Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent hospital visit (99232) provided November 6, 2019 to November 7, 2019.
You asked the Plan to pay for subsequent hospital visit. You say that claims were submitted under the same tax ID numbers but are two different departments and specialties. Please review and reconsider this claim for payment. The Plan denied your request. The Plan says Medicare does not pay separately for this service. The charge for this service is included in another procedure code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code subsequent hospital visit has a bundled relationship with code 99233 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 subsequent hospital visit (99232) provided November 6, 2019 to November 7, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided by an in-network hospital on August 8, 2019 to August 9, 2019.
You asked the Plan to waive the copayment for an emergency room visit. You say that you were an inpatient so this copayment should be waived. The Plan denied your request. The Plan says the correct copayment has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copayment for emergency care. You have been asked to pay a $90 copayment for an emergency room visit. Evidence was provided to show that observation services were provided. Observation services are considered outpatient; therefore, the copayment cannot be waived. An emergency room visit falls within the emergency care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an emergency room visit provided by an in-network hospital on August 8, 2019 to August 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling and root planing - four or more teeth per quadrant (quantity 4) (D4341).
You asked the Plan to pre-approve the dental services. You say that you need these services and cannot pay for these services out-of-pocket. The Plan denied your request. The Plan says the service is not a covered benefit under the plan.
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. This service is not listed in your EOC as a covered benefit; therefore, it is not covered. Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planing - four or more teeth per quadrant (quantity 4) (D4341).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrodes provided on October 23, 2019.
You asked the Plan to pay for the electrodes. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed with an invalid place of treatment.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. Review of the file shows that the electrodes were billed with place of treatment of 22 (on campus- outpatient hospital). This is not an approved place of treatment for this durable medical equipment provided. Records show that the electrodes were used in a hospital. Therefore, we decided that the Plan does not have to pay for the electrodes provided on October 23, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment forthe ambulance ride provided on November 6, 2019.You asked the Plan to reduce the copayment forthe ambulance ride. You say that your ambulance ride was not a part of the health system. You say a network ambulance should have been used. 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 $300 copayment per one-way trip for emergency ambulance services and non-emergency ambulance services. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $300copayment for the ambulance ride.You have been asked to pay a $224 copayment for the ambulance ride. The ambulance ride falls within the "Ambulance services" benefit category. The record shows you pay this amount for both in-and out-of-network ambulance services.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 forthe ambulance ride provided on November 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on December 4, 2019 by an out of network (OON) provider.
You asked the Plan to pay for skilled nursing services. You say that services were provided to the member at a skilled nursing facility. You say that it is the facility's responsibility to get prior authorization. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring facility is also 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 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 skilled nursing services provided on December 4, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for lens, polycarbonate or equal, any index, per lens (V2784), progressive lens per lens (V2781), U-v lens, per lens (V2755), anti-reflective coating  (V2750) and tint photochromatic lens/es (V2744) provided on December 2, 2019.You asked the Plan to pay for the eyewear. You say that based on your individual needs these services should be covered.The Plan denied your request. The Plan says the services are not a covered benefit under the plan.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the eyewear have not been met. The services are not a covered benefit under the plan.Therefore, we decided that the Plan does not have to pay for lens, polycarbonate or equal, any index, per lens (V2784), progressive lens per lens (V2781), U-v lens, per lens (V2755), anti-reflective coating  (V2750) and tint photochromatic lens/es (V2744) provided on December 2, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient hospital services provided from September 21, 2019 to September 22, 2019.
You asked the Plan to pay for the outpatient hospital services. The Plan denied your request. The Plan says the Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. The Plan also says that during the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the outpatient hospital services provided from September 21, 2019 to September 22, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral hygiene instructions provided on October 28, 2019.You asked the Plan to pay forthe oral hygiene instructions. You say that a plan representative told you that there were no in-network providers in your area and they would approve the services to be rendered by this out-of-network provider.The Plan denied your request. The Plan says this service 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 forthe oral hygiene instructions provided on October 28, 2019.Your complaint about being pressured by the provider to pay for your services is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an electrocardiogram (93010) provided on October 19, 2019.
You asked the Plan to pay for the electrocardiogram. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted records do not support the services 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 93010 is electrocardiogram, routine ECG with at least 12 leads; interpretation and report only. 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 electrocardiogram. Our reviewer says that CPT code 93010 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not fully support the definition associated with CPT code 93010, therefore this service cannot be validated as performed on October 19 2019.
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 electrocardiogram have not been met. Therefore, we decided that the Plan does not have to pay for an electrocardiogram (93010) provided on October 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the diabetic shoes and inserts provided on October 23, 2019. You asked the Plan to waive the coinsurance for the diabetic shoes and inserts. You say that you have never been charged for diabetic shoes and inserts previously. The Plan denied your request. The Plan says that the claim processed 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 20% coinsurance for diabetic shoes and inserts provided out of network. You have been asked to pay a 20% coinsurance for the diabetic shoes and inserts. The diabetic shoes and inserts fall within the diabetic shoes and inserts provided out of network 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 coinsurance for the diabetic shoes and inserts provided on October 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build-up including any pins (D2950) crown-porcelain/ceramic substrate (D2740) crown porcelain/ceramic (D0274) intraoral periapical first x-ray (D0220) intraoral periapical each additional x-ray (D0230) periodontal scaling and root planing (D4341).
You asked the Plan to pre-approve the dental services. You say that please reprocess this provider is in network. The Plan denied your request. The Plan says dental services provided by out-of-network dental providers are not covered by the plan.
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 pre-approve core build-up including any pins (D2950) crown-porcelain/ceramic substrate (D2740) crown porcelain/ceramic (D0274) intraoral periapical first x-ray (D0220) intraoral periapical each additional x-ray (D0230) periodontal scaling and root planing (D4341).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 10, 2019to C. Park by an out of network (OON) provider.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 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 areaurgent 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 forthe medical services provided on January 10, 2019 to C. Park by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an ankle x-ray (73600) provided on March 18, 2019.
You asked the Plan to pay for the x-ray. You say that you would like reconsideration because separate procedures were performed. The Plan denied your request. The Plan says anatomic-specific modifiers are required whenever they are appropriate.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 73600 26 52 59 is not supported in the record. Specifically, the record indicates that this service was specific to the left ankle. Anatomic-specific modifiers are required on individual claim lines when appropriate. Based on this information, we decided that Medicare rules for coverage of the x-ray have not been met. Therefore, we decided that the Plan does not have to pay for an ankle x-ray (73600) provided on March 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on October 23, 2019 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that your provider was called by the facility to treat your member. You say that your provider cannot deny and medical services that are essential to the member's health. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring facility is also 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 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 23, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the Chest X-ray (71045, R0070, Q0092) provided on October 8, 2019.
You asked the Plan to pay for the x-ray. You say that the services were medically necessary. The Plan denied your request. The Plan says services were not emergent or pre-authorized. There were network providers who could provide the services at issue.
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 Chest X-ray (71045, R0070, Q0092) provided on October 8, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on November 4, 2019 and billed under code G0483.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says there is not a valid physician order or physician documentation that supports the criteria for this testing were met.The Plan must follow Medicare rules. Medicare has specific documentation requirements for this type of testing. The physicians order and the medical records must specifically show how this testingwill be used to treat illness or disease present in the enrollee at the time of service as opposed to this testing being done for screening purposes. Based on the records provided, the required Medicare criteria are not met.Therefore, we decided that thePlan does not have to pay fordrug testing services provided to the enrollee on November 4, 2019 and billed under code G0483
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the unlisted neurological or neuromuscular diagnostic procedure provided on July 3, 2019.
You asked the Plan to pay for the unlisted neurological or neuromuscular diagnostic procedure. 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 separately payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 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 documentation shows that train of four testing was rendered. This service is considered integral to the primary procedure and therefore, part of the bundled payment. Based on this information, we decided that Medicare rules for coverage of the unlisted neurological or neuromuscular diagnostic procedure have not been met. Therefore, we decided that the Plan does not have to pay for the unlisted neurological or neuromuscular diagnostic procedure provided on July 3, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic casts (D0470) provided on January 10, 2020.
You asked the Plan to pay for the diagnostic casts. You say that the provider had to make a mold for your dentures. You also say that without this service you were not able to eat right, which is important because you are a diabetic. The Plan denied your request. The Plan says this service is not covered under your plan.
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 diagnostic casts (D0470) provided on January 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided on August 27, 2019.You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says the enrollee does not have out-of-network benefits. The enrollee generally must receive care from a provider in the Plan's 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 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 nurse practitioner services provided on August 27, 2019.