the enrollee. 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 critical care services rendered on September 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the pacemaker check provided by on August 15, 2019.
You asked the Plan to waive the copayment for the pacemaker check. You say that this was just a normal pacemaker check done by a technician. You say you have never received a bill for this procedure when it was done at an office. 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 $95 copayment for in-network diagnostic procedures and tests provided you a provider other than your primary care physician. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $95 copayment for the pacemaker check.
You have been asked to pay a $36.42 copayment for the pacemaker check. The pacemaker check 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 copayment for the pacemaker check provided on August 15, 2019.
Our decision is only about the August 15, 2019 service. If you have any questions about prior years billing, please contact the plan directly.