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

We decided that the Plan does not have to waive the coinsurance for a diagnostic mammogram provided on October 31, 2019.
You asked the Plan to waive the coinsurance for a diagnostic mammogram. You say that this coinsurance is an outrage. You say that you have to get this mammogram to make sure the pill is still working. The Plan denied your request. The Plan says the correct coinsurance 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 10% coinsurance for outpatient diagnostic tests/in-network/diagnostic service. You have been asked to pay a 10% coinsurance of the allowed amount for a diagnostic mammogram. The total allowed amount is $133.90 ($105.57 + $28.33 = $133.90). The total amount you are being asked to pay is $13.39 ($133.90 x 10% = $13.39). A diagnostic mammogram falls within the outpatient diagnostic tests/in-network/diagnostic service 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 a diagnostic mammogram provided on October 31, 2019.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve finger repair (26418).
You asked the Plan to pre-approve the repair. You say that you would like reconsideration because without this surgery you will not be able to use your finger. The Plan denied your request. The Plan says that this surgery is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 repair. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found there is evidence of acute injury and functional limitations that have failed over one month of initial conservative treatment. 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 repair have been met. Therefore, we decided that the Plan has to pre-approve finger repair (26418).
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve a consultation. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services can be provided by a network provider. 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a consultation to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis provided on December 5, 2019.
You asked the Plan to pay for the knee orthosis (L1833). You say that the orthosis was medically necessary.
The Plan denied your request. The Plan says there is no documentation of recent injury or surgery, or knee
instability.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at the file and Medicare rules. The medical records do not mention, or support medical necessity
for, the orthosis. Based on this information, we decided that Medicare rules for coverage of the knee orthosis
(L1833) have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis
provided on December 5, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient rehabilitation services provided by Hospital on September 1, 2019 to September 8, 2019.You asked the Plan to waive the copayment for an inpatient rehabilitation services. You say that you feel like the case worker was pushing you to go to an inpatient rehab facility. You say that if you knew how much this would be you would have never goneThe 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 $250 copayment per day for days 1-7. There is a $0 copayment for additional days for inpatient hospital care/in-network. You have been asked to pay a $250 copayment per day for days 1-7. There is a $0 copayment for additional days for an inpatient rehabilitation services. The total amount you are being asked to pay is $1,750 ($250 x 7 days = $1,750). An inpatient rehabilitation services falls within the inpatient hospital care/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 foran inpatient rehabilitation services provided by  Hospital on September 1, 2019 to September 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea FreeStyle Libre Continuous Glucose Monitoring system.You asked the Plan to pre-approvea continuous glucose monitor. You say that you take other medications and a CGM should be covered for you.The Plan denied your request. The Plansays the information submitted indicates you are not being treated with multiple daily injections of insulin.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor.We looked at the file and Medicare rules. The medical record shows you are not insulin treated three or more times a day. Based on this information, we decided that Medicare rules for coverage of a continuousglucose monitor have not been met.Therefore, we decided that the Plan does not have to pre-approvea FreeStyle Libre Continuous Glucose Monitoring system.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Trulicity.
You asked the Plan to pre-approve Trulicity. You say that you need this medication. The Plan denied your request. The Plan says coverage of this medication is the responsibility of your Part D prescription drug plan.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Trulicity.
Benefits for Trulicity 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services rendered on August 27, 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 the billing of 68 units of procedure code 08180 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 01810 is anesthesia for all procedures on nerves, muscles, tendons, fascia, and bursae of forearm, wrist, and hand.We find that CPT code 01810 is not supported in the medical record. Specifically, the documentation shows a start time of 13:40 and end time of 14:45 for the services,which does not support 68 billed units of the code. 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 anesthesia services rendered on August 27, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Mammaprint testing rendered on August 31, 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 the testing is not covered.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.We looked at the file and Medicare rules. There is no documentation to support that the Mammaprint testing was necessary for the enrollee. 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 Mammaprint testing rendered on August 31, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a colonoscopy provided by a participating provider on December 4, 2019.You asked the Plan to waive the copayment for a colonoscopy. You say that this should have been preventative. 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 $250 copayment for outpatient surgery. You have been asked to pay a $250 copayment for a colonoscopy. The rules say that, if during the course of the screening colonoscopy, a lesion or growth is detected which results in a biopsy or removal of the growth, the appropriate diagnostic procedure classified as a colonoscopy with biopsy or removal should be billed. A colonoscopy falls within the outpatient surgery 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 colonoscopy provided by a participating provider on December 4, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from October 4, 2019 to October 30, 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 services were billed incorrectly.
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, the facility claims billed with an incorrect type of bill. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from October 4, 2019 to October 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on December 10, 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 the enrollee's plan require utilization of network providers, and authorization for certain 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 forthe medical services provided on December 10, 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 the tubing equipment rendered to you on June 12, 2019.You asked the Plan to waive the coinsurance for these services. You say that the services should be paid in full.The Plan denied your request. The Plan says the coinsurance 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 20% of the total cost for Medicare-covered durable medical equipment. Review of the file shows that you received tubing equipment on June 12, 2019. You have been asked to pay 20% of the total cost for these services. These services fall within the Medicare-covered durable medical equipment 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 tubing equipment rendered to you on June 12, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from January 9, 2020 to January 11, 2020.You asked the Plan to pay for acute inpatient hospital care. You say that you disagree with the denial.The Plan denied your request. The Plan says that the services were not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee presented to the emergency department with two weeks of cough and shortness of breath. She was treated with intravenous fluids and antibiotics with supplemental oxygen and nebulizer treatments. The records support that, at the time of inpatient admission, the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met.Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from January 9, 2020 to January 11, 2020.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 27, 2019 to August 10, 2019 by an out of network (OON) provider.
You asked the Plan to pay for chiropractic services. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan.
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 July 27, 2019 to August 10, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses and suspension sleeves provided on December 10, 2019.
You asked the Plan to pay for the knee orthoses (L1833) and suspension sleeves (L2397). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the documentation submitted did not indicate the provider discussed the need for the billed supply codes, therefore the billed supply codes cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at this the file and Medicare rules. The medical records do not mention or support medical necessity for the orthoses. Based on this information, we decided that Medicare rules for coverage of the knee orthoses
(L1833) and suspension sleeves (L2397) have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthoses and suspension sleeves provided on December 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from October
1, 2019 to October 31, 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 the claim is billed with an invalid type of bill code.
The Plan must follow Medicare rules. Medicare rules say that home health services must be billed correctly.
The claim is missing a treatment authorization code, a HIPPS code, and a CBSA code. 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 home health services provided to the enrollee from October 1,
2019 to October 31, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing coded 80307 and G0480 provided on July 29, 2019.You asked the Plan to pay forthe drug testing. 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 supported by the documentation.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 80307 and G0480 are not supported in the medical record. Specifically, the documentation submitted did not include a physician order/lab requisition or medical records stating exactly what tests were to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met.Therefore, we decided that the Plan does not have to pay forthe drug testing coded 80307 and G0480 provided on July 29, 2019
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the adjacent tissue transfer or rearrangement services coded 14060 provided on October 16, 2019.You asked the Plan to pay for the adjacent tissue transfer or rearrangement 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 supported by the documentation.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 14060 is adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10 sq cm or less.We find that CPT code 14060 is not supported in the medical record. Specifically, the operative report did not include documentation of an adjacent tissue transfer or rearrangement of the eyelids, nose, ears and/or lips; defect 10sq cm or less. Based on this information, we decided that Medicare rules for coverage of the adjacent tissue transfer or rearrangement services have not been met.Therefore, we decided that the Plan does not have to pay for the adjacent tissue transfer or rearrangement services coded 14060 provided on October 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown to be provided by an out-of-network provider.
You asked the Plan to pre-approve the crown. You say that a Plan representative told you that your dentist was in-network. You also say that your dental group is the only one within a reasonable driving distance. The Plan denied your request. The Plan says this provider is a non-contracted provider. The Plan also says that no benefits are available for procedure performed by out-of-network providers or outside of the providers contracted period.
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 when they are received by an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve a crown to be provided by an out-of-network provider.