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

We decided that the Plan does not have to pre-approve crowns (D2750) for teeth # 2 and 3.
You asked the Plan to pre-approve the crowns. You say that you received dental work that led to the destruction of the crowns you previously had done. You say that you were in an accident in 2016. You also say that it would be a financial hardship to pay for the replacement crowns out of pocket. The Plan denied your request. The Plan says crowns are covered once every 5 plan years. The Plan also says that the frequency limit has been reached.
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 crowns are a covered service, the frequency limit of once every 5 plan years has been reached. The record shows that the Plan paid for a crown for tooth # 2 that you received on February 11, 2019 and a crown for tooth # 3 that you received on April 11, 2019. Therefore, we decided that the Plan does not have to pre-approve crowns (D2750) for teeth # 2 and 3.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Human Papillomavirus vaccination provided on September 11, 2019.You asked the Plan to pay for this service. You say that this immunization should be covered by the Plan.The Plan denied your request. The Plan says this is not the type of preventative immunization covered under Medicare Part B.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide this service under Medicare Part B. The Plan follows the same rules. The records do not show that you have been injured or directly exposed to any illness related to this service.Therefore, we decided that the Plan does not have to pay for the Human Papillomavirus vaccination provided on September 11, 2019.Benefits for this service may be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe limited oral evaluation (D0140) provided on November 26, 2019.You asked the Plan to pay forthe dental service. You say that the plan advised you should not have paid $95 cash for the service. You say that your plan also advised that you only owed $41.The Plan denied your request. The Plan says oral exams are covered once every 6 months. The Plan says that the frequency limit has been exceeded.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 oral exams are a covered service, the frequency limit has been exceeded. The record shows that the Plan paid for the comprehensive oral exam that you received on November 11, 2019.Therefore, we decided that the Plan does not have to pay forthe limited oral evaluation (D0140) provided on November 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on August 19, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe OON services. The Plan denied your request. The Plan says there is no network deficiency for these services, and alternate network providers were found.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 forthe medical services provided on August 19, 2019 by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ER visit provided on December 18, 2019.You asked the Plan to waive the copayment forthe ER visit. You say that you should not get billed.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 $90 copayment for emergency services in an emergency room.You have been asked to pay a $90 copayment for the ER visit. The ER visit falls withinthe "Emergency care" benefit category. The records show that you were treated in the ER. 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 forthe ER visit provided on December 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the replacement face mask rendered on September 23, 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 procedure code A7031 is 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 A7031 is face mask interface, replacement for full face
mask, each.
We find that CPT code A7031 is not supported in the medical record. Specifically, the documentation shows
that the records were altered and do not support coverage of the billed services. 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 replacement face mask rendered on September 23, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve three skilled nursing visits. You asked the Plan to pre-approve these services. You say that you want more in-home care. The Plan denied your request. The Plan says the services are not medically necessary. The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the submitted records do not show that you have complex wound care, intravenous (IV) medications, or other services that require skilled nursing care for an additional three visits. You do not require the services to effectively provide treatment or services to improve your condition, establish a maintenance program, or prevent deterioration. Your ongoing medication management does not require the additional three visits. We looked at this physician's review, the file, and Medicare rules. 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 pre-approve three skilled nursing visits.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 23, 2019 by an out
of network (OON) provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services were rendered by an out-of-network provider without 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 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 October 23, 2019
by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME and related supplies provided on November 18, 2019.
You asked the Plan to waive the coinsurance for DME and related supplies. You say that the anesthesiologist who injured your nerve should be responsible for the charges. 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 20% coinsurance for DME and related supplies. You received DME and related supplies on November 18, 2019. The total allowed amount is $966.61 and 20% of that is $193.32. You have been asked to pay the total coinsurance amount of $193.32 for DME and related supplies. DME and related supplies fall within the DME and related 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 coinsurance for DME and related supplies provided on November 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the CPAP supplies provided on December 16, 2019.You asked the Plan to pay for the CPAP supplies. You say that you would like a back dated authorization for the supplies provided.The Plan denied your request. The Plan says the supplies from the non-network provider 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 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 CPAP supplies provided on December 16, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF care provided to the enrollee from October 1, 2019 through October 15, 2019 and October 19, 2019 through October 30, 2019.You asked the Plan to pay forSNF care. You say that the stay was medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilledtherapy service needs. The beneficiary does not require skilled nursing or therapy services on a daily basis. This beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 SNF care have not been met.Therefore, we decided that the Plan does not have to pay forSNF care provided to the enrollee from October 1, 2019 through October 15, 2019 and October 19, 2019 through October 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF services provided on October 1, 2019 through October 31, 2019.
You asked the Plan to pay for the SNF services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this claim has been submitted with an invalid HIPPS code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met. Specifically, the HIPPS codes billed on this claim are invalid as they are not included on the master list of valid/termed codes issued by CMS. Therefore, we decided that the Plan does not have to pay for SNF services provided on October 1, 2019 through October 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit and does not have to waive
the coinsurance for a cervical cancer screening provided on July 19, 2019.
You asked the Plan to waive the copayment for a specialist visit and to waive the coinsurance for a cervical
cancer screening. You say that you were told that the provider was in-network and disagree with the charges.
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 $60
copayment for out-of-network specialist visits. Your contract with the Plan also clearly says that you must pay
40% coinsurance for out-of-network cervical and vaginal cancer screenings.
You had a specialist visit on July 19, 2019 with an out-of-network provider. Therefore, you are responsible to
pay the $60 copayment.
You received a cervical cancer screening on July 19, 2019 with an out-of-network provider. The total allowed
amount is $79.66 and 40% of that is $31.86.
The total amount you owe is: $91.86.
You have been asked to pay the total amount of $91.86 for a specialist visit and a cervical cancer screening. A
specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category.
A cervical cancer screening falls within the cervical and vaginal cancer screenings 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 a specialist visit and does not have to waive the coinsurance for a
cervical cancer screening provided on July 19, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the services provided to the enrollee from January 20, 2019 through January 21, 2019, by an out-of-network provider.
You asked the Plan to waive the copayment for the services. You say that the services were approved and the member should receive a larger reimbursement. The Plan denied your request. The Plan says the claim was processed accordingly with the member's 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). On August 29, 2019, the Plan issued a check for $25,000.00, which was cleared on November 15, 2019. The maximum payment amount was issued; therefore, no additional payment can be made. The member's EOC states, Worldwide Coverage: 20% coinsurance for emergency services outside of the U.S. and Puerto Rico after a $100 deductible. Benefit is limited to $25,000 each plan year or 60 consecutive days, whichever is reached first. Benefit does not apply to your combined annual deductible or your combined annual out-of-pocket maximum. 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 services provided to the enrollee from January 20, 2019 through January 21, 2019, by an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from November 7, 2019 to November 23, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the services that the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's condition no longer required daily skilled services at an inpatient skilled nursing facility (SNF) level of care.
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 November 7, 2019 to November 23, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve10 additional physical therapy sessions.You asked the Plan to pre-approve10 additional physical therapy sessions. You say that the services are medically 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 Medicare pays for medically necessary outpatient therapy.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 10 additional physical therapy sessions. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the enrollee has already met their original therapy goals. The enrollee has care giver assistance available in terms of being able to perform a home exercise / management program. Ongoing skilled therapy services are not medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 10 additional physical therapy sessions have not been met.Therefore, we decided that the Plan does not have to pre-approve10 additional physical therapy sessions.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cytopathology services coded 88112 provided on November 4, 2019.
You asked the Plan to pay for the cytopathology services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 88112 is cytopathology, selective cellular enhancement technique with interpretation (e.g., liquid based slide preparation method), except cervical or vaginal. We find that CPT code 88112 is not supported in the medical record. Specifically, it is inappropriate to report a procedure both as a global service and as a technical or professional components. Only the global service will be allowed. Based on this information, we decided that Medicare rules for coverage of the cytopathology services have not been met. Therefore, we decided that the Plan does not have to pay for the cytopathology services coded 88112 provided on November 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on August 14, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe OON services. You say that the claim is reimbursable just as in-network claims.The Plan denied your request. The Plan says there is no valid referral 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 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 forthe medical services provided on August 14, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular pathology procedures provided on November 8,
2019.
You asked the Plan to pay for the molecular pathology procedures. The Plan denied your request. The Plan
says the Plan requires utilization of network providers when possible and available, and requires authorization
for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency
situation, has been documented.
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
service 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 molecular pathology procedures provided on November 8, 2019.