Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99213) provided on June 23, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for an office visit. You say that the enrollee did not provide the correct insurance information. The Plan denied your request. The Plan says this was 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 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 an office visit (99213) provided on June 23, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids purchased on May 27, 2021, from an out-ofnetwork
provider.
You asked the Plan to pay for the hearing aids. You say that you purchased a pair of hearing aids from the innetwork
provider previously, but you were dissatisfied with how they worked and were told these issues could
not be fixed. You returned them and went to a different provider for functional hearing aids. The Plan denied
your request. The Plan says hearing aids are only covered when they are purchased through the specified innetwork
vendor.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for
hearing aids only when they are obtained from a contracted provider.
We looked at the file and the Plan's rules. The provider in this case is not contracted with the Plan. Based on
this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore,
we decided that the Plan does not have to pay for the hearing aids purchased on May 27, 2021, from an out-ofnetwork
provider
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the laboratory work provided on July 8, 2021.
You asked the Plan to waive the deductible for the laboratory work. You say that the laboratory work was a part of your annual exam, and you should not be charged. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $500 deductible which applies to laboratory work. The laboratory work you asked the Plan to waive the deductible for falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $500 deductible which applies to in-network Medicare-covered laboratory services. This cost sharing is a contractual obligation that had not been met at the time the laboratory work was received on July 8, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the laboratory work provided on July 8, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services (S9338) provided April 23, 2021 to April 24, 2021.
You asked the Plan to pay for the home health services. You say that the services were medically necessary. The Plan denied your request. The Plan says the code billed is not eligible for Medicare payment.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code S9338 is not supported in the medical record. Specifically, per the National Physician Fee Schedule, this code has a status of "I" and is invalid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to pay for home health services (S9338) provided April 23, 2021 to April 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro device.
You asked the Plan to pre-approve the MyoPro device. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
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 MyoPro device. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found the MyoPro is not known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in widespread use based on scientific evidence and there is insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes for this patient, improve hemiparetic arm function, or be safe for long term use. Furthermore, there is insufficient evidence in the literature that this device will increase participation in bimanual activities.
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 MyoPro device have not been met. Therefore, we decided that the Plan does not have to pre-approve the MyoPro device.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a robotic surgical system (S2900) provided on May 6, 2021.
You asked the Plan to pay for a robotic surgical system. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. CPT code S2900 has a status indicator of "I" on the Physician Fee Schedule. This means that it is "invalid for Medicare billing purposes." Based on this information, we decided that Medicare rules for coverage of a robotic surgical system have not been met. Therefore, we decided that the Plan does not have to pay for a robotic surgical system (S2900) provided on May 6, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (88304, 88305, 88312) provided July 28, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan
denied your request. The Plan says the documentation does not support the billed services.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT code 88304, 88305, & 88312 is not supported in the medical record. Specifically, the place
of service on the claim form (81, lab) does not match the place of service detailed in the records (11, office
setting). Based on this information, we decided that Medicare rules for coverage of the lab services have not
been met. Therefore, we decided that the Plan does not have to pay for lab services (88304, 88305, 88312)
provided July 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral periapical first radiographic image (x-ray)
(D0220) and intraoral- periapical each additional radiographic image (D0230) provided on August 20, 2021.
You asked the Plan to pay for the intraoral periapical x-rays. You say that the item was medically necessary.
The Plan denied your request. The Plan says these are not covered services.
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. Specifically, the services you obtained are not included in the Plan's
benefit chart. This means they are not covered. Therefore, we decided that the Plan does not have to pay for the
intraoral periapical first radiographic image (x-ray) (D0220) and intraoral- periapical each additional
radiographic image (D0230) provided on August 20, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician supervision of a nursing facility patient
(99379) provided on April 29, 2021.
You asked the Plan to pay for the physician supervision of a nursing facility patient. You say that you would
like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says
this service is always bundled for payment and is 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.
We looked at the file and Medicare rules. This code has a status code of "B" which indicates that payment for
this code is always bundled into payment for other services not specified. No separate payment will be made
for this service. Based on this information, we decided that Medicare rules for coverage of the physician
supervision of a nursing facility patient have not been met. Therefore, we decided that the Plan does not have to
pay for the physician supervision of a nursing facility patient (99379) provided on April 29, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a left ear eustachian tube dilation (ETD) for the
enrollee.
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your
request. The Plan says this procedure is considered experimental, investigational, and unproven.
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 surgery. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found based on the available clinical documentation, the requested services for ETD do not meet criteria for
being medically necessary and reasonable. ETD complications were generally few, mild, and self-limited and
that ETD was associated with improvement in subjective and objective outcomes for patients with Eustachian
tube dysfunction. However, the American Academy of Otolaryngology-Head and Neck Surgery Foundation
2019 clinical consensus statement on balloon dilation of the Eustachian tube concluded that nasal endoscopy is
a necessary part of diagnostic workup prior to consideration of dilation, not only to support the diagnosis of
obstructive Eustachian tube dysfunction but also to rule out extrinsic causes of the patient's symptoms, and
assess the Eustachian tube lumen and anatomic feasibility of ETD. The available documentation did not show
any evidence of nasal endoscopic findings. In summary, the requested ETD services do not meet criteria for
being medically necessary and reasonable to treat the enrollee's Eustachian tube dysfunction.
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 surgery have not been met. Therefore, we decided that the Plan does not
have to pre-approve a left ear eustachian tube dilation (ETD) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction (D7140) and two dimensional (2D) oral/facial photogenic image (D0350) provided on July 2, 2021, and August 13, 2021.
You asked the Plan to pay for the extraction and 2D oral/facial photogenic image. You say that you went online and got a list of approved providers. You also say that you got a notice of denial from the Plan stating the treating dentist is not an approved provider. The Plan denied your request. The Plan says these services are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
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 extraction (D7140) and two dimensional (2D) oral/facial photogenic image (D0350) provided on July 2, 2021, and August 13, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visits for assistance with activities of daily living
and personal care (99509) and sales tax provided from February 1, 2021, to February 26, 2021.
You asked the Plan to pay for the home visits and sales tax. You say that this claim should not be denied
because the services were medically necessary. The Plan denied your request. The Plan says your request is not
medically necessary because your records show you did not have a skilled need and were not receiving skilled
nursing or therapy services.
The Plan must follow Medicare rules. Medicare rules say that Medicare does not make separate payment for
sales tax. The rules also say that custodial care, which does not include services from trained medical or
paramedical staff, 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 home visits and sales tax. Our reviewer
says that the home visits were not medically reasonable and necessary. Our physician reviewer found that there
is no documentation that skilled therapy services were 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 services requested and provided
appear to be non-skilled services (assistance with bath, mobilization and transfers, bathroom assistance, meal
prep, skin care, exercises, laundry, lite housekeeping).
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 home visits and sales tax have not been met. Specifically, we find that the
services at issue in this case are considered custodial in nature, and sales tax is not separately payable.
Therefore, we decided that the Plan does not have to pay for the home visits for assistance with activities of
daily living and personal care (99509) and sales tax provided from February 1, 2021, to February 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating provider on May 24, 2021, to May 27, 2021.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you do not feel like you should have to pay for this. 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 $275 copayment per day for days 1-5. There is a $0 copayment for additional days for inpatient hospital care/inpatient hospital care.
You have been asked to pay a $275 copayment per day for days 1-3 for an inpatient hospital stay. The total amount you are being asked to pay is $825 ($275 x 3 days = $825). The correct copayment has been applied to the inpatient hospital care that was provided. An inpatient hospital stay falls within the inpatient hospital care/inpatient hospital care 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 inpatient hospital stay provided by a participating provider on May 24, 2021, to May 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for radiologic examination, hip (73502) provided August 23, 2021.
You asked the Plan to waive the copayment for the diagnostic services. You say that you did not have to pay for the previous x-rays you had done that were taken as follow up to your hip replacement. The Plan denied your request. The Plan says the claim was processed with the correct copayment applied per the Evidence of Coverage.
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 copayment for most x-rays and ultrasounds. You have been asked to pay $20 copayment for the diagnostic services. Diagnostic testing is not a part of global care following surgery. The diagnostic service 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 for radiologic examination, hip (73502) provided August 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on August 20, 2021.
You asked the Plan to waive the copayment for the office visit. You say that you had a routine physical and should not be charged for the office visit. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $5 copayment for primary care physician (PCP) office visit/other health care professional visit.
You have been asked to pay a $5 copayment for the office visit. The office visit falls within the "Physician/
Practitioner services, including doctor's office visits" benefit category. The record shows you were seen for
diabetes mellitus, hyperlipidemia, and hypothyroidism which is considered non-preventive. 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 on August 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services rendered from July 25, 2020,
to July 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 submitted records do not support the billing of DRG 871 and diagnosis code A41.9.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the
reported principal and secondary diagnosis codes.
In this case, you billed the inpatient services provided with DRG 871 and diagnosis A41.9 (sepsis, unspecified
organism). 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 these services. Our reviewer says
that the submitted records do not support the billing of DRG 871 and diagnosis code A41.9. Our physician
reviewer found the records support an admission for pneumonia but are unclear regarding a diagnosis of sepsis.
Supporting documentation for sepsis is not found within the submitted records. The enrollee was admitted for
sepsis due to pneumonia, acute pulmonary edema, and congestive heart failure exacerbation. Systemic
inflammatory response syndrome (SIRS criteria are expected as an appropriate response to infection; however,
the documentation does not support a manifestation of systemic infection beyond that evidenced by SIRS
criteria. The records therefore do not support the billing of DRG 871 and diagnosis A41.9.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay
for the inpatient hospital services rendered from July 25, 2020, to July 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Cxbladder testing rendered on June 17, 2021.
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 testing is not covered.
The Plan must follow Medicare rules. The rules say that the Cxbladder testing is non-covered. We looked at the file and Medicare rules. The test at issue is Cxbladder. This test is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the Cxbladder testing rendered on June 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for pathology services (88305) provided May 17, 2021.
You asked the Plan to pay for the pathology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim was not billed with an appropriate diagnosis code.
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 88305 is Surgical pathology, gross and microscopic examination. We find that CPT code 88305 is not supported in the medical record. Specifically, the documentation supports a level II Surgical Pathology code, therefore, this service would not be covered. Based on this information, we decided that Medicare rules for coverage of the pathology services have not been met. Therefore, we decided that the Plan does not have to pay for pathology services (88305) provided May 17, 2021