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

We decided that the Plan does not have to pay forthe services (CPT 99152) provided on June 15, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the billed code cannot be verified.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 99152 is "Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic ortherapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial fifteenminutes of intraservice time, patient age fiveyears or older."We asked our coder's 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 use of CPT code 99152 supported by the records provided. Our coding reviewer found that the procedure report does not include documentation of a trained observer to assist in monitoring the patient's level of consciousness and physiological status, which is required to report CPT99152. Therefore, the required services for reporting CPT 99152 cannot be verified as performed.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 forthe services (CPT 99152) provided on June 15, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral evaluation (D0120) and prophylaxis (D1110) provided.

You asked the Plan to pay for the dental services. You say that you received a denial letter for the claim. You say that you do not understand why the claim denied.The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that dental services that you receive out of network 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 oral evaluation (D0120) and prophylaxis (D1110) provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited problem focused exam and fixed partial denture sectioning received on October 7, 2020.
You asked the Plan to pay for the limited problem focused exam and fixed partial denture sectioning. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are 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 the limited problem focused exam and fixed partial denture sectioning received on October 7, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forinpatient hospital care provided from September 24, 2020, to September 26, 2020.You asked the Plan to waive the copayment forthe inpatient hospital care. You say that the copayment should be waived.The Plan denied your request. The Plan says the correct copayment was 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 $125 copayment per-admission for inpatient care. You have been asked to pay a $125 copayment for the inpatient hospital care. The inpatient hospital care falls within the inpatient 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 forinpatient hospital care provided from September 24, 2020, to September 26, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on June 12, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services are available in-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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on June 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe re-cement or re-bond crown, or pay more for the amalgam and resin-based composite provided on October 30, 2019 by an OON provider.You asked the Plan to pay forthe re-cement or re-bond crown, and pay more for the amalgam and resin-based composite. You say that you would like to be reimbursed for these services.The Plan denied your request. The Plan says there-cement or re-bond crown is not a covered benefit. The Plan also says that you were charged correctly for the amalgam and resin-based composite.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 re-cement or re-bond crown is not among those covered under this benefit. The contract also clearly states that you are responsible for a 55% coinsurance for amalgams and composite resin restorations, and you may pay more when receiving care OON.Therefore, we decided that the Plan does not have to pay forthe re-cement or re-bond crown, or pay more for the amalgam and resin-based composite provided on October 30, 2019 by an OON provider
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for wound prep (15002 an 15003) provided on August 21, 2019.

You asked the Plan to pay for the wound prep. 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 the service billed.

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 15002 is surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, trunk, arms, legs; first 100 sq cm or 1% of body area of infants and children.

The CPT Code Manual definition of code 15003 is surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, trunk, arms, legs; each additional 100 sq cm, or part thereof, or each additional 1% of body area of infants and children (List separately in addition to code for primary procedure)  

We asked our coder 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 wound prep. Our reviewer says that CPT codes 15002 and 15003 do not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not include sufficient documentation to validate that the services performed on August 21, 2019 were done in anticipation of surgical follow up. Therefore, CPT codes 15002 and 15003 cannot be validated.

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 wound prep have not been met. Therefore, we decided that the Plan does not have to pay for wound prep (15002 an 15003) provided on August 21, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment forinpatient services provided from April 10, 2020, to April 13, 2020.You asked the Plan to reduce the copayment forthe inpatient services. You say that your health statement is misleading and you believe you only owe a $380 copayment.The Plan denied your request. The Plan says you were charged the copayments 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 $380 copayment per day for days 1-5. for Inpatient Hospital Care. You have been asked to pay a $380 copayment per day for days 1-5 for the inpatient services. The inpatient services fall 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 reduce the copayment forinpatient services provided from April 10, 2020, to April 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay foroutpatient laboratory services provided to the enrollee on September 8, 2020.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthe service is not covered under any Medicare outpatient 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 consideredmedically reasonable and necessary in this case. Our physician reviewer found the review has determined that payment is not allowed, because the services were not covered under any Medicare outpatient benefit; therefore, units exceed maximum. The review has determined that the services at issue in this case were not medically reasonable or necessary. The claim was processed correctly.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 Plandoes not haveto pay foroutpatient laboratory services provided to the enrollee on September 8, 2020
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plandoes not haveto pay forpsychiatry services provided to the enrollee on July 20, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthe claim was not filed timely.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.The record shows thata claim for the services was not filed until September 1, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plandoes not haveto pay forpsychiatry services provided to the enrollee on July 20, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe moderate sedation services rendered on June 24, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure codes 99152 and 99153 are 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 99152 is moderate sedation services by physician also performing a procedure, patient 5 years of age or older, first 15 minutes. The definition of code 99153 is moderate sedation services by physician also performing a procedure, additional 15 minutes (List separately in addition to code for primary service).We find that CPT codes 99152 and 99153 are not supported in the medical record. Specifically, there is no documentation of the first 15 minutes of an independent trained observer to assist in monitoring the enrollee's level of consciousness and physiological status to support code 99152. Given that the primary procedure code 99152 is not supported, add-on code 99153 is also not supported. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe moderate sedation services rendered on June 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe chiropractic services rendered from June 23, 2020 to July 17, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. The provider submitted claims for procedure codes 99203 (office visit) and 97124 (massage therapy). These services are not covered when billed by a chiropractor.Therefore, we decided that the Plan does not have to pay forthe chiropractic services rendered from June 23, 2020 to July 17, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approveten (10) additional physical therapy visits.You asked the Plan to pre-approveadditional physical therapy visits. You say that the enrollee's mobility and function has improved since their surgery, however, the enrollee has not regained normal functioning. You state the enrollee continues to experience a loss of dexterity and fine motor skills.The Plan denied your request. The Plan says the notes do not show the ongoing skills of a physical therapist are needed.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determineif the Plan was correct in denying the request to pre-approve additional physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the requested additional therapy is not generally accepted as specific and effective therapy for the enrollee's condition. The enrollee has had prior therapy for this condition and the documentation does not indicate that the enrollee's functional level requires the unique skills of a professional therapist to safely and effectively provide treatment, or that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The requested services are not part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional physical therapy visits have not been met.Therefore, we decided that the Plan doesnot have to pre-approveten (10) additional physical therapy visits
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forambulance services provided on September 10, 2020.You asked the Plan to waive the copayment forambulance services. You say that you did not call the ambulance and feel that they only transported you to receive money.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 $225 copayment for ambulance services.You have been asked to pay a $225 copayment for ambulance services. Ambulance services fall 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 forambulance services provided on September 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe subsequent nursing facility care, per day (99309) rendered by the out of network (OON) provider on July 7, 2020.You asked the Plan to pay forthis service. You saythat you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says the service was 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 provider in this case is nota network provider with the Plan. The Plan had network providers available who could have provided the service 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 this service.Therefore, we decided that the Plan does not have to pay forthe subsequent nursing facility care, per day (99309) rendered by the out of network (OON) provider on July 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve8 additional LaryTubes (A7520) and tracheostomy shower protectors (A7523).You asked the Plan to pre-approve8 additional LaryTubes (A7520) and tracheostomy shower protectors (A7523). You say that the 8 additional LaryTubes (A7520) and tracheostomy shower protectors are medically necessary.The Plan denied your request. The Plan says the 8 additional LaryTubes (A7520) are not medically necessary. The Plan says that the tracheostomy shower protectors areclassified as a convenience item and arenot covered by Medicare or the Plan.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 8 additional LaryTubes (A7520). Our reviewer says that the 8 additional LaryTubes (A7520) are not medically necessary. Our physician reviewer found it is typically standard to change out a lary tube or a tracheostomy tube about every 3-6 months. The medical records do not show why the enrollee would need to change out his lary tubemore often than once every 3 months. Therefore, 4 lary tubes in a year should be sufficient.The rulesalsosay that for equipment to be covered, it must primarily serve a medical purpose.  Tracheostomy shower protectors with CPT code A7523 are a convenience item and are not covered.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 8 additional LaryTubes (A7520) and tracheostomy shower protectors (A7523) have notbeen met.Therefore, we decided that the Plan does not have to pre-approve8 additional LaryTubes (A7520) and tracheostomy shower protectors (A7523).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the general health panel rendered on September 1, 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 services are not covered.
The Plan must follow Medicare rules. The rules say that a GHP (code 80050) is not covered or paid for by Medicare. The services at issue are a GHP billed with code 80050. Therefore, we decided that the Plan does not have to pay for the general health panel rendered on September 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe mastectomy bras on October 6, 2020.You asked the Plan to waive the coinsurance forthe mastectomy bras. You say that since you placed the mastectomy bra order in September, your previous coverage level should apply. 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 20% coinsurance for prosthetic devices and related supplies. You have been asked to pay $30.60 which is 20% of the allowed amount for the mastectomy bras. The allowed amount is $153. ($153 x 20% = $30.60). The mastectomy bras fall within the "Prosthetic devices and related supplies" benefit category. The record shows your claim was processed onthe date ofservice billed by the provider using the benefit plan that you were enrolled in on the date of service.This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the coinsurance forthe mastectomy bras on October 6, 2020.