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

We decided that the Plan does not have to waive the copayment forthe acupuncture services you received on May 9, 2019 and May 16, 2019.You asked the Plan to waive the copayment forthe acupuncture services. You say that you had met your out-of-pocket maximum and should not have a copayment.The Plan denied your request. The Plan says that cost sharing is a contractual obligation under the plan and cannot be waived.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 Acupuncture Services. You have been asked to pay a $25 copayment for the acupuncture services. The acupuncture services fall within the Acupuncture Services benefit category. The Evidence of Coverage also indicates that Acupuncture services do not count towards your combined maximum out-of-pocket. 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 forthe acupuncture services you received on May 9, 2019 and May 16, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Computed Tomography (CT) of the abdomen (74150) provided.
You asked the Plan to waive the copayment for the CT scan. You say that the images were not clear enough to be useful and the copayment should be waive. The Plan denied your request. The Plan says the correct copayment was 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 $65 copayment for Outpatient Diagnostic Tests. You have been asked to pay a $65 copayment for the CT scan. The CT scan falls within the Outpatient Diagnostic Tests 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 Computed Tomography (CT) of the abdomen (74150) provided.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit, gonioscopy, fundus photography with interpretation and report, electroretinography, ophthalmoscopywith retinal drawing, each eye, an intravitreal injection of a pharmacologic agent, and an injection provided on August 6, 2019 by the out of network provider.You asked the Plan to pay forthe physician services. The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan says the enrollee's primary care physician did not refer them for the services. The Plan also says the services were not urgent or emergent.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 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 forthe office visit, gonioscopy, fundus photography with interpretation and report, electroretinography, ophthalmoscopy with retinal drawing,each eye, an intravitreal injection of a pharmacologic agent, and an injection provided on August 6, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible forthe services rendered to you on July 31, 2019.You asked the Plan to waive the deductible forthese services. You say that you disagree with the charges.The Plan denied your request. The Plan says the deductible was applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $500 in-network and out-of-network deductible for your covered medical services. The item or service you asked the Plan to waive the deductible for falls within the practitioner services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $500 in-network and out-of-network deductible for your covered medical services. This cost sharing is a contractual obligation that had not been met at the time these services were received on July 31, 2019. Therefore, we decided that the Plan does not have to waive the deductible forthe services rendered to you on July 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit and incision and drainage of abscess services provided on February 8, 2019 by out of network provider, "the provider".You asked the Plan to pay forthe office visit and incision and drainage ofabscess services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services rendered are not a covered benefit.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 forthe office visit and incision and drainage of abscess services provided on February 8, 2019 by out of network provider, "the provider".
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered to "the beneficiary" by "the provider" on July 2, 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 G0483 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 G0483 is definitive drug testing, 22 or more classes.We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation shows that fewer than 22 drug classes were testing. 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 drug testing rendered to "the beneficiary" by "the provider" on July 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe physician services rendered to you by "the doctor" on May 21, 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 provider has opted out of Medicare.The plan must follow Medicare rules. Medicare rules say that Medicare plans may not pay for services given by a physician or other practitioner who has opted out of Medicare. We looked at case file and the Medicare rules. We confirmed that "the doctor" has opted out of Medicare. 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 physician services rendered to you by "the doctor" on May 21, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home infusion therapy services coded S9328 provided from September 6, 2019 to September 13, 2019.You askedthe Plan to pay forthe home infusion therapy services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services provided are not a covered benefit.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 S9328 is Home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.We find that CPT code S9328 is not supported in the medical record. Specifically, this code has a status code of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy services have not been met. Therefore, we decided that the Plan does not have to pay forthe home infusion therapy services coded S9328 provided from September 6, 2019 to September 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe 2 office visits, and injections provided from May 31, 2019 to June 11, 2019 by the out of network provider.You asked the Plan to pay forthe physician services. You say that you were referred to the provider by the doctor at the hospital for follow-up treatment.The Plan denied your request. The Plan says the services were not authorized prior to you receiving them. The Plan also says there is no documentation that the services were directed by a Plan provider.Medicare rules say that plans can require enrollees toget 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 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 forthe 2 office visits, and injections provided from May 31, 2019 to June 11, 2019 by the out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic screening testing provided.
You asked the Plan to pay for genetic tests. You say that you are appealing with medical records. The Plan
denied your request. The Plan says the denial of payment for these services is correct, because this provider is
out-of-network with the Plan, the ordering practitioner is out-of-network with the Plan,
these tests were ordered by telemedicine which is a prohibited action, and these tests are not covered by
Medicare when performed for screening purposes.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
The tests at issue in this appeal, genetic tests, were requested solely for screening purposes. Medicare does not
cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to pay for
genetic screening testing provided.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided.
You asked the Plan to pay for the laboratory 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 supported by the documentation.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
Review of the file shows that the ordering provider's progress notes were not provided to support the validity
of the testing provided. The documentation does not support that the laboratory testing at issue in this appeal
was not requested solely for screening purposes. Medicare does not cover this test solely for screening
purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the adult prophylaxis (D1110) that you provided on August 26, 2019.You asked the Plan to pay for the dental service. You say that you thought prophylaxis was a covered service.The Plan denied your request. The Plan says the frequency limit for prophylaxis of once every 6 months has been exceeded.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 and adult prophylaxis is a covered service, the frequency limit of once every 6 months has been exceeded. The record shows that the enrollee last received prophylaxis on March 4, 2019.Therefore, we decided that the Plan does not have to pay for the adult prophylaxis (D1110) that you provided on August 26, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for gamma knife radiosurgery provided from June 27, 2019 to June 28, 2019.You asked the Plan to reimburse you for the gamma knife radiosurgery. You say that were diagnosed with trigeminal neuralgia and you were unsuccessful in treating your pain with medications. You say your wife consulted with a specialist in Taiwan and concluded that gamma knife radiosurgery was your last resort. You say the pain has gradually disappeared and you need help to pay the medical bills for this surgery. The Plan denied your request. The Plan says that the gamma knife treatment received in Taiwan was not considered as urgent or emergent.Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care.The Plan also says that services covered worldwide must meet the same conditions of medical necessity and appropriateness that would have applied if provided in the United States or its territories.We looked at the file and Medicare rules. The file shows that the gamma knife radiosurgery was a planned procedure and not due to an emergency or urgently needed service because of an unforeseen illness or condition. Based on this information, we decided that Medicare rules for coverage of the gamma knife radiosurgery have not been met. Therefore, we decided that the Plan does not have to reimburse you for gamma knife radiosurgery provided from June 27, 2019 to June 28, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic screening testing provided on July 19, 2019.You asked the Plan to pay for genetic test. You say that you are appealing based on medical necessity.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this test is considered to be experimental or investigational.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The test at issue in this appeal, genetic test, was requested solely for screening purposes. Although the enrollee has a reported diagnosis of breast cancer, the record does not show that this testing was ordered by the enrollee's treating physician or that the test results were requested to guide therapeutic decision-making. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay for genetic screening testing on July 19, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from April 9, 2019 through April 12, 2019.You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found based on the medical records provided the patient's stay from April 9, 2019 through April 12, 2019 in the inpatient hospital was 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 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 April 9, 2019 through April 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on January 8, 2019 and billed under code 99242.You asked the Plan to pay for services billed to code 99242. You say that this claim should be paid.The Plan denied your request. The Plan says this claim cannot be paid as billed.The Plan must follow Medicare rules. Medicare does not allow two physicians from the same group who have treated an enrollee for the same date of service to bill separately. Prior to this billing a claim had already been submitted for payment for the same enrollee and he same physician group for the same service. Medicare rules for coverage of services billed to code 99242 have not been met.Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on January 8, 2019 and billed under code 99242
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forCPT code 49905 provided on March 26, 2019.You asked the Plan to pay forCPT code 49905. You say that the medical records support the billing of CPT code 49905.The Plan denied your request. The Plan says the medical records do not support the billing of CPT code 49905.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 49905 is Omental flap, intra-abdominal (List separately in addition to code for primary procedure).We asked our physicianreviewer 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 CPT code 49905. Our reviewer says that the medical records do not support the billing of CPT code 49905. Our physician reviewer found CPT code 49905 is not supported. The medical record does not contain evidence that an omental flap was created for repair of a defect of the abdominal wall.  National Correct Coding Initiative (NCCI) Policy Manual, chapter I states: Physicians must report services correctly. Procedures shall be reported with the most comprehensive CPT code that describes the services performed. Physicians must avoid upcoding. A HCPCS/CPT code may be reported only if all services described by that code have been performed.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CPT code 49905 have not been met.Therefore, we decided that the Plan does not have to pay forCPT code 49905 provided on March 26, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forinpatient hospital care provided from June 21, 2019 through June 23, 2019.You asked the Plan to waive the copaymentforinpatient hospital care. You say that you are appealing your cost-share responsibility for the services you received.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received inpatient hospital care from June 21, 2019 through June23, 2019. You were asked to pay a $275 copayment per day from June 21, 2019 through June 22, 2019, days 1-2 of your inpatient hospital care. You were discharged on June 23, 2019 and there was no copayment charge for the day of discharge. Per your contractthere is a $275 copayment per day required for days 1-5. 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 forinpatient hospital care provided from June 21, 2019 through June 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fortrain of four testing provided on September 25, 2018.You asked the Plan to pay forthe testing. You say that this should be paid for.The Plan denied your request. The Plan says train of four is considered a bundled procedure, and payment for it is included in the payment for thealready approved neuromonitoring.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 code95999 is "Unlisted neurological or neuromuscular diagnostic procedure" -used for train of four testing.We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the testing. Our reviewer says that the services at issue in this case were not coded correctly. Our coding reviewer found unlisted CPT code 95999, reported for train of four testing, is not supported. According to CPT rules, train of four is included in intraoperative neuromonitoring services and is not separately reportable.We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the testing have not been met.Therefore, we decided that the Plan does not have to pay fortrain of four testing provided on September 25, 2018.