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

We decided that the Plan does not have to waive the copayment forthe colonoscopy provided on November 19, 2019.You asked the Plan to waive the copayment forthe colonoscopy. You say that you were advised you had a screening. You say that the colonoscopy should be covered in full.The Plan denied your request. The Plan says the copayment applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250copayment for Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient facility.You have been asked to pay a $250 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient surgery, including servicesprovided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show the colonoscopy was performed for diagnostic purposes. This means that you have been asked to pay the correct amount based on your contract withthe Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment forthe colonoscopy provided on November 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services rendered to the enrollee on October 18, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 88350 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 88350 is immunofluorescence, per specimen; each additional single antibody stain procedure (List separately in addition to code for primary procedure).We find that CPT code 88350 is not supported in the medical record. Specifically, the code is an add-on code that was not billed with a required primary procedure code. 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 forthe laboratory services rendered to the enrollee on October 18, 2019.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay forthe skilled nursing services provided from November 21, 2019 to November 30, 2019.You asked the Plan to pay forthe skilled nursing services. You say that you are a valid provider, and have been since 1994.The Plandenied your request. The Plan says that the provider does not have a valid Medicare CMS Certification Number (CCN) on file.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. We have been unable to confirm the Plan's finding that the CCN was not valid on the dates of service at issue. The most current file uploaded to the CMS website shows that the CCN has no associated expiration date and has an effective date of 10/1/2019. As such, we find that the Plan's denial based on no valid Medicare CCN is not supported. Thus, the plan has not substantiated their denial of payment in this case.Therefore, we decided that the Plan has to pay forthe skilled nursing services provided from November 21, 2019 to November 30, 2019.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or sendus the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forradiationtreatment management provided from September 19, 2019 through October 17, 2019.You asked the Plan to waive the copayment forradiation treatment management. You say that all services were provided in-network. You say that the total cost should be $250.The Plan denied your request. The Plan says the copaymentsapplied 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 $50 for each Medicare-covered visit withan in-network specialist. You have been asked to pay a total of $994.05 for radiation treatment management. Date of ServiceServiceAllowed AmountStandard CopaymentMember LiabilitySeptember 19, 20195 Radiation Management Services$198.81$250 ($50/service)$198.81September 26, 20195 Radiation Management Services$198.81$250 ($50/service)$198.81October 3, 20195 Radiation Management Services$198.81$250 ($50/service)$198.81October 10, 20195 Radiation Management Services$198.81$250 ($50/service)$198.81October 17, 20195 Radiation Management Services$198.81$250 ($50/service)$198.81TOTAL:$994.05 Radiation treatment management 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 forradiation treatment management provided from September 19, 2019 through October 17, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe eyeglasses.You asked the Plan to pre-approvethe eyeglasses. You say that your eyeglasses broke and you need a new pair.The Plandenied your request. The Plan says this request exceeds the benefit frequency limitation.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers this service once every 2 years. The records show that the eyewear benefit was used on  December 21, 2018 and this benefit will not be eligible until December 1, 2020.We looked at the file and the Plan's rules. This service is limited to once every 2 years. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met.Therefore, we decided that the Plan does not have to pre-approvethe eyeglasses.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvevaricose veintreatment to be provided by an out of network (OON) provider.You asked the Plan to pre-approvevaricose vein treatment. You say that this is a continuation of care.The Plan denied your request. The Plan says services have not been provided since 2017. The Plan says you have been approved to see two in-network providers.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. Please contact the Plan for a list of in-network providers available for these services. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided thatthe Plan does not have to pre-approvevaricose vein treatment to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe acute inpatient hospital care rendered to the enrollee from November 8, 2019 to November 9, 2019.Youasked the Plan to pay foracute inpatient hospital care. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were 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 services were not medically necessary. Our physician reviewer found the enrollee presented to the emergency department (ED) on November 7, 2019 with neck pain after a fall two to three weeks prior. While the enrollee spent two midnights in the hospital, at the time of admission, it was not reasonable to expect that two midnights of inpatient level care would be medically necessary. The ED evaluation showed no significant trauma, acute medical issues or uncontrolled co-morbidities. While additional evaluation and monitoring may have been reasonable, the enrollee could have been safely placed on observation status to undergo such evaluation and monitoring. As is, no additional issues were identified and the enrollee was discharged in stable condition. 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 forthe acute inpatient hospital care rendered to the enrollee from November 8, 2019 to November 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and the initial periapical x-ray (D0220) provided on December 17, 2019.
You asked the Plan to pay for the dental services. You say that you followed all of the steps to ensure the services that you received would be covered. You also say that you were given this dentist by a plan representative. The Plan denied your request. The Plan says the limited oral evaluation is not listed as a covered service. The Plan also says periapical x-ray 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 dental services that you received are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) and the initial periapical x-ray (D0220) provided on December 17, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on November 11, 2019.
You asked the Plan to pay for the dental service. You say that bitewing x-rays are not specifically excluded from your dental coverage. You also say that had you been advised that bitewing x-rays were excluded, then you would have opted for another type of x-ray. The Plan denied your request. The Plan says bitewing x-rays are 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 bitewing x-rays are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on November 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve complete upper dentures and partial lower dentures.You askedthe Plan to pre-approve the dentures. You say that your dentures are no good. You say that there is a metal portion that stabs you every time you eat. You say that you used to weigh 160 pounds and now weigh 120 pounds. You say that you are only able to eat soft food and liquids.The Plan denied your request. The Plan says your benefit for dentures has been exhausted for the 2020 plan year.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 benefit for dentures is limited to once every five years. The records show that you received coverage for dentures on December 12, 2017.Therefore, we decided that the Plan does not have to pre-approve complete upper dentures and partial lower dentures.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the unspecified adjunctive procedure (D9999) provided on October 22, 2019.
You asked the Plan to reimburse you for the dental service. The Plan denied your request. The Plan says the dental benefit allowance of $750 has been exhausted.
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 dental benefit allowance of $750 has been exhausted.
Therefore, we decided that the Plan does not have to reimburse you for the unspecified adjunctive procedure (D9999) provided on October 22, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram (EKG) rendered to the enrollee on October 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 93010 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 93010 is electrocardiogram, routine ECG with at least 12 leads; interpretation and report only. We find that CPT code 93010 is not supported in the medical record. Specifically, there is no documentation that an EKG was performed for the billed date of service. 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 electrocardiogram (EKG) rendered to the enrollee on October 4, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe non-emergency ambulance services provided on August 30, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe ambulance services. You say that the enrollee was receiving 2 liters per minute of oxygen via nasal cannula. Attachedare records of records of transport for review and reconsideration.The Plan denied your request. The Plan says that non-emergent ambulance services requires 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 inthis 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 non-emergency ambulance services provided on August 30, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the services provided from November 8, 2019, to November 30,2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the provider does not have a valid Medicare CMS Certification Number (CCN) on file.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The plan shows the CCN provided having an expiration date of August 11, 2016, however, the Provider Specific File now does not have that information and only shows an active registration with an October 1, 2019, effective date. The plan has not supported that the CCN was expired on the date of service.Therefore, we decided that the Plan has to pay for the services provided from November 8, 2019, to November 30, 2019.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for echocardiography provided on April 24, 2019.
You asked the Plan to waive the coinsurance for echocardiography. You say that you feel the echocardiography should be considered preventative. 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 diagnostic procedures and tests. You received echocardiography on April 24, 2019. Echocardiography is considered diagnostic, not preventative. Therefore, you are responsible to pay your share of the cost-sharing charges. The allowed amount is $576.34 and 20% of that is $115.27. You have been asked to pay the total coinsurance amount of $115.27 for echocardiography. Echocardiography 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 echocardiography provided on April 24, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on November 4, 2019 by an OON provider.
You asked the Plan to pay for the subsequent nursing facility care. You say that although your providers are out-of-network, the facility is in-network. You also say that you rely on the facility to obtain any necessary authorizations when your providers are asked to see patients at their facility for medical treatment. The Plan denied your request. The Plan says this provider is not in-network, and there is no authorization on file. The Plan also says that the service was not plan directed.
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 subsequent nursing facility care provided on November 4, 2019 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
You asked the Plan to pre-approve a Freestyle Libre CGM. You say that due to severe arthritis and the amputation of one of your fingers you do not have the ability to do finger pinch to monitor your glucose. The Plan denied your request. The Plan says that that you did not meet medical necessity criteria for coverage of Freestyle glucose monitoring system.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has not provided any medical records. Without the support of medical records, we are unable to substantiate the Plan's denial rationale that this CGM is not medically necessary. Therefore, we decided that the Plan has to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cognitive therapy to be provided by the facility.
You asked the Plan to pre-approve cognitive therapy. You say that you do not need speech therapy. You say
that the Plan's network provider does not have the expertise available to provide cognitive therapy. The Plan
denied your request. The Plan says cognitive therapy is available within the KPCO speech pathology
department.
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 cognitive therapy at issue in this appeal. We found no exception that would
require the Plan to pre-approve the requested services. Therefore, we decided that the Plan does not have to
pre-approve cognitive therapy to be provided by the facility.