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

We decided that the Plan does not have to pay for CPT code 23650 billed for date of service October 13, 2019.
You asked the Plan to pay for CPT code 23650. You say that the documents support the services billed. The Plan denied your request. The Plan says the documentation submitted did not indicate that the provider performed the service in dispute.
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 23650 is closed treatment of shoulder dislocation, with manipulation; without anesthesia. We find that CPT code 23650 is not supported in the medical record. Specifically the enrollee is noted to have had a shoulder separation (i.e., AC joint dislocation) not a shoulder dislocation. Based on this information, we decided that Medicare rules for coverage of CPT code 23650 have not been met. Therefore, we decided that the Plan does not have to pay for CPT code 23650 billed for date of service October 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on February 2, 2020 by an out of network (OON) provider.You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and approved for a payment.The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the member's primary care physician did not refer these services.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 services provided on February 2, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the rest home visit provided on January15, 2020 by an out of network (OON) provider.You asked the Plan to pay for the rest home visit. 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 when 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 rest home visit provided on January 15, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on April 8, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network 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 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 physician services provided on April 8, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for wound care provided on May 22, 2020 by an out of network (OON) provider.You asked the Plan to pay for wound care. You say that these services were medically necessary.The Plan denied your request. The Plan says prior authorization was obtained for these services.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 wound care provided on May 22, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit and injection provided on January 15, 2020 by an out of network (OON) provider.
You asked the Plan to pay for an office visit and injection. You say that these services were medically necessary. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the member's primary care physician did not refer these services.
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 an office visit and injection provided on January 15, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab tests provided on January 23, 2020 by an out of network (OON) provider.You asked the Plan to pay for lab tests. You say that you received a request from the referring provider's office. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says the referring provider is out-of-network. The plan says that prior authorization was not 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 lab tests provided on January 23, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to reimburse the copayment for a CT scan provided on April 5, 2019.
You asked the Plan to reimburse the copayment for a CT scan. You say that you should only owe a $20 copayment and request to be reimbursed the additional $80. 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 $100 copayment for advanced imaging services. You have been asked to pay a $100 copayment for a CT scan. A CT scan falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reimburse the copayment for a CT scan provided on April 5, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services provided on January 8, 2020 by an out of network (OON) provider.
You asked the Plan to pay for outpatient hospital services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained for these services.
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 outpatient hospital services provided on January 8, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the elbow orthosis, and the shoulder-elbow-wrist-hand
orthosis provided on March 19, 2020.
You asked the Plan to pay for the elbow orthosis (L3761), and the shoulder-elbow-wrist-hand orthosis (L3960).
You say that the orthoses were medically necessary. The Plan denied your request. The Plan says they were
unable to discover any evidence of an established relationship between the enrollee and the ordering physician.
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 the elbow orthosis (L3761), and the
shoulder-elbow-wrist-hand orthosis (L3960). Our reviewer says that the orthoses are not medically necessary.
Our physician reviewer found the enrollee's chief complaints were chronic pain in the elbow right and the
shoulder right, documented in 2 separate notes on the same date of service. The documentation in the case file
does not support that the requested shoulder/arm orthosis was medically reasonable and necessary for the
enrollee in this case. A physical examination of the shoulder would reasonably be required to adequately assess
whether the shoulder/arm orthosis was medically necessary for an enrollee. The documentation does not
support that the orthosis was medically reasonable and necessary for the enrollee in this case, as there is
insufficient documentation of a credible physical examination of the shoulder.
The documentation in the case file does not support that the requested elbow orthosis was medically reasonable
and necessary for the enrollee in this case. An appropriate history and a physical examination of the elbow
would reasonably be required to adequately assess whether the elbow orthosis was medically reasonable and
necessary. The documentation does not support that the elbow orthosis was medically reasonable and necessary
in this case, as there is insufficient documentation of a credible physical examination of the elbow.
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 elbow orthosis (L3761), and the shoulder-elbow-wrist-hand orthosis
(L3960) have not been met. Therefore, we decided that the Plan does not have to pay for the elbow orthosis,
and the shoulder-elbow-wrist-hand orthosis provided on March 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth (D4212), pontic -porcelain/ceramic (D6245) and retainer crown -porcelain/ceramic (D6740) provided on March 11, 2020.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 exhausted your maximum benefit allowance.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.Review of the file shows that gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth (D4212) is not listed in your EOC as a covered benefit; therefore, it is not covered. You exhausted your $1,000 maximum benefit allowance on March 11, 2020. Your EOC states, "you have a $1,000 annual maximum. After the annual maximum is exhausted, any remaining charges are your responsibility." Therefore, you are responsible for any amount over and above the $1,000 allowance amount.Therefore, we decided that the Plan does not have to pay for gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth (D4212), pontic -porcelain/ceramic (D6245) and retainer crown -porcelain/ceramic (D6740) provided on March 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on November 19, 2019.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis CPT code. We looked at the file and Medicare rules. The testing in question was billed with 27 CPT codes. Per Medicare rules, the testing should have been billed with one proprietary laboratory analysis CPT code. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on November 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing panel provided on January 6, 2020.You asked the Plan to pay for the definitive drug testing. You say that this testing is medically necessary and should be paid.The Plan denied your request. The Plan says there is no valid order for this testing.The Plan must follow Medicare rules. Medicare rules say that lab testing may be covered when ordered by a treating provider.In this case, the file does not contain any order form for the testing at issue. Only a form delineating the provider's custom panel is provided.Therefore, we decided that the Plan does not have to pay for the definitive drug testing panel provided on January 6, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the injection provided on February 11,
2020.
You asked the Plan to waive the copayment for the injection. You say that you were not given the information
to make a well-informed decision about receiving the injection. You say if you had known it would cost more
than $45, you would not have had the injection. 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 $295
copayment for surgery services at an in-network outpatient hospital. For this date of service, you have been
asked to pay the allowed amount of the claim because this amount is less than the $295 copayment for the
injection.
You have been asked to pay a $249.06 copayment for the injection. The injection falls within "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 copayment for the injection provided on February 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing services provided on January 29, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the billed code is not supported.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. 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 forthe drug testing services provided on January 29, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forthe acute inpatient hospital care provided to the enrollee from February 20, 2019 to March 28, 2019.You asked the Plan to pay foracute inpatient hospital care. You say that these services were medically necessary.The Plan denied your request. The Plan says that that inpatient services were not 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 supports that the criteria for inpatient payment are met in this case. The record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department and/or observation care) would span two midnights. Our physician reviewer found that the enrollee's condition met Medicare criteria for inpatient hospital services.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 been met.Therefore, we decided that the Plan has to pay forthe acute inpatient hospital care provided to the enrollee from February 20, 2019 to March 28, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine vision services provided on February 10, 2020.
You asked the Plan to pay for the routine vision services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says routine vision services are not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The services you asked the Plan to pay for are considered routine vision services or eyewear and are not covered under your 2020 benefit year. Therefore, we decided that the Plan does not have to pay for the routine vision services provided on February 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the urgent care visit provided on December 18, 2019.
You asked the Plan to waive the coinsurance for the urgent care visit. You say that you had already met your maximum out-of-pocket. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance but no more than $25 for each visit. You have been asked to pay $24.40, which is 20% of the allowed amount for the urgent care visit. The allowed amount is $122 (20% x $122 = $24.40). The urgent care visit falls within the "Urgently Needed Services" benefit category. The records show that your maximum out-of-pocket had not been met prior to the urgent care visit. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the urgent care visit provided on December 18, 2019.