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

We decided that the Plan does not have to pay for skilled nursing services provided on September 2, 2020 by an out of network (OON) provider.
You asked the Plan to pay for skilled nursing services. You say that you thought that the authorization on file covered all services provided at the skilled nursing facility. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.
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 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 September 2, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs to get out of the
intensive care unit. The Plan denied your request. The Plan says the enrollee will not benefit from or improve
with LTACH management.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our physician
reviewer found that the enrollee was admitted to the acute care hospital for acute respiratory failure. Her
hospital course was complicated by Covid-19, septic shock, and a heart attack. The enrollee is receiving
appropriate care at the present acute care hospital. She does not require services at the LTACH that are not
available at the acute care hospital where she is currently receiving care. There are no services available at the
LTACH that she requires that are not available at the health care setting being offered by the health plan.
Therefore, the requested LTACH services are not medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the pontic and two retainer crowns provided on January 4, 2021.

You asked the Plan to pay for the pontic and retainer crowns. You say that you believe these services should be
covered. The Plan denied your request. The Plan says that the information sent by your dentist does not say
why a denture cannot be used to replace your missing teeth. The Plan also says that the submitted narrative
fails to indicate or support any specific physical or psychological condition(s) that preclude the use of a
removable prosthesis.

The Plan must follow Medicare rules. The rules say that the health plan must provide you with a clear and
accurate description of the Original Medicare and/or mandatory/optional supplemental benefits offered under
your plan contract including applicable conditions and limitations and any other conditions associated with the
use or receipt of the benefits.

We looked at the file and Medicare rules. The record shows that the Plan denied these services for
documentation not being submitted stating why a denture could not be used, or supporting any specific
condition that would preclude the use of a removable prosthesis. The EOC states that bridges are a covered
benefit, and does not clearly specify that bridges are only covered when a removable prosthodontic cannot be
used. You reasonably believed this service would be covered, because it is listed as a covered service in your
EOC. Based on this information, we decided that the Plan's rules for coverage of the pontic and retainer crowns
have been met. Therefore, we decided that the Plan has to pay for the pontic and two retainer crowns provided
on January 4, 2021.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services coded S9502 provided from December 16, 2020 to December 22, 2020.
You asked the Plan to pay for the home infusion therapy 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 S9502 is home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 8 hours, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.
We find that CPT code S9502 is not supported in the medical record. Specifically, this code 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 home infusion therapy services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy services coded S9502 provided from December 16, 2020 to December 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on January 19, 2021.

You asked the Plan to pay for the office visit. You say that the service was performed out of medical necessity to best treat the patient. You say that the information warrants a reversal of the denial and payment of the claim. The Plan denied your request. The Plan says the service was not urgent or emergent in nature and the service was 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 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 office visit provided by an out-of-network provider on January 19, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on November 18, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not
payable.
The Plan must follow Medicare rules. Medicare rules say that Medicare covers services in an emergency
department only if the emergency clinic is affiliated with a hospital.
We looked at the file and Medicare rules. The services in question were provided in an emergency department
that is not affiliated with a hospital. 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 the services
provided on November 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist services you received on January 6, 2021.

You asked the Plan to waive the copayment. The Plan denied your request. The Plan says you are responsible for the copayment.

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 $50 copayment for specialty care. Review of the file shows that you were provided specialist services on January 6, 2021. You have been asked to pay a $50 copayment for the services.

The services fall within the physician 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 the specialist services you received on January 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost for the x-ray and CT scan provided on January 12,
2021.
You asked the Plan to waive the cost for the x-ray and CT scan. You say that you are requesting coverage on
the procedures and pharmacy drugs. The Plan denied your request. The Plan says the advanced imaging
copayment applied correctly and the self-administered drugs were approved.
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 $275
copayment for advanced imaging services at an in-network outpatient hospital.
You have been asked to pay a $275 copayment for the x-ray and CT scan. The x-ray and CT scan fall within
the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan
does not have to waive the cost for the x-ray and CT scan provided on January 12, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation (A0427, A0425) received January 21, 2021.
You asked the Plan to waive the copayment for the ambulance transportation. You say that you were told the ambulance transportation would be covered in full. The Plan denied your request. The Plan says the correct cost share applied to the claim.
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 the ambulance transportation. The ambulance transportation falls 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 for the ambulance transportation (A0427, A0425) received January 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewings - four radiographic images (D0274), periodic
oral evaluation - established patient (D0120), intraoral - periapical first radiographic image (D0220), intraoral -
periapical each additional radiographic image (D0230), prophylaxis - adult (D1110), and unspecified
preventative procedure, by report (D1999) provided February 24, 2021.
You asked the Plan to pay for the bitewing x-rays, periodic oral exam, intraoral x-rays, dental cleaning and
unspecified preventative procedure. You say that these services are covered under your dental benefits. The
Plan denied your request. The Plan says the services were provided by one of the third-party dental vendor's
Premier dentists and therefore the services 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. The Plan covers the bitewing
x-rays, periodic oral exam, intraoral x-rays, dental cleaning and unspecified preventative procedure when the
services are provided by one of the Plan's participating dentists.
We looked at the file and Medicare rules. The Plan provided documentation showing that this provider is part
of the dental vendor's Premier dentist. Based on this information, we decided that the Plan's rules for coverage
of the bitewing x-rays, periodic oral exam, intraoral x-rays, dental cleaning and unspecified preventative
procedure have not been met. Therefore, we decided that the Plan does not have to pay for the bitewings - four
radiographic images (D0274), periodic oral evaluation - established patient (D0120), intraoral - periapical first
radiographic image (D0220), intraoral - periapical each additional radiographic image (D0230), prophylaxis -
adult (D1110), and unspecified preventative procedure, by report (D1999) provided February 24, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the cost for the ER visit and self-administered drugs provided on February 5, 2021.
You asked the Plan to waive the cost for the ER visit and self-administered drugs. You say that you received a bill and want the amount you owe resolved. The Plan denied your request. The Plan says the ER copayment applied correctly and you are responsible for the full cost of the self-administered drugs.
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 services at an emergency room. You have been asked to pay a $90 copayment for the ER visit and self-administered drugs. The ER visit falls within the "Emergency care" benefit category. The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.
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 for the ER visit and self-administered drugs provided on February 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).
You asked the Plan to pre-approve RFA. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that the thermal radiofrequency destruction of cervical, thoracic, or lumbar paravertebral facet joint (medial branch) nerves are considered medically reasonable and necessary when specific 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 pre-approve RFA. Our reviewer says that the services are not medically necessary. Our physician reviewer found the LCD requires a second set of confirmatory MBBs which achieve greater than 80% pain relief. This has not been done and therefore, at this time, the request is considered not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of RFA have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office services (CPT code 99212) provided to the
enrollee on March 29, 2021, by an out-of-network provider.

You asked the Plan to pay for the office services. You say that the claim should be paid. The Plan denied your
request. The Plan says this provider is out-of-network, the services were not referred by a network provider,
and the services were not urgent or emergent, nor were they approved in advance.

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 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 office services (CPT code 99212) provided to
the enrollee on March 29, 2021, by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on October 3, 2020, through October 9, 2020.You asked the Plan to waive the copayment for inpatient hospital care. You say that the services should be covered.The Plan denied your request. The Plan says the cost share was applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $320 copayment each day one through five before being covered for inpatient hospital care. You have been asked to pay a $320 copayment each day one through five before being covered for inpatient hospital care. This service falls within the inpatient hospital care benefit category. You received inpatient hospital care for six days and are being charged a copayment for five of them ($320 x 5 = $1,600). 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 inpatient hospital care provided on October 3, 2020, through October 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on October 23, 2020 by an out of network (OON) provider.You asked the Plan to pay for skilled nursing services. 

You say that prior authorization is not needed.The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.

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 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 October 23, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on January 5, 2021.

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 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 for the services provided by an out-of-network provider on January 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant360 testing (81120, 81121, 81173, 81201, 81210, 81235, 81270, 81272, 81275, 81276, 81293, 81299, 81309, 81310, 81311, 81314, 81318, 81321, 81400, 81401, 81402, 81403, 81404, 81405, 81406) provided on January 1, 2021.
You asked the Plan to pay for Guardant360 testing. You say that this was medically necessary. The Plan denied your request. The Plan says this was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. To report a CGP service, test providers should use CPT code 81479 at this time. We find that CPT codes 81120, 81121, 81173, 81201, 81210, 81235, 81270, 81272, 81275, 81276, 81293, 81299, 81309, 81310, 81311, 81314, 81318, 81321, 81400, 81401, 81402, 81403, 81404, 81405, and 81406 are not supported in the medical record. Specifically, the testing at issue is considered a CGP service are should be reported with 81479. Based on this information, we decided that Medicare rules for coverage of Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for Guardant360 testing (81120, 81121, 81173, 81201, 81210, 81235, 81270, 81272, 81275, 81276, 81293, 81299, 81309, 81310, 81311, 81314, 81318, 81321, 81400, 81401, 81402, 81403, 81404, 81405, 81406) provided on January 1, 2021.