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

We decided that the Plan does not have to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray provided on December 17, 2019.
You asked the Plan to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray. You say that you cannot afford your bills. You also say that you do not have the money to pay for this. The Plan denied your request. The Plan says you had exceeded your annual maximum benefit.
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 Plan offers a $2,000 annual dental benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are responsible for the full charges of any additional dental services. The record shows that you met the annual maximum benefit on June 18, 2019 and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray provided on December 17, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on December 10,
2019 by an out of network dentist.
You asked the Plan to pay for the dental service. You say that the x-rays should be covered. The Plan denied
your request. The Plan says the panoramic x-ray is not 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 panoramic x-ray is not among
those covered under this benefit. The Summary of Dental Benefits specifically lists full mouth, panoramic, and
periapical x-rays as excluded dental services. Therefore, we decided that the Plan does not have to pay for the
panoramic x-ray (D0330) provided on December 10, 2019 by an out of network dentist.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe acute inpatient hospital care provided from July 26, 2019 through July 27, 2019.You asked the Plan to pay foracute 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 midnightsor 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 forthe acute inpatient hospital care provided from July 26, 2019 through July 27, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services rendered on March 31, 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 the claim has not been processed by the primary insurer.The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan confirmed that the enrollee was active with a different primary insurer for the date of service at issue. The Plan has not received an Explanation of Benefits (EOB) from the primary insurer for this claim. As the secondary insurer, the Plan cannot be held responsible for these services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay forthe laboratory services rendered on March 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam provided on January 8, 2020.
You asked the Plan to waive the copayment for the eye exam. You say that this was a routine eye exam. You
say that you shouldn't have to pay the copayment. 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 $25
copayment for each in-network, Medicare-covered service. Covered services include outpatient physician
services for the diagnosis and treatment of diseases and injuries of the eye, including treatment for age-related
macular degeneration.
You have been asked to pay a $25 copayment for the eye exam. The eye exam falls within the "Vision care"
benefit category. The records show that astigmatism, cataracts and dry eye syndrome were assessed, which
makes the eye exam medical in nature. 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 eye
exam provided on January 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on November 26, 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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 drug testing rendered on November 26, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the assay of creatinine and body fluid testing rendered on October 10, 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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 assay of creatinine and body fluid testing rendered on October 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the pain management services rendered on October 24, 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 64636 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 64636 is destruction by neurolytic agent, paravertebral
facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint
(List separately in addition to code for primary procedure).
We find that CPT code 64636 is not supported in the medical record. Specifically, the operative report does not
contain documentation that destruction of paravertebral facet joint nerves was performed. 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 pain management services rendered on October 24, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on June 24, 2019 to June 26,
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 the services are not payable.
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component
(TC) indicator of 9 represents a code for which the concept of a professional/technical component does not
apply.
We looked at the file and Medicare rules. The file shows that the services were billed with the -26 modifier.
These codes have a PC/TC indicator of 9; therefore, a PC does not apply and is not payable. 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 laboratory services rendered on June 24, 2019 to June 26,
2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for self-administered drugs provided on November 28, 2019.
You asked the Plan to pay for self-administered drugs. You say that the plan should cover the cost of these
drugs. The Plan denied your request. The Plan says claims for self-administered drugs must be submitted to
your Medicare Part D carrier.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided
by on November 28, 2019.
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 19, 2019 by a non-network provider.
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 the services were rendered by a non-network provider without prior authorization.
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 medical services provided on December 19, 2019 by a non-network provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on June 17, 2019.You asked the Plan to pay for the physician services. You say that the enrollee was not in hospice until after they were discharged from the hospital.The Plan denied your request. The Plan says the Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay forthe subsequent nursing facility care provided on June 17, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital discharge day management; more than 30 minutes (CPT Code 99239) provided on November 28, 2019.You asked the Plan to pay for the services. You say that the claim should be paid.The Plan denied your request. The Plan says the Centers for Medicare and Medicaid Services (CMS) have identified services that are not reasonably performed on the same date of service or do not meet correct code editing guidelines. The Plan states services that are considered conflicting or medically unlikely to be performed together on the same date of service are not appropriate. Two or more of the procedures submitted have been identified as services that are not reasonably performed on the same date.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. The billed service, 99239, was denied because this service is considered conflicting or medically unlikely to be performed together on the same date of service as code 99223 submitted under claim for the same date of service.Therefore, we decided that the Plan does not have to pay for hospital discharge day management; more than 30 minutes (CPT Code 99239) provided on November 28, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from September 3, 2019 through September 6, 2019.You asked the Plan to waive the copayment for the inpatient stay. You say that you were not aware of the care you received. You say that you object to paying for the hospital days.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 $275 copayment per day, days 1-7 for each Medicare covered hospital stay.You have been asked to pay a $550 copayment, which is less than the standard $825 copayment for the 3 day inpatient stay. The inpatient stay falls 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 stay provided from September 3, 2019 through September 6, 2019.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the molecular pathology procedures provided on November 5, 2019.
You asked the Plan to pay for the molecular pathology procedures. You say that your doctor ordered genetic
testing for cancer and you had no knowledge of who would do this testing or where the testing would be done.
The Plan denied your request. The Plan says that the services for genetic testing are available within the Plan's
network of providers.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract
provider are considered approved by the plan unless notice is provided that the services will not be covered.
The Plan follows these rules.
The molecular pathology procedures were ordered for you by a contract provider. The file does not show that
the Plan provided notice that the molecular pathology procedures would not be covered prior to the services
being rendered. Under Medicare rules, this means the molecular pathology procedures is considered approved
by the Plan. Therefore, we decided that the Plan has to pay for molecular pathology procedures provided on
November 5, 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive or reducethe 20% coinsurance charged for injections and infusion services provided from November 12, 2019 to January 16, 2020.You asked the Plan to waive or reducethis coinsurance. You say that no one told you what the cost of these treatmentswould be.The Plan denied your request. The Plan says this coinsurance was charged based on the services provided and the Plan contract agreement.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 Medicare Part B drugs such as injection or infusion services. 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 or reducethe 20% coinsurance charged for injections and infusion services provided from November 12, 2019 to January 16, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the Nursing Facility Care (99308) provided on June 10, 2019
by an out of network (OON) provider.
You asked the Plan to pay for the nursing facility care. You say that the services were medically necessary. The
Plan denied your request. The Plan says the services were not emergent or preauthorized. There were network
providers available.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the Nursing Facility Care (99308) provided on
June 10, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided from December 19, 2019 to December 26, 2019.You asked the Plan to pay for home infusion therapy. You say that this is a valid code.The Plan denied your request. The Plan says this code is not valid for Medicare purposes.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code S9328 is not supported in the medical record. Specifically, this code has a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of home infusion therapy have not been met.Therefore, we decided that the Plan does not have to pay forhome infusion therapy (S9328) provided from December 19, 2019 to December 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for pulp vitality tests (D0460) provided on December 9, 2019 by
an out-of-network provider.
You asked the Plan to pay for the dental services. You say that your primary dentist referred you to this
provider. 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. Therefore, we decided that the Plan does not have to pay for pulp vitality tests (D0460)
provided on December 9, 2019 by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician and venipuncture services provided on January 30, 2020 by an out of network (OON) provider. You asked the Plan to pay for physician and venipuncture services. You say that you were told that this provider would be in-network starting in 2020. 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 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 physician and venipuncture services provided on January 30, 2020 by an out of network (OON) provider.