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

 We decided that the Plan does not have to pay for the laboratory services rendered on May 10, 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 services were not billed correctly.  The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results.     We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on May 10, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 We decided that the Plan has to pay for the initial hospital care (99220) provided on October 31, 2020.  You asked the Plan to pay for the initial hospital care. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not covered.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. In this case, the Plan is denying payment for the physician services saying that observation care may only be reported by the physician who ordered hospital outpatient observation services and was responsible for the patient during her observation care. The Plan goes on to say that payment for observation care codes is for all the care rendered by the ordering physician on the date(s) the patient is in an observation status and may only be reported once per day. However, the file shows that the billing provider matches the physician who ordered observation services and was responsible for the enrollee during her observation care. The Plan has not substantiated their reasoning for the denial of payment based on Medicare criteria. Therefore, we decided that the Plan has to pay for the initial hospital care (99220) provided on October 31, 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: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the chest x-ray you had at an outpatient hospital facility on July 1, 2021.  You asked the Plan to waive the copayment for the chest x-ray. You say that you were told this service was covered and you were never given other locations to have this service done at no charge. The Plan denied your request. The Plan says you were charged this copayment 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 basic radiological services at an outpatient hospital.   You have been asked to pay a $90 copayment for the chest x-ray. The chest x-ray falls within the basic radiological services at an outpatient hospital 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 chest x-ray you had at an outpatient hospital facility on July 1, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for psychotherapy services provided on May 26 and June 1, 2021, by an out-of-network provider.  You asked the Plan to pay for psychotherapy services. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for out-of-network care have not been met.  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 psychotherapy services provided on May 26 and June 1, 2021, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for prolotherapy, a transcutaneous electrical nerve stimulator (TENS) and supplies, and a pneumatic device provided to the enrollee on January 14, 2021.  You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.  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 pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case.   Our physician reviewer found the services provided were not readily consistent with the generally accepted standards of practice/care for the management of neuropathy/neuropathic pain. The vitamin/nutrient injections administered have not been shown in well designed studies to have any meaningful impact on patient care and/or outcome. Nor have they been shown to result in superior outcomes compared to standard pharmacotherapy. In as much these services would not have been 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 the services have not been met. Therefore, we decided that the Plan does not have to pay for prolotherapy, a transcutaneous electrical nerve stimulator (TENS) and supplies, and a pneumatic device provided to the enrollee on January 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to reduce the cost sharing for the nasal endoscopy you had at an outpatient hospital facility on August 17, 2021.  You asked the Plan to reduce the cost sharing for the nasal endoscopy. You say that this is a diagnostic test, not a procedure, so you should have a lower copayment. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for this service ($156.79) is less than your copayment obligation, you are responsible for the full allowed 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 $335 copayment for outpatient surgery at an outpatient hospital facility.    You have been asked to pay a $335 copayment for the nasal endoscopy. Medicare considers nasal endoscopies to be surgical procedures. That is why the nasal endoscopy falls within the outpatient surgery at an outpatient hospital facility 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 reduce the cost sharing for the nasal endoscopy you had at an outpatient hospital facility on August 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for diabetic supplies provided on August 17, 2021.  You asked the Plan to waive the copayment for diabetic supplies. You say that the services should be covered as it is medically necessary, and you are on financial assistance with the Plan. The Plan denied your request. The Plan says the coinsurance applied correctly based on the services provided.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Durable medical equipment (DME) and related supplies.     You have been asked to pay a 20% coinsurance for diabetic supplies (the total allowed amount for the claims is $399.40, 20% of that is $79.88). The Plan states that you are enrolled in their medical financial assistance program, however, these supplies and services do not fall under what would be covered based on the plan's guidelines. Diabetic supplies, specifically IV Infusion pumps fall within the Durable medical equipment (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 copayment for diabetic supplies provided on August 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services provided to the enrollee on July 8, 2021.  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 if a laboratory assays two or more genes in a patient in parallel, then those two or more genes will be considered part of the same panel.  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 services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on July 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the outpatient office visit (99215) provided on August 9, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the office visit. You say that the enrollee was seen to establish for a physical and surgical clearance. This claim is for a follow-up visit as the enrollee was diagnosed with hypertension and diabetes. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.  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 the outpatient office visit (99215) provided on August 9, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Cxbladder detect test provided to the enrollee on May 26, 2021.  You asked the Plan to pay for the test. You say that this is medically necessary. The Plan denied your request. The Plan says this is not an approved test.  The Plan must follow Medicare rules. Medicare rules say that the CxBladder test is not covered.  Medicare does not consider the denied test is not medically reasonable or necessary. Based on this information, we decided that Medicare rules for coverage of the test have not been met. Therefore, we decided that the Plan does not have to pay for the Cxbladder detect test provided to the enrollee on May 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a wig purchased on July 28, 2021.  You asked the Plan to pay for a wig. You say that this wig was medically necessary. The Plan denied your request. The Plan says wigs are not covered by Medicare.  Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are ordered by a physician. The Plan follows these same rules. In this case, although the wig may be appropriate, it does not meet the definition of the above benefit categories. It does not directly treat a medical condition. It does not replace an internal body organ or attached tissue. As such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would provide coverage for a wig. Therefore, we decided that the Plan does not have to pay for a wig purchased on July 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for anesthesia services (00790) provided on July 2, 2021.  You asked the Plan to pay for anesthesia services. You say that this is supported. The Plan denied your request. The Plan says this is not documented.  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 00790 is anesthesia for intraperitoneal procedures in upper abdomen including laparoscopy; not otherwise specified.  We find that CPT code 00790 is supported in the medical record. Specifically, the submitted documentation does not included a detailed anesthesia record. Without this information, this code cannot be verified. Based on this information, we decided that Medicare rules for coverage of anesthesia services have been met. Therefore, we decided that the Plan does not have to pay for anesthesia services (00790) provided on July 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for a targeted genomic sequence analysis panel (0239U) provided on February 1, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for a targeted genomic sequence analysis panel. You say that this service is a medically necessary laboratory test for patients with advanced stage, solid tumor cancers who have decided to seek further treatment. You also say that you are the sole provider for this testing, and you request the Plan process this claim as an in-network benefit. The Plan denied your request. The Plan says the non-urgent services are not authorized because the provider is a non-network provider with the Plan, and the referral was from another non-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 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 a targeted genomic sequence analysis panel (0239U) provided on February 1, 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 Ear mold/insert, not disposable, any type (V5264) purchased September 23, 2021.  You asked the Plan to pay for the ear mold. You say that the enrollee has coverage and a benefit for hearing aids through the policy. You request immediate reconsideration and payment of this claim. The Plan denied your request. The Plan says this will exceed the benefit maximum.  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 contract says that there is a $5,000 combined in-network and out of network allowance on hearing aids every 3 years.  We looked at the file and the Plan's rules. The benefit maximum has been exhausted. Based on this information, we decided that the Plan's rules for coverage of the ear mold have not been met. Therefore, we decided that the Plan does not have to pay for Ear mold/insert, not disposable, any type (V5264) purchased September 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the retainer crowns - porcelain fused to high noble metal (D6750) and pontics - porcelain fused to high noble metal (D6240) provided April 27, 2021.  You asked the Plan to pay for the retainer crowns and pontics. You say that the services were necessary, and you expected to have a $0 copayment. The Plan denied your request. The Plan says these services are not covered under your benefits.  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 retainer crowns - porcelain fused to high noble metal (D6750) and pontics - porcelain fused to high noble metal (D6240) provided April 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an office visit (99203, 90732, 90471) provided on June 9, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for an office visit. You say that the patient has not chosen a PCP to authorize services and the patient continues to seek treatment with the ordering provider. The Plan denied your request. The Plan says the ordering provider is out of network.  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 (99203, 90732, 90471) provided on June 9, 2021 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 the out-of-network primary care visit you had on March 12, 2021.  You asked the Plan to waive the copayment for the out-of-network primary care visit.. You say that this doctor told you that he accepted your insurance. The Plan denied your request. The Plan says you were charged this copayment 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 $35 copayment for out-of-network primary care visits.   You have been asked to pay a $35 copayment for the out-of-network primary care visit. 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. In addition, the Plan cannot be held responsible for incorrect information provided to you by an out-of-network provider.  Therefore, we decided that the Plan does not have to waive the copayment for the out-of-network primary care visit you had on March 12, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ambulance service, advanced life support, emergency transport, level 1 (A0427) provided June 8, 2021.  You asked the Plan to waive the copayment for the ambulance transport. You say that you would like the copayment waived. The Plan denied your request. The Plan says the copayment has been 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 $250 copayment for each one-way Medicare-covered ground trip by ambulance.  You have been asked to pay a $250 copayment for the ambulance transport. The ambulance transport falls within the Ambulance services 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 ambulance service, advanced life support, emergency transport, level 1 (A0427) provided June 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a re-bonded crown (D2920) provided by a participating provider on August 4, 2021.  You asked the Plan to pay for a re-bonded crown. You say that you saved the Plan money by having the crown fixed. The Plan denied your request. The Plan says the dental work that was provided is not a covered benefit.  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 a re-bonded crown (D2920) provided by a participating provider on August 4, 2021.