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

We decided that the Plan does not have to pay for a partial mastectomy (19301) and tissue transfer (14001) provided on July 24, 2019.
You asked the Plan to pay for the partial mastectomy and tissue transfer. You say that the assistant at surgery provider treated the member in the emergency room for emergency care and that payment should be issued based on medical necessity. The Plan denied your request. The Plan says these services have a status indicator of 0, which means that co-surgeons are not permitted for this procedure.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS. In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for a partial mastectomy (19301) and tissue transfer (14001) provided on July 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for mental health services provided on July 29, 2019 out of network.
You asked the Plan to pay for out of network providers. You say that the Plan should cover this service. The Plan denied your request. The Plan says you did not have prior authorization for 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 must 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 mental health services provided on July 29, 2019 out of network.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to the enrollee on April 3, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing rendered to the enrollee on April 3, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay fordrug testing provided tothe enrollee on May 20, 2019 and billed under codes G0482 and 80307.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says the claim submitted has errors in regard tothe place of service (POS) code and ordering documentation. The Plan says that for Current Procedural Terminology (CPT) codes80307and G0482 the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11.  Also, the laboratory results submitted indicate the specimen was collected on May 20, 2019 accessioned by the lab on May 21, 2019.  The enrollee resides in Tennessee and the billing laboratory is inTexas. This means the billed codescannot be verified.  It is noted multiple attempts were made to obtain additional information from the providerto resolve this claim. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT codeand POS code. In this case, the medical records provided contradict the POS codes recorded. The Plan states a corrected claim would be reviewed if submitted. Medicare rules for coverage of this service have not been met.Therefore, we decided that the Plan does not have to pay fordrug testing provided to the enrollee on May 20, 2019 and billed under codes G0482 and 80307.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit and physician services provided on September 17, 2019 by the out of network provider.
You asked the Plan to pay for an office visit and physician services. You say that you were referred to this doctor by your primary care physician. The Plan denied your request. The Plan says no prior authorization was obtained for these services. The Plan says that there is no referring provider listed for this service.
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 physician services provided on September 17, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forpsychotherapy provided on March 25, 2019 by the out of networkprovider. You asked the Plan to pay forpsychotherapy. You say that you would like this claim reprocessed and approved for payment. You say that you will take further action if these claims are not paid.The Plan denied yourrequest. The Plan says the referring provideris out-of-network. The Plan says that the referring facility provider is also out-of-network. The Plan says that 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 forpsychotherapy provided on March 25, 2019 by the out of network provider.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient hospital care provided to the enrollee from March 27, 2018 through March 29, 2018.
You asked the Plan to pay for inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says that the stay is not medically necessary.
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. There is no evidence provided to suggest that rules for Medicare coverage of these services have not been met. Therefore, we decided that the Plan has to pay for inpatient hospital care provided to the enrollee from March 27, 2018 through March 29, 2018.
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 waive the copayment for the comprehensive hearing test provided on
October 2, 2019.
You asked the Plan to waive the copayment for the comprehensive hearing test. You say that you asked for a
routine hearing test. You say that you were informed the routine test and comprehensive test was the same. 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 $20
copayment for specialist visits for diagnostic hearing and balance evaluations.
You have been asked to pay a $20 copayment for the comprehensive hearing test. The comprehensive hearing
test falls within the "Hearing services" benefit category. The records show that the hearing test was performed
due to hearing loss, which is considered diagnostic. 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 comprehensive hearing test provided on October 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waivethe copayment charged to the enrollee for specialist services provided on August 13, 2019. You asked the Plan to waivethis copayment. You say that you do not believe this copayment is correct.The Plan denied your request. The Plan says this copayment was charged based on the medical records and the Plan contract agreement.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay $35 copayment for specialist services. The enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.Therefore, we decided that the Plan does not have to waivethe copayment charged to the enrollee for specialist services provided on August 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the portable oxygen concentrator purchased on July 23, 2019.You asked the Plan to reimburse you for the Zen-O Portable Oxygen Concentrator system. You say that local Medicare approved suppliers could not provide the necessary equipment on short notice.The Plan denied your request. The Plan says the supplier is not Medicare certified and therefore the claim is not payable.The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or provider who has opted out of the program except in cases involving emergencies or urgently needed care. Medicare rules say that only rented oxygen equipment is eligible for coverage.The services at issue in this appeal were provided in a non-urgent, non-emergent situation by provider. This provider has opted out of the Medicare program. The file shows that provider entered into a private contract with you regarding payment. Also, purchased oxygen equipment is statutorily non-covered by Medicare.Therefore, we decided that the Plan does not have to reimburse you for the portable oxygen concentrator purchased on July 23, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for
the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says care could be received in another setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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 IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The
documentation does not reveal that the enrollee's medical status requires the intensity of an IRF stay with close
physician or nursing supervision. The enrollee may benefit and participate in additional therapy of PT and OT
but the enrollee's current functional status does not require this on an intensive rehabilitation facility therapy
program level in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for intermittent limb compression device.
You asked the Plan to pay for intermittent limb compression device. You say that the claim should be paid. The Plan denied your request. The Plan says pneumatic devices are covered only for the treatment of lymphedema or for the treatment of chronic venous insufficiency with venous stasis ulcers.
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers. The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous stasis ulcers. Therefore, we decided that the Plan does not have to pay for intermittent limb compression device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe root canal (D03310 provided on August 28, 2019.You asked the Plan to pay forthe root canal. You say that you had to have the services before you had a hip replacement surgery. You also say that you cannot afford to pay this bill and the bill for your hip surgery.The Plan denied your request. The Plan says the root canal is not a covered service.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the root canal is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay fortheroot canal (D03310 provided on August 28, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment charged for x-rays provided on October 14, 2019.
You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The Plan denied your request. The Plan says the plan contract is clear that cost share applies for each service 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 $50 copayment for outpatient imaging services. You have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment charged for x-rays provided on October 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye exam (92004), an injection of aflibercept (J0178), an injection of a drug into the eye (67028), and diagnostic imaging of the retina (92134), provided on August 13, 2019 by an out of network provider.
You asked the Plan to pay for an eye exam, injections, and diagnostic imaging of the retina. You say that you are appealing the claim payment denial for services rendered to the member on date of service August 13, 2019 as the documentation supports the necessity of the services provided. The Plan denied your request. The Plan says the rendering provider is a non-participating provider. The plan did not authorize any services for this provider. There are multiple in-network providers within 30 miles of the member's residence that could have rendered the services. The services are not considered urgent/emergent in nature.
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 eye exam (92004), an injection of aflibercept (J0178), an injection of a drug into the eye (67028), and diagnostic imaging of the retina (92134), provided on August 13, 2019 by the out of network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the physical therapy visits provided from May 10, 2019 to August 7, 2019.You asked the Plan to waive the copayments for the physical therapy visits. You say that you are on disability and overwhelmed with medical bills. You say you would like the copayments to be waived. 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 $30 copayment for each Medicare-covered physical therapy and speech-language therapy visit. You have been asked to pay a $30 copayment for each of the physical therapy visits. ($30 x 22 visits = $660). The physical therapy visits 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 waive the copayments for the physical therapy visits provided from May 10, 2019 to August 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a high frequency chest wall air pulse generator (E0483).
You asked the Plan to preapprove a high frequency chest wall air pulse generator. You say that the claim should be paid. The Plan denied your request. The Plan says the enrollee does not have a Medicare Approved indication for coverage of this DME.
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 preapprove a high frequency chest wall air pulse generator. Our reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee is noted to have COPD. There is no evidence that the enrollee has cystic fibrosis, bronchiectasis or a neuro-muscular disease. Therefore, the requested DME is not shown to be medically necessary or reasonable.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a high frequency chest wall air pulse generator. have not been met. Therefore, we decided that the Plan does not have to preapprove a high frequency chest wall air pulse generator (E0483).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular genetic hereditary predictive testing provided to
the enrollee on January 10, 2019.
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request.
The Plan says Medicare says tests with no relation to a medical diagnosis of disease for the health of the patient
are not a benefit.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are 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 pay for the testing. Our reviewer says that the
services at issue in this case were not medically reasonable or necessary. Our physician reviewer found the
available documentation does not support that the requested pharmacogenomic testing would impact the health
of the enrollee in this case. Testing which has no proven relation to the management of a medical diagnosis of
disease for the health of an enrollee is not a covered Medicare benefit.
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 testing have not been met. Therefore, we decided that the Plan does not have
to pay for molecular genetic hereditary predictive testing provided to the enrollee on January 10, 2019.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the BLS emergency ambulance service (0429) and ground mileage (A0425) provided April 19, 2019.
You asked the Plan to pay for the ambulance service. You say that the documents provided should support the necessity of the services in dispute. The Plan denied your request. The Plan says that the no fault carrier's payment exceeded the plan's allowable.
The Plan must follow Medicare rules. Medicare rules say 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 auto carrier, covered 80% of the billed charges as the primary payer. The actual charge of $748.00 minus the primary payment of $598.40 = $146.15. Therefore, the plan, has to pay the secondary payment in the amount of $149.60. Therefore, we decided that the Plan has to pay for the BLS emergency ambulance service (0429) and ground mileage (A0425) provided April 19, 2019.