Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from June
14, 2019 to June 25, 2019.
You asked the Plan to pay for home health services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the type of bill is inconsistent with the place of service
billed.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must
be completed for home health care services to be covered.
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that
Medicare rules for completing the claim for home health services have not been met. Specifically, a Federal
Information Processing Standards (FIPS) code is required to identify the county where the services were
rendered. Therefore, we decided that the Plan does not have to pay for the home health services provided to the
enrollee from June 14, 2019 to June 25, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on December 3, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on December 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on October 22, 2019. You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized. 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on October 22, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay fordrug testing provided by Cordant Health Solutions on November 11, 2019.You asked the Plan to pay fordrug tests. You say that you are appealing with medical records.The Plan denied your request. The Plan says the denial of payment for these services is correct, because the documentation submitted does not include a valid physician order, lab requisition, or medical records stating exactly which tests were to be performed.The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a physician order or clear intent to order the specific lab services billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug tests have not been met.Therefore, we decided that the Plan does not have to pay fordrug testing provided by Cordant Health Solutions on November 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on May 13, 2019 by an out of network (OON) provider.You asked the Plan to pay for the out of network services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services provided are not a covered benefit.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 medical services provided on May 13, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy.
You asked the Plan to pre-approve HBO therapy. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that the use of HBO therapy is covered as adjunctive therapy only after there are no measurable signs of healing for at least 30-days of treatment with standard wound therapy and must be used in addition to standard wound care. 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 HBO therapy. Our reviewer says that the service is not medically necessary. Our physician reviewer found the visit note from March 30, 2020 reports: "Her ulcers are improving but slowly." The NCD requires that "there are no measurable signs of healing for at least 30 days of treatment with standard wound therapy." We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of HBO therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from November 11, 2017 through November 15, 2017.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you thought the services were taken care of and you did not receive a bill until two years later. The Plan denied your request. The Plan says the claim was processed accordingly with your 2017 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that you were admitted on November 11, 2017 and discharged on November 15, 2017. You were asked to pay a $350 copayment per day from November 11, 2017 through November 14, 2017, days 1-4 of your inpatient hospital care. You were discharged on November 15, 2017 and there was no copayment charge for the day of discharge. Per your contract there is a $350 copayment per day required for days 1-5. 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 inpatient hospital care from November 11, 2017 through November 15, 2017.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Lifevest provided on October 5, 2019.
You asked the Plan to waive the coinsurance for the Lifevest. You say that you were not told you would be
charged for the rental. The Plan denied your request. The Plan says that you received the applicable services as
such coinsurance is due.
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%
coinsurance for DME items that have a purchase cost of $100 or more.
You have been asked to pay a 20% coinsurance for the Lifevest. The Lifevest falls within the DME items that
have a purchase cost of $100 or more 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 coinsurance for
the Lifevest provided on October 5, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from October 26, 2019 to November 5, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the services which the enrollee required and received are coverable under the Medicare Act.
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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from October 26, 2019 to November 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora CT scan provided at an outpatient hospital facility on September 14, 2019.You asked the Plan to waive the copayment fora CT scan. You say that you feel that you should only owe a $50 copayment.The Plan denied your request. ThePlan 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 $50 copayment for CT scans provided at a freestanding provider or a $250 copayment at an outpatient hospital setting. The record shows that you had a CT scan at an outpatient hospital facility on September 14, 2019. Therefore, you are responsible to pay the $250 copayment. You have been asked to pay a $250 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 waive the copayment fora CT scan provided at an outpatient hospital facility on September 14, 2019.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to pay for emergency care services provided on May 13, 2019.
You asked the Plan to pay for emergency care services. You say that the enrollee presented to the emergency room and was taken for treatment. The Plan denied your request. The Plan says that the denial of payment for these services is correct, because authorization was not obtained.
The Plan must follow Medicare rules. The rules say that an emergency exists based on a prudent layperson standard, not a retrospective medical review. For symptoms to be considered emergent in nature, they must be such that a prudent layperson with an average knowledge of medicine would reasonably expect the absence of immediate medical attention would result in serious jeopardy to their health. We decided that this case does meet prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine would reasonably expect the absence of immediate medical care to seriously jeopardize their health in this case. Therefore, we decided that the Plan has to pay for emergency care services provided on May 13, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a virtual colonoscopy (74262).
You asked the Plan to pre-approve the virtual colonoscopy. You say that you were advised in the past to avoid
conventional colonoscopies because your colon might get punctured. The Plan denied your request. The Plan
says your medical records do not show documentation that you have had tests showing blood loss from the
bowel, bowel problems symptoms and/or that you were advised to undergo a colonoscopy.
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 pre-approve the virtual colonoscopy. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found part of the diagnostic value of colonoscopy in diarrhea evaluation is the exclusion by
biopsy of microscopic colitides, pseudomembranes, and histologic assessment of colitis activity. CT
colonography does not permit colon biopsies, and thus is inferior to standard colonoscopy for your indications
of diarrhea and ulcerative colitis dysplasia surveillance.
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 virtual colonoscopy have not been met. Therefore, we decided that the Plan
does not have to pre-approve a virtual colonoscopy (74262).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 8 additional extractions of an erupted tooth or exposed root (D7140), the 2 surgical extractions (D7210), and the upper immediate denture (D5130) provided on November 26, 2019.
You asked the Plan to pay for the dental services. You say that you were under the impression that you would only be liable for $946.10 for the services after speaking to a plan representative. You also say that you cannot afford to pay the bill that you received for $1952.90. The Plan denied your request. The Plan says 2 extractions per calendar year are covered with a 50% coinsurance when you receive them in network. The Plan says that the frequency limit has been exceeded. The Plan also says that dentures are 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 and extractions are a covered service, the frequency limit of 2 extractions per calendar year has been exceeded. The record shows that the Plan paid for the extractions for teeth # 3 and 5 that you received on November 26, 2019. The coinsurance amount only applies to services that are covered, therefore the coinsurance was not applied to the remaining 10 extractions. Additionally, dentures are not a covered service. Therefore, we decided that the Plan does not have to pay for the 8 additional extractions of an erupted tooth or exposed root (D7140), the 2 surgical extractions (D7210), and the upper immediate denture (D5130) provided on November 26, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (CPT 71045) provided to the enrollee on December 4, 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 this is a duplicate of a charge considered on a previous claim.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 71045 is "Radiologic examination, chest."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 services. Our reviewer says that the services at issue in this case were not coded correctly. Our physician reviewer found a review of the records shows a portable chest x-ray done on 12/4/19 at 3:44 pm, with the report signed. A second chest x-ray was entered in the records also on 12/4/19 at 6:45 pm. However, there is no report in the records for this second exam. As such, the documentation indicates that is it only appropriate to reimburse for the first exam. Without a signed report for the second exam, it cannot be reimbursed.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 pay for radiology services (CPT 71045) provided to the enrollee on December 4, 2019
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services rendered to enrollee on October 21, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure codes 11642 and 12051 are 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 11642 is excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 1.1 to 2.0 cm. The definition of code 12051 is repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less.We find that CPT codes 11642 and 12051 are not supported in the medical record. Specifically, the records do not include a detailed procedure note indicating that excision of a malignant lesion of the face, ears, eyelids, nose, or lips of 1.1 to 2.0 cm was performed to support code 11642. There is no detailed procedure note including repair of intermediate wounds of the ace of 2.5 cm or less to support code 12051. 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 forthe services rendered to enrollee on October 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve provided on February 6, 2019.You asked the Plan to pay for the transcatheter aortic valve replacement. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are missing the mandatory clinical trial number.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 33362 is transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open femoral artery approach.We find that CPT code 33362 is not supported in the medical record. Specifically, a mandatory clinical trial number for these services is required. Review of the file shows that the clinical trial number was not billed on the claim. Based on this information, we decided that Medicare rules for coverage of the transcatheter aortic valve replacement have not been met.Therefore, we decided that the Plan does not have to pay for the transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve provided on February 6, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic treatment provided on November 14, 2019.
You asked the Plan to pay for the chiropractic treatment. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for chiropractic treatment provided on November 14, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment formicrofluidic analysis utilizing an integrated collection and analysis device, tear osmolarity (CPT Code 83861) provided on December 16, 2019.You asked the Plan to waive the copayment forthe services. You say that you think it is wrong that the provider is billing you for a medical eye exam and you have never been billed for an eye exam in the past. You state you should not have a copay for being a diabetic per your contract.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received a microfluidic analysis utilizing an integrated collection and analysis device, tear osmolarity (CPT Code 83861) provided on December 16, 2019. The copayment for date of service December 16, 2019 is for a tear osmolarity test which is done for the purpose of diagnosing Dry Eye Syndrome. The medical records confirm that a "tear osmolarity" test was completed. This service falls under your laboratory benefit. Your contract states that you have a $15 copayment for each Medicare-covered laboratory test. Thismeans 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 formicrofluidic analysis utilizing an integrated collection and analysis device, tear osmolarity (CPT Code 83861) provided on December 16, 2019.