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

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider on August 7, 2020. You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized. 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 you by an out-of-network provider on August 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvespecialist services to be provided by an out of network (OON) provider.You asked the Plan to pre-approveurology services. You say that you would like to see this provider because he is highly recommended.The Plan denied your request. The Plan says there are in-network providers 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.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. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvespecialist services to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services (87101, 87220) provided on June 1, 2020 by an out of network (OON) provider.You asked the Plan to pay forlaboratory services. You say that these procedures do not require authorization.The Plan denied your request. The Plan says OON services require 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 forthe laboratory services (87101, 87220) provided on June 1, 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 additional intraoral x-ray (D0230) provided on July 29, 2020.
You asked the Plan to pay for the dental service. You say that the cost of a "set" of intraoral x-rays should be covered in full. You say that the Plan mandates dental providers take an upper and lower image as a set. You say that your policy describes the intraoral x-rays as "one set..." and fully covered when performed in network. You also say that the policy appears to support the ADA set mandate. The Plan denied your request. The Plan says 1 intraoral x-ray procedure is covered per year. The Plan 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, the frequency limit of 1 intraoral x-ray procedure per calendar year has been exceeded. The record shows that the Plan paid for the initial intraoral x-ray that you received on the same date of service. Therefore, we decided that the Plan does not have to pay for the additional intraoral x-ray (D0230) provided on July 29, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on August 25, 2020.You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says with limited exceptions,members of the Plan must use network providers to get medical care and services. The only exceptions are medical emergencies, urgently needed care when the network is not available, out-of-area dialysis servicesand cases in which the Plan authorizes the use of out-of-network providers.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 laboratory services.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 laboratory services provided on August 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe cone beam CT capture and interpretation (D0364) provided on March 30, 2020.You asked the Plan to pay forthe cone beam CT capture and interpretation. You say that the treating provider needed to take the cone beam CT scan in order to determine if you needed a root canal to alleviate your pain.The Plan denied your request. The Plan says this service is not a covered benefit under your dental 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 forthe cone beam CT capture and interpretation (D0364) provided on March 30, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for a behavioral health inpatient admission provided from July
11, 2020, through July 14, 2020.
You asked the Plan to pay for the behavioral health inpatient admission. The Plan denied your request. The
Plan says prior authorization was not obtained by the provider or facility.
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 a behavioral health inpatient admission provided from July 11,
2020, through July 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fordiabetic test strips you received from May 21, 2020, and September 19, 2020.You asked the Plan to waive the copayment forthe diabetic test strips. You say that you should not have to pay this much for test strips.The Plan denied your request. The Plan says you were charged these 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 $10 copayment for a 30-day supply for diabetic test strips. You have been asked to pay a $10 copayment for a 30-day supply for the diabetic test strips. 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 fordiabetic test strips you received from May 21, 2020, and September 19, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forout of network physicians services provided on August 12, 2020.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.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 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 forout of network physicians services provided on August 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe maxillary immediate denture and mandibular immediate denture provided on July 16, 2020 by an OON provider.You asked the Plan to pay forthe maxillary immediate denture and mandibular immediate denture. You say that you were told that this provider would accept your visa flex card, and you only have a balance of $795.00.The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that no benefits are available for procedures performed by OON providers.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 covered when they are received OON.Therefore, we decided that the Plan does not have to pay forthe maxillary immediate denture and mandibular immediate denture provided on July 16, 2020 by an OON provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services provided to the enrollee on July 2, 2018.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says this 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 that a claim for this service was not filed until March 5, 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 Plan does not have to pay forphysician services provided to the enrollee on July 2, 2018.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services provided.

You asked the Plan to pay for the outpatient services. You say that you would like reconsideration because the right to recover for services provided to eligible beneficiarys is not extinguished by specific plan requirements such as network participation.The Plan denied your request. The Plan says this claim was submitted without the appropriate revenue code.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The rules also say that all charges, except for therapies, telehealth originating site facility fee, PPV, influenza virus vaccine, hepatitis B vaccine and hospital-based ambulance services are combined and reported under revenue code 0510.

We find that CPT code  is not supported in the record. Specifically, this claim was submitted without the appropriate revenue code. Based on this information, we decided that Medicare rules for coverage of the outpatient services have not been met.Therefore, we decided that the Plan does not have to pay for outpatient services provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe comprehensive oral evaluation (D0150) provided on July 20, 2020.You asked the Plan to pay forthe dental service. You say that the evaluation was not routine. You say that the evaluation was required before you could confirm the necessity and potential difficulty of the procedure. You also say that the service should be covered.The Plan denied your request. The Plan says 1 comprehensive oral evaluation every 3 plan years is 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, the frequency limit of 1 comprehensive oral evaluation every 3 plan years has been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation that you received on July 6, 2020.Therefore, we decided that the Plan does not have to pay forthe comprehensive oral evaluation (D0150) provided on July 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the protein testing (84166) provided on June 10, 2020.
You asked the Plan to pay for the testing. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says these services are not a Medicare benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the protein testing (84166) provided on June 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services provided on June 28, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the claim was submitted after the timely filing limit.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 that a claim for the services was not filed until August 24, 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 Plan does not have to pay forthe services provided on June 28, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlab work provided on February 20, 2020 by an out of network (OON) provider.You asked the Plan to pay forlab work. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says prior authorization was not obtained. The Plan say's that referring provider 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 forlab work provided on February 20, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea sacroiliac joint injection (27096).You asked the Plan to pre-approvea sacroiliac joint injection. You say that this is medically necessary.The Plan denied your request. The Plan says the medical records do not show that the sacroiliac joint is the source of the enrollee's pain.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 requestto pre-approve a sacroiliac joint injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found some of the provocation tests to localize sacroiliac joint involvement are Patrick's test, Thigh thrust test, SI compression test, Yeoman's test, or Gaenslan's test. The medical records provided do not document that these tests have been performed. Therefore, this procedure is not medically necessary and reasonable.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a sacroiliac joint injection have not been met.Therefore, we decided that the Plan does not have to pre-approveasacroiliac joint injection (27096).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay fortransport services provided to the enrollee on September 2, 2020.You asked the Plan to pay forthis service. You say that this claim should be covered by the Plan.The Plan denied your request. The Plan says insufficient medical records were provided to 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, insufficient records were submitted to support the services billed. Medicare rules for coverage of this service have not been met.Therefore, we decided that the Plan does not have to pay fortransport services provided to the enrollee on September 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar sacral orthosis (L0650) provided on July 27, 2020.
You asked the Plan to pay for a lumbar sacral orthosis. You say that the enrollee reported that their current brace did not work. The Plan denied your request. The Plan says the enrollee previously received a brace of the same kind in June.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that the enrollee had a lumbar sacral orthosis at the time this lumbar sacral orthosis was received. Therefore, we decided that the Plan does not have to pay for a lumbar sacral orthosis (L0650) provided on July 27, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the SNF services provided from July 1, 2020, to July 10, 2020 by an OON provider.
You asked the Plan to waive the coinsurance for SNF care. You say that no one requested the enrollee be put into a private room, and you assume the enrollee was assigned to a private room due to COVID 19. You also say that you do not believe the enrollee should be responsible for the extra charges for a private room. The Plan denied your request. The Plan says the copayment amount the enrollee is being charged is correct.
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 a 40% coinsurance per day for days 1 to 100 for out-of-network Skilled Nursing Facility (SNF) care. The allowed amount of this claim is $2,267.52, resulting in a coinsurance amount of $907.01. The enrollee has been asked to pay a 40% coinsurance per day for days 1 to 100 for out-of-network SNF care. SNF care falls within the Skilled Nursing Facility (SNF) care 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 the SNF services provided from July 1, 2020, to July 10, 2020 by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe assistant surgeon services provided on April 11, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says this service is not payable.The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT code 27235. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the services have not been met.Therefore, we decided that the Plan does not have to pay forthe assistant surgeon services provided on April 11, 2020
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an ultrasound (76870) provided on May 22, 2020.
You asked the Plan to pay for an ultrasound. You say that this is a covered service. The Plan denied your request. The Plan says this was not billed with the correct revenue code.
The Plan must follow Medicare rules. Medicare rules say that all charges, except for therapies, telehealth originating site facility fee, PPV, influenza virus vaccine, hepatitis B vaccine and hospital-based ambulance services are combined and reported under revenue code 0510 (clinic visit) on TOB 13X (hospital outpatient). We looked at the file and Medicare rules. This service was billed under revenue code 0402. Based on this information, we decided that Medicare rules for coverage of an ultrasound have not been met. Therefore, we decided that the Plan does not have to pay for an ultrasound (76870) provided on May 22, 2020.