Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services (D7210, D7953, D7140, D7310, D5130, D5214) received September 3 - 8, 2020 from the opt-out provider.
You asked the Plan to pay for the dental services. You say that the requested services were necessary. The Plan denied your request. The Plan says if you use a provider that has opted out of Medicare you will not receive reimbursement.
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 Plan has submitted evidence that the provider in this case was opted out of Original Medicare on these dates of service. Therefore, we decided that the Plan does not have to pay for the dental services (D7210, D7953, D7140, D7310, D5130, D5214) received September 3 - 8, 2020 from the opt-out provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit and the electrocardiogram to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the office visit and the electrocardiogram. You say that you are an established patient of your doctor who knows your heart conditions. You say you do not want to see another cardiologist. The Plan denied your request. The Plan says the provider is out-of-network.
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 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 the office visit and the electrocardiogram to be provided by an out of network (OON) provider.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services provided on July 29, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the psychotherapy 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.
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 had network providers available who could have provided 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 psychotherapy services provided on July 29, 2019 by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit provided on November 19, 2020 by an OON provider.
You asked the Plan to pay for the domiciliary or rest home visit. You say that the rendering physician depends upon the hospital staff to verify eligibility and to obtain the proper authorization from the enrollee's insurance company. The Plan denied your request. The Plan says the service was rendered by a non-participating provider. The Plan also 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 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 domiciliary or rest home visit provided on November 19, 2020 by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services rendered from January 4, 2021 to January 7, 2021.
You asked the Plan to waive the copayment for these services. You say that you were booked for a day surgery and the doctors didn't want to release you. The Plan denied your request. The Plan says the copayment 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 $350 copayment per day for days 1-5 for inpatient hospital care.
Review of the file shows that you received three days of inpatient hospital care from January 4, 2021 to January 7, 2021. You were not assessed a copayment for your date of discharge on January 7, 2021. You have been asked to pay a $350 copayment per day for these services, for a total of $1,050. These services fall within the inpatient hospital 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 for the inpatient hospital services rendered from January 4, 2021 to January 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for an Apple Watch with Fitness provided on
November 27, 2020.

You asked the Plan to reimburse you for the Apple Watch with Fitness. You say that the Fitbit or Garmin is not
as beneficial. The Plan denied your request. The Plan says an Apple Watch is excluded from coverage.

The Plan contract says that an Apple Watch is excluded from coverage.

We looked at the file and the Plan's rules. The file shows that an Apple Watch is excluded from the Wallet
Benefit. Therefore, we decided that the Plan does not have to reimburse you for an Apple Watch with Fitness
provided on November 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing facility care provided by an out-of-network provider
on November 24, 2020.

You asked the Plan to pay for nursing facility care. You say that the provider depends on the hospital staff to
verify eligibility and to obtain proper authorization. You say that the services provided were medically
necessary and the claim should be processed for payment. The Plan denied your request. The Plan says prior
authorization was required but 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 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 nursing facility care provided by an out-ofnetwork
provider on November 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided December 31, 2020 to January 2, 2021.

You asked the Plan to waive the copayment for the inpatient services. You say that any time you have been in the hospital in the past you had $0 copay. The Plan denied your request. The Plan says the claim was processed correctly per the Evidence of Coverage

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 $275 per day for days 1-5 and $0 after day 5 for the Inpatient hospital care. 

You have been asked to pay $550 ($275 + $275) for 2 days for the inpatient services. The inpatient services fall within the Inpatient hospital 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 for the inpatient hospital services provided December 31, 2020 to January 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show that you have narrowing of the lumbar spine (spinal stenosis). Current evidence and medical guidelines do not support the use of the Superion spacer over the gold standard of a lumbar laminectomy. The services are considered experimental in nature and not medically necessary. We looked at this physician's review, the file, and Medicare rules. 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 pre-approve a Vertiflex Superion spacer.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that a power seat elevation feature (E2300) is not covered. We looked at the file and Medicare rules. The requested power seat elevation system is not covered by Medicare because it does not serve a purpose that is primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory work provided on December 14, 2020, by an
OON provider.
You asked the Plan to pay for the laboratory work. You say that the service is medically necessary. The Plan
denied your request. The Plan says no prior authorization was 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 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 laboratory work provided on December 14,
2020, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services coded 99152 provided on April 5, 2020.

You asked the Plan to pay for the moderate sedation 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 99152 is moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older.

We find that CPT code 99152 is not supported in the medical record. Specifically, the submitted medical records do not include procedure notes to support that moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the enrollee's level of consciousness and physiological status; initial 15 minutes of intraservice time, was performed. Based on this information, we decided that Medicare rules for coverage of the moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services coded 99152 provided on April 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient office visit (99213) provided January 21, 2021.
You asked the Plan to waive the copayment for the office visit. You say that you feel that the copay should be waived because it was short virtual visit, and you should not have to pay for something like that. The Plan denied your request. The Plan says the claim was processed, and the correct copayment was applied per the Evidence of Coverage
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 $15 for each covered visit or consultation in an outpatient location with a specialist. You have been asked to pay $15 for the office visit. The 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, we decided that the Plan does not have to waive the copayment for the outpatient office visit (99213) provided January 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on June 15, 2020, and August 26, 2020 by an OON provider.
You asked the Plan to pay for the dental services. You say that you would like these services to be covered. The Plan denied your request. The Plan says these services were rendered by an OON provider.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the dental services provided on June 15, 2020, and August 26, 2020 by an OON provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the cytopathology services coded 88173 provided on May 19, 2020.

You asked the Plan to pay for the cytopathology 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 88173 is cytopathology, evaluation of fine needle aspirate; interpretation and report. 

We find that CPT code 88173 is not supported in the medical record. Specifically, the documentation supports one unit of this code, which was previously approved and paid by the plan. There is no additional documentation supporting an additional study was performed. Based on this information, we decided that Medicare rules for coverage of the cytopathology services have not been met. Therefore, we decided that the Plan does not have to pay for the cytopathology services coded 88173 provided on May 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and addition provided on October 13, 2020.
You asked the Plan to pay for the knee orthosis and addition. 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 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 means that 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 noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for the knee orthosis and addition provided on October 13, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for esophagogastroduodenoscopy, flexible, transoral, biopsy single or multiple (43239) provided July 17, 2020.
You asked the Plan to waive the copayment for the diagnostic procedure. You say that the copay should be waived because you recently had throat surgery and is unable to work so can't afford to pay this copay. The Plan denied your request. The Plan says the claim was processed, and the correct copayment was applied per the Evidence of Coverage.
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 $325 per day for Medicare covered diagnostic radiology services. You have been asked to pay $325 per day for the diagnostic procedure. The diagnostic procedure 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 esophagogastroduodenoscopy, flexible, transoral, biopsy single or multiple (43239) provided July 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the laboratory services rendered from December 9, 2020 and December 10, 2020.
You asked the Plan to waive the copayments for these services. You say that you had two payment coupons in the amount of $10 each from the provider. The Plan denied your request. The Plan says the copayments were 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 $10 copayment for Medicare-covered lab services.
Review of the file shows that you received laboratory services on December 9, 2020 and December 10, 2020. You have been asked to pay a $10 copayment per date of service for these services, for a total of $20. These services fall within the Medicare-covered lab services 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 copayments for the laboratory services rendered from December 9, 2020 and December 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider on April 22, 2020.
You asked the Plan to pay for the services. 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 had network providers available who could have provided 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 services provided to the enrollee by an out-of-network provider on April 22, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on June 26, 2020.
You asked the Plan to pay for the physical therapy services. The Plan denied your request. The Plan says services rendered by non-participating providers require prior authorization as outlined in the enrollees EOC.
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 did not pre-approve the physical therapy services. 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 physical therapy services provided on
June 26, 2020.