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

We decided that the Plan does not have to pay for the dental services provided on February 4, 2020 by an outof-
network provider.
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 do not have out-of-network benefits.
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.
Review of the file show that you received the dental services on February 4, 2020 by an out-of-network
provider. Your EOC states, to be covered in-network, you need to use a provider that is contracted with our
dental vendor to provide supplemental dental services. Care rendered by a provider that is not part of our
supplemental dental network is not covered. 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 dental services
provided on February 4, 2020 by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for the laboratory work provided on
November 18, 2019.
You asked the Plan to reduce the coinsurance for the laboratory work. You say that you were not aware the
provider was out-of-network. You say you would like the claim processed as in-network. 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 50% of
the Medicare allowed amount for each Medicare-covered laboratory test service in all settings.
You have been asked to pay $130.37 which is 50% of the allowed amount for the laboratory work. The allowed
amount is $260.74. ($260.74 x 50% = $ 130.37). The laboratory work falls within "Outpatient diagnostic tests
and therapeutic services and supplies" benefit category. The record shows the provider is out-of-network.
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 coinsurance for the laboratory work provided on November 18, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says skilled services are no longer required.
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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. You appear to have reached a plateau in function. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs at this point are custodial and, as a practical matter, can be provided at a lower level of care (ex. home, AL, LTC, Hospice). 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit (99212).
You asked the Plan to pre-approve an office visit. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 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 an office visit. Our reviewer says that the services are not medically necessary. Our physician reviewer found the provider's service include an office visit or reexamination, which is not a covered service per Medicare guidelines. The treatment includes heat, electrical muscle stimulation, myofascial release (soft tissue therapy) and trigger point therapy (soft tissue therapy). Medical necessity is not established. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an office visit have not been met. Therefore, we decided that the Plan does not have to pre-approve an office visit (99212).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids and services purchased on February 20,
2020 from a non-participating provider.
You asked the Plan to pay for the services. You say that you thought the provider was in-network and approved
by the Plan. The Plan denied your request. The Plan says there is no coverage if hearing aids or related services
are received from a provider not part of the plan's hearing aid vendor's network.
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.
Review of the file show that you purchased the hearing aids and services from a non-participating provider.
There is no coverage if hearing aids or related services are received from a provider not part of the plan's
hearing aid vendor's network. Your EOC states, hearing aids ordered through providers other than the plan's
hearing aid vendor's network are not covered. 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. Furthermore, your plan does not cover hearing service, miscellaneous
(V5299). Therefore, we decided that the Plan does not have to pay for the hearing aids and services purchased
on February 20, 2020 from a non-participating provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical pathology services coded 88305 provided on February 13, 2020.
You asked the Plan to pay for the surgical pathology services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.
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 88305 is not supported in the medical record. Specifically, this procedure was reported twice for the same date of service. One was billed with modifier 26 (professional component) and another without a modifier (global service). In this case, only the global service is allowed. Based on this information, we decided that Medicare rules for coverage of the surgical pathology services have not been met. Therefore, we decided that the Plan does not have to pay for the surgical pathology services coded 88305 provided on February 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the CPAP (E0601) and humidifier provided on February 20,
2020.
You asked the Plan to pay for the CPAP (E0601) and humidifier. You say that you were not compliant because
you were ill for several weeks. The Plan denied your request. The Plan says you did not use the device
consistently to meet medical necessity compliance standards.
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 CPAP (E0601) and humidifier. Our
reviewer says that criteria for continued coverage of CPAP are not met. The enrollee was unable to meet the
minimum usage criteria for CPAP, of at least 4 hrs/night for at least 70% of nights, during the trial period.
Continue CPAP is therefore considered not medically necessary. For consideration of additional coverage of
CPAP, the enrollee would need to have a clinical followup visit to address the reasons for inability to use the
CPAP consistently. If the compliance issues can be addressed satisfactorily in that visit, then another trial of
CPAP may be considered reasonable and medically necessary. For now, the denial is upheld.
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 CPAP (E0601) and humidifier have not been met. Therefore, we decided
that the Plan does not have to pay for the CPAP (E0601) and humidifier provided on February 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on January 22, 2020.
You asked the Plan to waive the copayment for the office visit. You say that you should not be responsible for the copayment because you did not see the physician. 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 for each in-network and out-of-network office visit to your POC, or other primary care provider. You have been asked to pay a $20 copayment for the office visit. The office visit falls within the "Physician/
Practitioner services, including doctor's office visits" benefit category. The record shows the nurse practitioner is considered a professional practitioner.
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 office visit provided on January 22, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the observation stay provided from July 5, 2019 to July 6, 2019.
You asked the Plan to reduce the copayment for the observation stay. You say that you would like the copayment reduced to the $150 inpatient copayment. The Plan denied your request. The Plan says a corrected claim was submitted and 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 $275 copayment for in-network outpatient hospital observation services. You have been asked to pay a $275 copayment for the observation stay. The observation stay falls within the "Outpatient hospital services" benefit category. The medical record shows that you were under observation.
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 observation stay provided from July 5, 2019 to July 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment and supplies provided from
January 1, 2020 to February 17, 2020 by an out of network provider.
You asked the Plan to pay for the nebulizer and supplies. You say that you did not know the supplier was outof-
network. The Plan denied your request. The Plan says the services were not emergent and prior
authorization was not requested.
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 at issue in this appeal. The Plan did not pre-approve the items at issue. We
found no exception that would require the Plan to pay for these items. Therefore, we decided that the Plan does
not have to pay for the durable medical equipment and supplies provided from January 1, 2020 to February 17,
2020 by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for needle electromyography (95870) provided on November 5, 2019.
You asked the Plan to pay for the needle electromyography. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service billed.
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 95870 is Needle electromyography; limited study of muscles in 1 extremity or non-limb (axial) muscles (unilateral or bilateral), other than thoracic paraspinal, cranial nerve supplied muscles, or sphincters. We asked our coder 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 needle electromyography. Our reviewer says that CPT code 95870 does not meet criteria for billing or reimbursement consideration. Our reviewer found the procedure report does not indicate that a needle electromyography 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 needle electromyography have not been met. Therefore, we decided that the Plan does not have to pay for needle electromyography (95870) provided on November 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided from October 7, 2019 to
October 10, 2019.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says no medical
records were received.
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, initial and subsequent hospital care was provided to the enrollee. We find that the billed codes are
not supported. There are insufficient medical records provided to show Medicare coverage rules have been met.
Therefore, we decided that the Plan does not have to pay for inpatient hospital care provided from October 7,
2019 to October 10, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the Lumbar Spine (72148).
You asked the Plan to pre-approve the MRI. You say that the MRI is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. 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 MRI. Our reviewer says that the MRI is not medically necessary. Our physician reviewer found physical examination notes no obvious anatomic abnormalities or neurologic deficits. Imaging of the cervical and thoracic spine have been non-actionable. The documentation is insufficient to show that additional imaging of the lumbar spine is currently 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 the MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the Lumbar Spine (72148).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for closure of eyelids by suture (67875) provided on January 8,
2020.
You asked the Plan to pay for the eyelid closure. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says the documentation submitted does not support
the service billed.
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 67875 is temporary closure of eyelids by suture (eg, Frost
suture).
We asked our coder 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 eyelid closure. Our reviewer says that CPT code 67875
does not meet criteria for billing or reimbursement consideration. Our reviewer found the operative report does
indicate that temporary closure of eyelids by sutures was completed.
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 eyelid closure have not been met. Therefore, we decided that the Plan does
not have to pay for closure of eyelids by suture (67875) provided on January 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision services provided on March 12, 2020 by an out-of-network
provider.
You asked the Plan to pay for the vision services. You say that you did not know you needed an authorization.
The Plan denied your request. The Plan says you do not have out-of-network benefits.
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 vision services provided on March 12, 2020 by
an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for limited oral evaluation - problem focused (D0140) and cone
beam CT capture and interpretation with limited field of view - less than one whole jaw (D0364) provided on
February 5, 2020 by an out-of-network provider.
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 the services are not covered.
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 the plan paid for procedure code D0140 provided to you
on February 04, 2020. Furthermore, cone beam CT capture and interpretation with limited field of view - less
than one whole jaw (D0364) is not listed in your EOC as a covered benefit. Therefore, we decided that the Plan
does not have to pay for limited oral evaluation - problem focused (D0140) and cone beam CT capture and
interpretation with limited field of view - less than one whole jaw (D0364) provided on February 5, 2020 by an
out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the office visit provided on January 23,
2020.
You asked the Plan to waive the deductible for the office visit. You say that this was a simple follow up visit.
You say that you were overcharged for the service you received. The Plan denied your request. The Plan says
the deductible applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that your annual deductible is $200, which applies to all items and service except
those specifically excluded by the Plan's contract. This is the amount you have to pay out-of-pocket before the
Plan will pay its share for your covered Medicare Part A and Part B services.
The item or service you asked the Plan to waive the deductible for falls within the "Physician/Practitioner
services, including doctor's office visits" benefit category. The Plan has followed Medicare rules by clearly
disclosing in the contract that your $200 annual deductible applies to primary care services. This cost sharing is
a contractual obligation that had not been met at the time the office visit was received on January 23, 2020.
Therefore, we decided that the Plan does not have to waive the deductible for the office visit provided on
January 23, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99190) provided on January 28, 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 28, 2020.