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

We decided that the Plan does not have to waive the copayments for outpatient surgeries provided on November 18, 2019 and November 20, 2019.
You asked the Plan to waive the copayments for outpatient surgeries. You say that you were not informed of the cost-sharing charges prior to receiving the services. 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 $0 copayment for each outpatient hospital facility visit or for any surgical procedure provided during a colorectal cancer screening and a $200 copayment for all other outpatient surgical services. You received an outpatient surgery on November 18, 2019. Therefore, you are responsible to pay the $200 copayment. You received an outpatient surgery on November 20, 2019. Therefore, you are responsible to pay the $200 copayment. The total amount you owe is: $400. You have been asked to pay the total copayment amount of $400 for outpatient surgeries. Outpatient surgeries fall within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for outpatient surgeries provided on November 18, 2019 and November 20, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services coded S5501 provided from September 17 to September 30, 2019.
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 payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code S5501 is home infusion therapy, catheter care / maintenance, complex (more than one lumen), includes 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 S5501 is not supported in the medical record. Specifically, code S5501 has a status code of "I". A status code of I means 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 S5501 provided from September 17 to September 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on November 21, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider is on the
sanctioned list.
The Plan must follow Medicare rules. Medicare rules say that the Office of the Inspector General (OIG)
maintains a sanction list that identifies those individuals found guilty of fraudulent billing, misrepresentation of
credentials, etc.
We looked at the file and Medicare rules. The effect of an OIG exclusion is that no Federal health care program
payment may be made for any items or services furnished (1) by an excluded person or (2) at the medical
direction or on the prescription of an excluded person. The exclusion and the payment prohibition continue to
apply to an individual even if he or she changes from one health care profession to another while excluded.
This payment prohibition applies to all methods of Federal health care program payment, whether from
itemized claims, cost reports, fee schedules, capitated payments, a prospective payment system or other
bundled payment, or other payment system and applies even if the payment is made to a State agency or a
person that is not excluded. The requested provider is on the OIG exclusion/sanction list. Payment cannot be
made to providers on this list. Therefore, we decided that the Plan does not have to pay for the services
provided on November 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2750) for tooth #14.
You asked the Plan to pre-approve the crown. You say that the enrollee needs a crown on tooth #14 due to super-eruption of #14, margin of fracture is above the crestal bone. The Plan denied your request. The Plan says this service exceeds the enrollee's benefit allowance of two per calendar 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, crowns are limited to 2 per 1 calendar year. The record shows that the enrollee was approved for crowns on tooth #'s 29 and 5 on February 25, 2020 and your crowns benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a crown (D2750) for tooth #14.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for anti-reflective coating for eyeglasses provided on December
6, 2019.
You asked the Plan to pay for the anti-reflective coating. The Plan denied your request. The Plan says anti-reflective
coating is not a covered benefit.
The Plan follows Medicare rules. Medicare rules say that that anti-reflective coating (V2750) are covered only
when they are medically necessary for the individual beneficiary and the medical necessity is documented by
the treating physician. The Plan contract says that the eyewear benefit does not include lens options.
We looked at the file, Medicare's rules and the Plan's rules. Medicare only covers anti-reflective coating when
documented by the treating physician as medically necessary. The file does not contain documentation from the
treating physician to substantiate Medicare's coverage criteria for the anti-reflective coating. The file shows
that the Plan's eyewear benefit does not include coverage for lens options. Therefore, we decided that the Plan
does not have to pay for anti-reflective coating for eyeglasses provided on December 6, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve continued hematology/oncology care and treatment with an out of state, non-contracted provider.
You asked the Plan to pre-approve continued hematology/oncology care and treatment with an out of state, non-contracted provider. You say that the requested continued hematology/oncology care and treatment is medically necessary. The Plan denied your request. The Plan says that the requested continued hematology/oncology care and treatment can be approved for 1 visit with the out of state, non-contracted provider. The Plan states the enrollee can return to the service area and receive further care and treatment with a contracted provider.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet the enrollees' needs. The enrollee's contract with the Plan says that, with few exceptions, enrollees must use contract providers for care. We looked at the file and Medicare rules. The file shows that during this COVID-19 pandemic, the enrollee is unable to return to the Plan's service area for medically necessary hematology/oncology care and treatment. This shows the medically necessary hematology/oncology care and treatment is not accessible to the enrollee with a contracted provider in the Plan's service area.
Based on this information, we decided that Medicare rules for coverage of continued hematology/oncology care and treatment with an out of state, non-contracted provider have been met. Therefore, we decided that the Plan has to pre-approve continued hematology/oncology care and treatment with an out of state, non-contracted provider.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services provided on July 10, 2019 to July 25, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the chiropractic services. You say that you would like the plan to reconsider their decision. The Plan denied your request. The Plan says the services received were provided by an OON provider.
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 chiropractic services provided on July 10, 2019 to July 25, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 panel rendered on November 21, 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 covered.
The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure code 81479. The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. 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 Guardant360 panel rendered on November 21, 2019.
The Plan references Local Coverage Determination (LCD) L35396 in their determination; however, this LCD does not provide specific coverage criteria for the services at issue and was not used in the MAXIMUS determination.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for urology services (CPT 52240) provided to the enrollee on
October 17, 2019.
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 Current Procedural Terminology (CPT) code 52240 was 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 52240 is "Cystourethroscopy, with fulguration (including
cryosurgery or laser surgery) and/or resection of; LARGE bladder tumor(s)."
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 services. Our reviewer says that the
services at issue in this case were not coded correctly. Our coding reviewer found the medical records provided
do not include documentation of a Cystourethroscopy, with fulguration (including cryosurgery or laser surgery)
and/or resection of; LARGE bladder tumor(s) being performed on October 17, 2019. There is no
documentation to validate the size of the tumor was larger than 5 cm. This information is necessary to verify
that CPT 52240 was performed.
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 services have not been met. Therefore, we decided that the Plan does not
have to pay for urology services (CPT 52240) provided to the enrollee on October 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the EEG provided on March 20, 2019.
You asked the Plan to waive the copayment for the EEG. You say that you are on a fixed income. You say that you cannot afford to pay this bill. 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 $400 copayment for all other diagnostic procedures and tests. You have been asked to pay a $400 copayment for the EEG. The EEG falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show that you were only charged one copayment for the EEG provided on March 20, 2019. 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 EEG provided on March 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for reline dentures (D5750 and D5751) provided on May 1, 2019.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says you are appealing for reconsideration of the denied charges.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. The services are not listed in your EOC as a covered benefit; therefore, the services are not covered. Therefore, we decided that the Plan does not have to pay for reline dentures (D5750 and D5751) provided on May 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the special supplies provided on July 23, 2019 to December 9, 2019 by an out of network (OON) provider.
You asked the Plan to pay for these OON items. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the supplies were provided by an out of network provider.
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 special supplies provided on July 23, 2019 to December 9, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea tier exception for FreeStyle Precision Neo test strips for the enrollee.You asked the Planto pre-approvethe tier exception. You say that these are the only strips that are compatible with the enrollee's testing system.The Plandenied your request. The Plansaystier exceptions are only available for certain Part D drugs.The Plan must follow Medicare rules. Medicare rules say that tier exceptions are only available for Part D drugs. The requested drug is covered under Part B. Based on this information, we decided that Medicare rules for coverage of the tier exception have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea tier exception for FreeStyle PrecisionNeo test stripsfor the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0676).
You asked the Plan to preapprove a pneumatic compression device. You say that the device is necessary to prevent deep vein thrombosis. The Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to preapprove a pneumatic compression device (E0676).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for retainer crown - porcelain fused to high noble metal (D6750) and pontic - indirect resin based composite (D6205) provided on July 9, 2019 by an out-of-network provider.
You asked the Plan to pay for the dental services. You say that the services were done for the injury directly related to the fall you had on April 5, 2019. The Plan denied your request. The Plan says the services are not covered under Medicare or the Health Plan.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. You only have limited non-routine dental benefits. The services received are considered routine dental services which are not a Medicare or Health plan benefit. Therefore, we decided that the Plan does not have to pay for retainer crown - porcelain fused to high noble metal (D6750) and pontic - indirect resin based composite (D6205) provided on July 9, 2019 by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forhospital services provided on October 11, 2019 by an out of network (OON) provider.You asked the Plan to pay forhospital services. You say that you would like this appeal reprocessed and approved for payment.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 forhospital services provided on October11, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay the remaining amount forthe extractions for teeth # 21, 23, 24, and 25 provided on December 12, 2019.You asked the Plan to pay the remaining amount forthe dental services. You say that you cannot eat solid foods without teeth. You say that you are requesting an exception to get the dental waiver to get the remaining bills paid for last year. You also say that you have no money left over after paying your rent to put towards this bill.The Plan denied your request. The Plan says that the maximum allowance has been exceeded.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 did not substantiate their claim that the enrollee used up their dental benefit while processing this claim. Without evidence of the amount of benefit used prior toreceiving the services on December 12, 2019, we are unable to determine that the enrollee's dental benefit was used up.Therefore, we decided that the Plan has to pay the remaining amount forthe extractions for teeth # 21, 23, 24, and 25 provided on December 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe assembly and operation of a pump with oxygenator or heat exchanger (99190) provided on September 23, 2019.You asked the Plan to pay forthe assembly and operation of a pump with oxygenator or heat exchanger. You say that this was a mandatory service.The Plan denied your request. The Plan says payment for this service is included in the DRG.The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule. The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of "C" on Addendum B of the 2019 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission.Therefore, we decided that the Plan does not have to pay forthe assembly and operation of a pump with oxygenator or heat exchanger (99190) provided on September 23, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on December 6, 2019.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are not covered.
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, the lab services, was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on December 6, 2019.