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

We decided that the Plan does not have to pay for the extractions (D7140 x 7), the immediate upper denture (D5130), the immediate lower denture (D5140), and the unspecified removable prosthodontic procedures (D5899 x 9) provided on September 14, 2020.
You asked the Plan to pay for the dental services. You say that the Plan should pay for these services like they promised. The Plan denied your request. The Plan says the services that you received are not listed as covered. The Plan says that you did not contact the Plan to verify benefits. The Plan also says that although it is not required, it is recommended that if a procedure or treatment is expected to exceed $300, you or your dentist, can submit a treatment plan for review prior to the start of treatment.
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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the extractions (D7140 x 7), the immediate upper denture (D5130), the immediate lower denture (D5140), and the unspecified removable prosthodontic procedures (D5899 x 9) provided on September 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a participating provider on December 15, 2020.
You asked the Plan to waive the copayment for a specialist office visit. You say that you do not agree with this copayment. The Plan denied your request. The Plan says the correct copayment has been applied.
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 $25 copayment for physician/practitioner services/in-network/specialist. You have been asked to pay a $25 copayment for a specialist office visit. The correct copayment has been applied to the services that were provided. A specialist office visit falls within the physician/practitioner services/in-network/specialist 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 office visit provided by a participating provider on December 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on October 21, 2020.
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 codes 80201, 80162, 80159, and 80179 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. We find that CPT codes 80201, 80162, 80159, and 80179 are not supported in the medical record. Specifically, the records show that the testing was performed on urine specimens and not blood specimens. 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 laboratory services rendered on October 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit and deductible for a diagnostic test provided by a participating provider on February 20, 2018.
You asked the Plan to waive the copayment for a specialist office visit and deductible for a diagnostic test. You say that you do not agree with these charges. The Plan denied your request. The Plan says the correct copayment and deductible amount has been applied.
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 $40 copayment and a $147 deductible for physician/practitioner services/specialist and outpatient diagnostic tests. You have been asked to pay a $40 copayment for a specialist office visit and a $18.46 deductible for a diagnostic test. The total amount you are being asked to pay is $58.46 ($40 + $18.46 = $58.46). A specialist office visit falls within the physician/practitioner services/specialist benefit category and a diagnostic test falls within the outpatient diagnostic tests 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 office visit and deductible for a diagnostic test provided by a participating provider on February 20, 2018.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Gel-Syn.

You asked the Plan to pre-approve Gel-Syn. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the enrollee does not meet the criteria for use of Gel-Syn.

The Plan follows Medicare rules. Medicare rules state that viscosupplementation of the knee using drugs such as Gel-Syn is only covered when certain criteria are met. 

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 Gel-Syn. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested use of Gel-Syn. Our physician reviewer found the records do not show that the enrollee has failed at least 3 months of conservative 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 Gel-Syn have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Gel-Syn.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the outpatient diagnostic services rendered on July 22, 2020 and August 12, 2020.

You asked the Plan to waive the copayments for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the copayments were 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 $110 copayment for in-network basic radiological services in an outpatient hospital.

Review of the file shows that you received an echocardiogram on July 22, 2020. You have been asked to pay a $110 copayment for these services. These services fall within the in-network basic radiological services in an outpatient hospital benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.

The file shows that you received device interrogation services on August 12, 2020. Per the contract with the Plan, there is a $110 copayment for in-network basic radiological services in an outpatient hospital. However, the Medicare allowed amount for these services was $36.68. Given that the allowed amount was less than the $110 copayment, you have been asked to pay $36.68 for these services.

The total amount you have been asked to pay for these services is $146.68. 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 outpatient diagnostic services rendered on July 22, 2020 and August 12, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided by a participating provider on November 17, 2020.
You asked the Plan to waive the copayment for an ultrasound. You say that you did not pay this much in 2019. The Plan denied your request. The Plan says the correct copayment has been applied.
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 $150 copayment for outpatient diagnostic tests/radiological diagnostic services/in-network. You have been asked to pay a $150 copayment for an ultrasound. The correct copayment has been applied to the services that were provided. An ultrasound falls within the outpatient diagnostic tests/radiological diagnostic services/in-network 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 an ultrasound provided by a participating provider on November 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist services rendered on November 10, 2020.
You asked the Plan to waive the copayment for these services. You say that the services should be covered without a copayment. The Plan denied your request. The Plan says the copayment was 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 $45 copayment for services obtained from an in-network specialist.
Review of the file shows that you received specialist services on November 10, 2020. These services fall outside of the 90-day global surgical period for the procedure you had on June 25, 2020. You have been asked to pay a $45 copayment for these services. These services fall within the services obtained from an in-network specialist benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the specialist services rendered on November 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye surgery services provided on November 10, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the OON services. You say that the services were approved. The Plan denied your request. The Plan says authorization was not provided for services at the rendering facility.

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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 eye surgery services provided on November 10, 2020 by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered on May 7, 2020 to May 28, 2020.

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 claims were billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that home health services are paid based on a 60-day episode of care made in two parts. 

We looked at the file and Medicare rules. The file shows that the claims were not billed based on the 60-day episode of care. 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 home health services rendered on May 7, 2020 to May 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on July 7, 2020 by a non-participating 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 a non-participating 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 referring provider is not a network provider with the Plan. The Plan had network providers available who could have provided 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 laboratory services provided on July 7, 2020 by a non-participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis rendered on October 14, 2020.
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 proof of delivery.
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS suppliers are required to maintain proof of delivery. We looked at the file and Medicare rules. There is no valid proof of delivery in the 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 lumbar-sacral orthosis rendered on October 14, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF services provided on December 16, 2018.
You asked the Plan to pay for the SNF care. The Plan denied your request. The Plan says the documentation does not contain a Plan of Care to support the episode of care.
The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. The file shows that you did not submit sufficient information to justify payment of the claim. Based on this information, we decided that Medicare rules for coverage of the SNF care have not been met. Therefore, we decided that the Plan does not have to pay for SNF services provided on December 16, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral-periapical first radiographic image (D0220) provided on December 7, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit under your contractual policy.
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 service provided is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the intraoral-periapical first radiographic image (D0220) provided on December 7, 2020.
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pre-approve home health services.

You asked the Plan to pre-approve home health services. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.

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 home health services. Our reviewer says that the services are medically necessary. Our physician reviewer found the review has determined that the records show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the patient's condition and/or prevent deterioration. The records show that skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's level of function, or to establish/perform a maintenance program to maintain the patient's level of function and/or prevent deterioration. The review has determined that the requested nursing services are 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 home health services have been met. Therefore, we decided that the Plan has to pre-approve home health services.

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on August 13, 2020.

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 this should be reported with CPT 81479.

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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. 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 Comprehensive Genomic Profile (CGP) testing provided to the enrollee on August 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the partial upper denture (D5213) provided on November 6, 2020.

You asked the Plan to pay more for the dental item. You say that you were told that the Plan would pay $519 for the services. You say that only $239 was paid. You also say that more than 30% should be covered for a total treatment. The Plan denied your request. The Plan says the claim was processed correctly.

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 the partial denture is listed as covered, there is a 70% coinsurance for a partial denture that you receive from an in network provider. The record shows that the pre-estimate amount for the partial denture, specifically, is the same as what the Plan paid for the partial denture that you received in this claim. Therefore, we decided that the Plan does not have to pay more for the partial upper denture (D5213) provided on November 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit services provided to the enrollee from October
29, 2019.

You asked the Plan to pay for home visit 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 payable.

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 visit services have not been met. Specifically, this code may
only be billed when services are provided in the enrollee's private residence (place of service 12). To bill these
codes, the physician must be physically present in the enrollee's home. The provided records do not support
that a physician or non-physician practitioner (PA or NP) were physically present. Therefore, we decided that
the Plan does not have to pay for the home visit services provided to the enrollee from October 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician visit provided on September 1, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the OON services. You say that the doctor saw the enrollee in good faith. The Plan denied your request. The Plan says prior authorization was not obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The 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 the physician visit provided on September 1, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided by a participating provider on October 13, 2020.

You asked the Plan to waive the copayment for an office visit. You say that you do not agree with this copayment. The Plan denied your request. The Plan says the correct copayment has been applied.

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 $35 copayment for physician/practitioner services/specialist. 

You have been asked to pay a $35 copayment for an office visit. The correct copayment has been applied to the services that were provided. An office visit falls within the physician/practitioner services/specialist 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 an office visit provided by a participating provider on October 13, 2020.