Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from September 6, 2019 to September 17, 2019.
You asked the Plan to pay for home health services. You say that this denied in error. The Plan denied your request. The Plan says this was billed without a correct Type of Bill.
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, this claim was billed without an appropriate Type of Bill code. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from September 6, 2019 to September 17, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forgenetic screening testing provided by "the provider" on July 8, 2019.You asked the Plan to pay forscreening tests. You say that you believe this charge is fraudulent because your provider never ordered these tests.The Plandenied your request. The Plan says the denial of payment for these tests is correct, because these tests were not ordered by your treating physician and were not performed to manage or treat any specific medical problem or diagnosis.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.There is no documentation in the record of a concern for a specific issue for which this testing was ordered. This was provided in the absence of signs/symptoms of a medical condition. This means it is screening in nature which is not covered by Medicare. Therefore, we decided that the Plan does not have to pay forgenetic screening testing provided by "the provider" July 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office consultation services coded 99245 provided on July 18, 2019.
You asked the Plan to pay for the office consultation services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
The Plan must follow Medicare rules. 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 99245 is Office consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 80 minutes are spent face-to-face with the patient and/or family. We find that CPT code 99245 is not supported in the medical record. Specifically, code 99245 has a status code of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the office consultation services have not been met. Therefore, we decided that the Plan does not have to pay for the office consultation services coded 99245 provided on July 18, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for an unlisted pelvis or hip procedure (27299) and an unlisted arthroscopy procedure (29999) provided on October 11, 2019.You asked the Plan to pay for the unlisted procedures. You say that you would like reconsideration based on the records submitted. ThePlan denied your request. The Plan says 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, CPT codes 27299 and 29999 are notlisted in the 2019 ASC list of covered procedures. We find that CPT codes 27299 and 29999 are not supported in the record. Specifically, these codes are not listed as covered procedures when performed in an ambulatory surgical center. Based on this information, we decided that Medicare rules for coverage of the unlisted procedures. have not been met. Therefore, we decided that the Plan does not have to pay for an unlisted pelvis or hip procedure (27299) and an unlisted arthroscopy procedure (29999) provided on October 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the extractions for tooth #'s 22-27.You asked the Plan to pre-approve the extractions. You say that you are appealing the denial.The Plan denied your request. The Plan says the services are not medically necessary.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. The Plan covers the extractions when the services are medically necessary and reasonable. 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 extractions. Our reviewer says that the criteria for coverage has not been met. Our reviewer says that radiographs indicate that tooth #'s 22-27 have bone loss and intact crowns.Our physician reviewer found that the requested service is more involved than is necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the extractions have not been met.Therefore, we decided that the Plan does not have to pre-approvethe extractions for tooth #'s 22-27.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pre-approve routine transportation.
You asked the Plan to pre-approve routine transportation. You say that you had surgery and need to get to your appointments. The Plan denied your request. The Plan says that the denial of authorization for routine transportation is correct, because transportation to this destination is more than 50 miles.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine transportation only to destinations within 50 miles of the pickup location. We looked at your request, the records in the case file, and the rules. The requested destination is within 50 miles of the pickup location. Based on this information, we decided that the Plan's rules for coverage of routine transportation have been met. Therefore, we decided that the Plan has to pre-approve routine transportation.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for PT provided on October 24, 2019.
You asked the Plan to waive the copayment for PT. You say that you were never informed that you would owe a copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are 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). Your contract with the Plan clearly says that you must pay a $40 copayment for outpatient rehabilitation services. You have been asked to pay a $40 copayment for PT. PT falls within the outpatient rehabilitation 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 PT provided on October 24, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for Magnetic Resonance Imaging (MRI) of the Spine (72148)
provided on August 29, 2019
You asked the Plan to pay for the MRI. You say that the services were provided for the patient who presented
through the Emergency Department and were medically necessary. The Plan denied your request. The Plan
says the Place of Service on the claim submitted indicates the service was performed in an outpatient setting. It
does not indicate that the services were emergent. Radiology services provided by an out-of-network provider
in the outpatient setting require preauthorization when non-emergent, and when in-network providers are
available.
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 service 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 Magnetic Resonance Imaging (MRI) of the Spine (72148) provided on August
29, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the nuclear medicine test or the Part B injections provided on September 10, 2019.
You asked the Plan to waive the cost share for the nuclear medicine test and the Part B injections. You say that you should not be responsible for the coinsurance because you have never had to pay a coinsurance before. 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 $100 copayment for Medicare-covered nuclear medicine at a freestanding provider and 20% coinsurance for Medicare Part B-covered chemotherapy drugs and other Medicare Part B-covered drugs (including certain drugs that are used with nebulizers, insulin pumps, and IV infusion pumps). You have been asked to pay a $148.89 for the nuclear medicine test and the Part B injections. The nuclear medicine test falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The Part B injections fall within the "Medicare Part B Prescription Drugs" benefit category. See chart below.
September 10, 2019
Nuclear medicine test
$471.16
$100.00
$100.00
September 10, 2019
Regadenosan injection
$237.08
20%
$47.42
September 10, 2019
Aminophyllin injection
$7.33
20%
$1.47
Total
$148.89
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 cost share for the nuclear medicine test or the Part B injections provided on September 10, 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a chest x-ray (71045) provided on August 5, 2019.
You asked the Plan to pay for the chest x-ray. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support that the services were performed by the billing provider more than once on the same date of service.
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the chest x-ray have not been met. Specifically, the record does not indicate that multiple services were performed by the billing provider on the same date of service. Therefore, we decided that the Plan does not have to pay for a chest x-ray (71045) provided on August 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrolle by an out-of-network provider on May 14, 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 May 14, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient mental health care provided to the enrollee from May 17, 2019 through May 21, 2019.You asked the Plan to pay forinpatient mental health care. You say that the stay was medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient mental health care. Our physician reviewer found based upon review the records provided for the admission of this patient does not meet the criteria for continued acute inpatient mental health treatment for the dates in question of May 17, 2019 forward as this patient was not shown to be a danger to herself or others. She was not showing any auditory or visual hallucinations and was cooperative/compliant with treatment.
We looked atthis physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health care have not been met.Therefore, we decided that the Plan does not have to pay forinpatient mental health care provided to the enrollee from May 17, 2019 through May 21, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the oncology (prostate) gene expression profile provided to the enrollee on October 1, 2019.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the coverage criteria are
not met.
The Plan follows Medicare rules. Medicare rules say that one biomarker test is covered when the above criteria
are met.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for the testing. Our reviewer says that the
requested oncology (prostate) gene expression profile was not medically reasonable and necessary. Our
physician reviewer found that the coverage criteria cited above have not been met. Specifically, PSA level is
highly elevated and not moderately elevated (between 3 and 10), as is required for coverage.
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 testing have not been met. Therefore, we decided that the Plan does not have to pay for the oncology (prostate) gene expression profile provided to the enrollee on October 1, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a cataract surgery provided on October 29, 2019.
You asked the Plan to waive the copayment for a cataract surgery. You say that you feel that you should only owe a $45 copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are 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). Your contract with the Plan clearly says that you must pay a $300 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You have been asked to pay a $300 copayment for a cataract surgery. A cataract surgery falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 cataract surgery provided  on October 29, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the sensorimotor exam provided on August 1, 2019.
You asked the Plan to waive the copayment for the sensorimotor exam. You say that you accept your $40 copayment responsibility but you are appealing the remaining $62.27. 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 $65 copayment for each in-network covered diagnostic procedure or test at a network doctor's office. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $65 copayment for the sensorimotor exam.
You have been asked to pay a $62.27 copayment for the sensorimotor exam. The sensorimotor exam falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows the sensorimotor exam is considered a diagnostic test.
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 sensorimotor exam provided on August 1, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (80053, 86360, 86480, 86481, 86708, 86803, 87536) provided on June 24, 2019 by an out of network provider.
You asked the Plan to pay for lab services. You say that you are seeking a review and requesting payment. The Plan denied your request. The Plan says non-urgent non-covered screening services are not authorized because this practice is a non-network provider with the member's health plan, and another non-network provider with the member's health plan referred the member for services. The member self-directed. The member's network primary care physician (PCP) did not refer for services. The health plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 laboratory services (80053, 86360, 86480, 86481, 86708, 86803, 87536) provided on June 24, 2019 by the out of network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for orthopedic services (CPT 26990) provided to the enrollee on September 10, 2018.
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 CPT 26990 is not supported by the medical records submitted.
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 26990 is "Incision and drainage, pelvis or hip joint area; deep abscess or hematoma." We asked our coding 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 services at issue in this case were not coded correctly. Our coding reviewer found the medical records submitted do not include documentation of the drainage of a deep abscess or hematoma, therefore the service cannot be verified. We looked at this coder'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 orthopedic services (CPT 26990) provided to the enrollee on September 10, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an outpatient hospital visit on August 22, 2019.
You asked the Plan to waive the deductible for an outpatient hospital visit. You say that you did not know that the provider was out-of-network. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 a $500 deductible for out-of-network outpatient hospital services. You had an outpatient hospital visit at an out-of-network provider on August 22, 2019. The record shows that you had paid $0 toward the $500 deductible prior to receiving the services. Therefore, you are responsible to apply the allowed amount of $81.34. The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient hospital services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible for out-of-network outpatient hospital services. This cost sharing is a contractual obligation that had not been met at the time an outpatient hospital visit was received on August 22, 2019. Therefore, we decided that the Plan does not have to waive the deductible for an outpatient hospital visit on August 22, 2019.