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

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond
July 8, 2020.
You asked the Plan to pre-approve the continued SNF care. You say that the enrollee would benefit from
continued skilled care in the facility. The Plan denied your request. The Plan says the enrollee no longer
requires daily skilled care at this time.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is 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 the continued SNF care. Our reviewer
says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the
SNF on 6/20 after worsening diabetic foot infection. From a nursing perspective, the beneficiary received oral
medications. The beneficiary had stable vital signs. She had uncomplicated wound care to her lower extremity
ulcers. Regarding rehabilitation services, the beneficiary received PT and OT in the SNF. By the dates in
question, the beneficiary required moderate to maximal assist with bed mobility and transfers and remained
non-ambulatory. The beneficiary required varying assist with activities of daily living.
There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs.
This beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a
skilled nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the continued SNF care have not been met. Therefore, we decided that the Plan
does not have to pre-approve continued skilled nursing facility (SNF) care beyond July 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for liposuction (38999) provided from November 12, 2019 to
November 14, 2019.
You asked the Plan to pay for liposuction. You say that this was medically necessary. The Plan denied your
request. The Plan says this was cosmetic.
The Plan follows Medicare rules. Medicare rules say that cosmetic surgery or expenses incurred in connection
with such surgery is not covered. The rules also say that the provider, supplier, or beneficiary, as appropriate,
must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the
amount of payment.
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 liposuction. Our reviewer says that the
submitted documentation does not show that the criteria for coverage have been met. Our physician reviewer
found the documentation in the case file is insufficient to determine whether the procedure are issue was
cosmetic or reconstructive. The case file is lacking medical records documenting a history, physical
examination, and an operative report. It cannot be determined that the procedure at issue was reconstructive
rather than cosmetic.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of liposuction have not been met. Therefore, we decided that the Plan does not
have to pay for liposuction (38999) provided from November 12, 2019 to November 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99190) provided on January 23, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for this
service is included in the Part A DRG payment to the facility.
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other
than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all
necessary covered services to the beneficiary either directly or under arrangements made with outside
providers. Payment for all fees related to this service would have been included under the facility claim.
Therefore, we decided that the Plan does not have to pay for the services (CPT 99190) provided on January 23,
2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on September 24, 2019.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says nonemergent,
non-urgent services with out-of-network providers require 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 did not pre-approve the
laboratory 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 laboratory services provided on September 24, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a fine needle aspiration provided on
February 6, 2020.
You asked the Plan to waive the copayment for a fine needle aspiration. You say that you disagree with the
charges because you do not consider the procedure to be an outpatient surgical procedure. The Plan denied
your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250
copayment for outpatient hospital services.
You have been asked to pay a $250 copayment for a fine needle aspiration. A fine needle aspiration falls within
the outpatient hospital 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 copayment for a
fine needle aspiration provided on February 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in-network rate for an oral exam (D0120) and cleaning
(D1110) provided March 9, 2020.
You asked the Plan to pay the in-network rate for the dental services. You say that the services should be fully
covered because you were told the dentist at issue was in-network. The Plan denied your request. The Plan says
records show you were not told the dentist was in-network. The correct amount was paid based on the plan
contract.
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. The Plan covers the dental
services provided out-of-network up to the Medicare allowed amount with the enrollee responsible for the
remainder.
We looked at the plan contract, the file, and Medicare rules. The record shows the correct amount was billed
based on the plan contract. Based on this information, we decided that the Plan's rules for coverage of the
dental services have not been met. Therefore, we decided that the Plan does not have to pay the in-network rate
for an oral exam (D0120) and cleaning (D1110) provided March 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services coded S9500 provided
from February 29, 2020 to March 10, 2020.
You asked the Plan to pay for the 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 billed are not supported by the
documentation.
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 S9500 is home infusion therapy, antibiotic, antiviral, or
antifungal therapy; once every 24 hours; 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 S9500 is not supported in the medical record. Specifically, code S9500 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 for the home infusion therapy services coded S9500 provided from February 29, 2020 to March
10, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the physical therapy re-evaluation and
physical therapy services provided on April 20, 2020.
You asked the Plan to reduce the copayment for the physical therapy re-evaluation and physical therapy
services. You say that you have always only paid a $20 copayment for physical therapy. The Plan denied your
request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20
copayment per Medicare-covered visit of physical therapy, occupational therapy, and speech language therapy
services.
You have been asked to pay a $20 copayment for the physical therapy re-evaluation and a $20 copayment for
the physical therapy services. The physical therapy re-evaluation and physical therapy services fall within the
"Outpatient rehabilitation 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 reduce the copayment for
the physical therapy re-evaluation and physical therapy services provided on April 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on November 6, 2019.
You asked the Plan to pay for drug tests. You say that you have submitted a valid physician laboratory
requisition form. The Plan denied your request. The Plan says the denial of payment for these services is
correct, because the documentation submitted does not support the tests billed.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific
lab services is required for covered lab services.
We looked at the file and Medicare rules. The documentation submitted does not include a valid physician
order or clear intent to order the specific lab services billed on this claim. Based on this information, we
decided that Medicare rules for coverage of drug tests have not been met. Therefore, we decided that the Plan
does not have to pay for drug testing provided on November 6, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BRCA1 and BRCA2 testing.
You asked the Plan to pre-approve the BRCA1 and BRCA2 testing. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this request is not approved because the member would need another close family member to have breast or ovarian cancer in order to meet Medicare coverage criteria.
The Plan must follow Medicare rules. Medicare rules say that BRCA1/BRCA2 genetic testing is considered not reasonable and necessary for testing of individuals with no personal history of breast, ovarian, fallopian tube, primary peritoneal, pancreatic or prostate cancer. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the BRCA1 and BRCA2 testing have not been met. Specifically, the medical records do not show that the enrollee has a personal history of breast, ovarian, fallopian tube, primary peritoneal, pancreatic or prostate cancer. Therefore, we decided that the Plan does not have to pre-approve BRCA1 and BRCA2 testing.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9500) provided on February 20, 2020 through February 27, 2020.
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code S9500 has a status code of I which is invalid 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 S9500 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code S9500 has a status code of I. This means that CPT code S9500 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9500) provided on February 20, 2020 through February 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive exam (for a new patient, or an established patient after 3 or more years of inactivity from dental treatment) (D0150) and panoramic x-ray for evaluation of the teeth and mouth (D0330) provided on March 2, 2020.
You asked the Plan to pay for the dental services. You say that the services were needed. The Plan denied your request. The Plan says you exhausted your benefit frequency limit.
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. You exhausted your benefit frequency limit, because you ha these services done on July 23, 2018. Your EOC states, comprehensive exam (for a new patient, or an established patient after 3 or more years of inactivity from dental treatment) (D0150) - one (1) procedure every three (3) plan years and panoramic x-ray for evaluation of the teeth and mouth - one (1) procedure every three (3) plan years. Therefore, we decided that the Plan does not have to pay for comprehensive exam (for a new patient, or an established patient after 3 or more years of inactivity from dental treatment) (D0150) and panoramic x-ray for evaluation of the teeth and mouth (D0330) provided on March 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for oxygenator assembly and operation services (CPT 99190)
provided to the enrollee on February 18, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says payment for this service is the responsibility of the facility to any vendor.
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 99190 is "Assembly and operation of pump with
oxygenator or heat exchanger (with or without ECG and/orpressure monitoring); each hour."
We find that CPT code 99190 is not supported in the medical record. Specifically, payment for this code is
included in the payment to the facility. Based on this information, we decided that Medicare rules for coverage
of the services have not been met. Therefore, we decided that the Plan does not have to pay for oxygenator
assembly and operation services (CPT 99190) provided to the enrollee on February 18, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion (CPT 99601) provided to the enrollee from January 20, 2020 to March 12, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this is an invalid procedure code for this service.
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 99601 is "Home infusion/specialty drug administration, per visit (up to 2 hours)." We find that CPT code 99601 is not supported in the medical record. Specifically, this code has a status indicator of "I" which means that it is invalid for use with Medicare. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for home infusion (CPT 99601) provided to the enrollee from January 20, 2020 to March 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on December 9, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. 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.
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
service 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 physician's services provided on December 9, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you on October 22, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim must first be submitted to 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 has identified your primary insurer. As the secondary insurer, the Plan cannot be held responsible for the services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the services provided to you on October 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on December 2, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the service 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 physician's services provided on December 2, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tetanus shot (TDAP) provided on February 27, 2020.
You asked the Plan to pay for the Tetanus shot. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Tetanus shot. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the Tetanus shot. Therefore, we decided that the Plan does not have to pay for the Tetanus shot (TDAP) provided on February 27, 2020.
Benefits for the Tetanus shot 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating facility on October 24, 2019 to November 18, 2019.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that it was the doctor's fault. The Plan denied your request. The Plan says the correct copayment has been applied for the services that were provided.
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 $220 copayment per day for days 1-8. There is a $0 copayment for additional days for inpatient hospital care. You have been asked to pay a $220 copayment per day for days 1-8 for an inpatient hospital stay. The total amount you are being asked to pay is $1,760 ($220 x 8 days = $1,760). An inpatient hospital 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 an inpatient hospital stay provided by a participating facility on October 24, 2019 to November 18, 2019.