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

We decided that the Plan does not have to pay for After-Hours Service (99053) provided on June 13, 2019.
You asked the Plan to pay for the physician services. You say that the services were medically necessary and
correctly billed. The Plan denied your request. The Plan says the service shares a bundled relationship with
another service already paid.
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, we have confirmed that code 99053
has a bundled relationship with code 99285 and cannot be paid as billed. This code cannot be paid as a separate
line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided
that the Plan does not have to pay for After-Hours Service (99053) provided on June 13, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory work provided on November 4, 2019.
You asked the Plan to waive the copayment for the laboratory work. You say that last year you had this exact same test at the exact same provider and the claim was paid in full. The Plan denied your request. The Plan says you have been charged 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 diagnostic lab services and diagnostic procedures and tests (per day, per facility). You have been asked to pay a $5 copayment for the laboratory work. The laboratory work 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 laboratory work provided on November 4, 2019.
Our decision is only about the 2019 services. If you have any questions about prior years billing, please contact the plan directly.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on October 14, 2019 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that these services were medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained for these 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 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 physician services provided on October 14, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH) for the enrollee.You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary.The Plan denied your request. The Plan says the services could be provided in another setting.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an ACH, having been admitted with a fever. The enrollee was initially treated for suspected aspiration and subsequently for a UTI.The enrollee has a tracheotomy and feeding tube at baseline. The enrollee is not on a ventilator. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care,there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long-term care needs.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 LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe inpatient stay provided from November 12, 2019 through November 15, 2019.You asked the Plan to waive the copayment forthe inpatient stay. You say that you don't think you should have had to go to the emergency room.The Plan denied your request. The Plan says the copayment applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $185 per day, days 1-7 for each inpatient stay.You have been asked to pay $555 copayment for the inpatient stay. ($185/day x 3 days = $185). The inpatient stay falls within the "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 forthe inpatient stay provided from November 12, 2019 through November 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the radiation treatment provided on November 12, 2019.
You asked the Plan to waive the copayment for radiation treatment. You say that the cost is a lot. You say that you want help with the copayment. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $60 copayment for each Medicare-covered, in-network, radiation (radium and isotope) therapy service. You have been asked to pay a $60 copayment for the radiation treatment. The radiation treatment 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 the radiation treatment provided on November 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on September 4, 2019, and September 10, 2019. You asked the Plan to pay for the services. The Plan denied your request. The Plan says non-emergent services rendered by non-participating providers in non-participating facilities require prior authorization as outlined in the enrollee's EOC. 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 for the medical services provided to the enrollee by an out-of-network provider on September 4, 2019, and September 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient hospital services provided on November 13, 2019 billed including CPT code 77049.
You asked the Plan to pay for the outpatient hospital services. You say that you feel that this was denied incorrectly and should be paid due to medical necessity. The Plan denied your request. The Plan says this outpatient hospital claim was submitted with a CPT code that is not payable under the OPPS. As such, this claim cannot be paid as billed.
The Plan must follow Medicare rules. Medicare rules say that outpatient hospital services are paid via the OPPS. CPT codes are granted specific status indicators which state whether they can be paid under the OPPS and how payment is made. CPT code 77049 has a status indicator of "B" in the OPPS. This means that the code is not recognized when submitted on an outpatient hospital Part B bill type. An alternate code that is recognized by OPPS when submitted on an outpatient hospital Part B bill type (12x and 13x) may be available. Therefore, we decided that the Plan does not have to pay for the outpatient hospital services provided on November 13, 2019 billed including CPT code 77049.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on April 19, 2019 to the enrollee by an out of network (OON) provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-network provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on April 19, 2019 to the enrollee by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Contour Next Test Strip. You asked the Plan to pre-approve the supplies. You say that this is medically necessary. The Plan denied your request. The Plan says they have other preferred meters and test strips. 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 supplies. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no specific clinical rationale for the requested Contour Next Test Strip. There is no specific medical necessity for this brand of supply. 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 supplies have not been met.Therefore, we decided that the Plan does not have to pre-approve the Contour Next Test Strip.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full amount for the re-cement for a crown (D2920) provided on June 20, 2019.
You asked the Plan to pay the full amount for the dental service. You say that you have never heard of the only in network provider in your area. You say that there has never been a coverage issue for preventive care that you received from your family dentist. You say that this was an emergency situation, "why should it be any different?" You also say that the 2019 Evidence of Coverage is quite ambiguous regarding this matter. The Plan denied your request. The Plan says that for non-Medicare covered comprehensive dental services there is a 50% coinsurance.
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 re-cement for a crown is a covered service, there is a 50% coinsurance for non-Medicare covered comprehensive dental services. The record shows that the total billed amount was $110, the Plan paid $55, and your responsibility is the remaining 50% coinsurance. Therefore, we decided that the Plan does not have to pay the full amount for the re-cement for a crown (D2920) provided on June 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on October 23, 2019.You asked the Plan to waive the copayment for the office visit. You say that the copayment is not what was advertised. You say that you shouldn't have to pay.The Plan denied your request. The Plan says the copayment applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment per office visit for Medicare-covered specialist services. You have been asked to paya $40 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that the provider is a cardiologist. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe office visit providedon October 23, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered on March 5, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says procedure code 95999 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 95999 is unlisted neurological or neuromuscular
diagnostic procedure.
We find that CPT code 95999 is not supported in the medical record. Specifically, the file shows that Train of
Four testing was provided and there is a more specific code for these services. Based on this information, we
decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the
Plan does not have to pay for the services rendered on March 5, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on March 26, 2019.You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met.Therefore, we decided that the Plan does not have to pay forthe laboratory services provided on March 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 3, 2019 to January 3, 2020 by an out of network (OON) provider.You asked the Plan to pay forthese services. You say that the provider told you that they were out-of-network but that you could submit a claim for reimbursement.The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without prior authorization.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. The Plan cannot be held responsible for possible misinformation given by an out-of-network provider regarding coverage. 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 forthe medical services provided on September 3, 2019 to January 3, 2020 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 fillings for teeth #7, 8, 9, and 10 provided on September 20, 2019.
You asked the Plan to pay for the fillings for teeth # 7, 8, 9, and 10. You say that a plan representative misinformed the provider office regarding your coverage. You say that you should be held responsible for the representatives misinformation. The Plan denied your request. The Plan says 2 fillings per calendar year are covered. The Plan also says that the frequency limit has been exceeded.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage and fillings are a covered service, the frequency limit has been exceeded. The record shows that the Plan paid for the fillings that you received for teeth # 5 and 6, thus exhausting the benefit for fillings. Therefore, we decided that the Plan does not have to pay for the fillings for teeth # 7, 8, 9, and 10 provided on September 20, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services.
You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan
denied your request. The Plan says this can be done as outpatient or observation status.
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 does not support that the criteria for inpatient payment are met in this case. Our
physician reviewer found the review has determined that the record did not show that at the time of inpatient
admission the admitting physician reasonably expected that the patient'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 not been met. Therefore, we decided that the
Plan does not have to pay for inpatient hospital services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an outpatient surgical procedure provided on March 18, 2019.
You asked the Plan to waive the coinsurance for an outpatient surgical procedure. You say that the charges are too high and the enrollee cannot afford them. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay 20% coinsurance for outpatient surgical services. The enrollee received an outpatient surgical procedure on March 18, 2019. The allowed amount is $8,240.63 and 20% of that is $1,648.13. The enrollee has been asked to pay the total coinsurance amount of $1,648.13 for an outpatient surgical procedure. An outpatient surgical procedure falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for an outpatient surgical procedure provided on March 18, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for a brief emotional/behavioral assessment (96127) provided on September 24, 2019. You asked the Plan to pay for the behavioral assessment. You say that the services were medically necessary. The Plan denied your request. The Plan says the maximum number of units were exceeded. The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. In this case, the MUE for CPT code 96127 is 3. You billed 6 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the behavioral assessment have not been met. Therefore, we decided that the Plan does not have to pay for a brief emotional/behavioral assessment (96127) provided on September 24, 2019.