Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for ambulance transportation services provided on October 8, 2020.
You asked the Plan to pay for the ambulance transportation services. You say that the records provided support that the services in dispute were medically necessary. The Plan denied your request. The Plan says that the enrollee could have been safely transported by another type of motor vehicle, possibly a van transport vehicle.
Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. 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 ambulance transportation services. Our reviewer says that the criteria for coverage have been met. Our physician reviewer found the enrollee had a three-day history of fever, cough, nausea, vomiting, and headache that was not improving. The enrollee had a week prior to symptoms tested negative for COVID-19. In these circumstances, a prudent layperson would believe that without immediate medical attention there would be serious jeopardy to his or her health. An emergency existed. The elements of the coverage criteria are satisfied. 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 ambulance transportation services have been met. Therefore, we decided that the Plan has to pay for ambulance transportation services provided on October 8, 2020.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for specialist services provided on September 16, 2020 by an out of network (OON) provider.
You asked the Plan to pay for specialist services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained.
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 specialist services provided on September 16, 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 domiciliary or rest home visit (99335) provided on December 24, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the domiciliary or rest home visit. You say that you request reconsideration of the claim to reprocess for payment. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 domiciliary or rest home visit (99335) provided on December 24, 2020 by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for mental health office visits (99214) provided June 2, 2020, to December 17, 2020.
You asked the Plan to waive the copayment for mental health office visits. You say that you believe that the Plan had waived copayments during the COVID-19 waiver. The Plan denied your request. The Plan says the copayments have processed correctly in this case.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for outpatient mental health care.
You have been asked to pay a $40 copayment for each mental health office visits you received. These services fall within the outpatient mental health care benefit category. Although the Plan did have a waiver in place during the dates in question, this waiver is only for contracted providers. The provider in this case is an OON provider and not subject to the waiver. 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 mental health office visits (99214) provided June 2, 2020, to December 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial inpatient physician consultation billed for date of service November 5, 2018, billed with code 99222.
You asked the Plan to pay for the inpatient physician consultation. You say that you were told that this was taken care of, but this bill continues to appear on your credit report. You wish for the Plan to pay this charge. The Plan denied your request. The Plan says this charge cannot be paid because the provider billed with an inpatient procedure code and POS code, and you were an outpatient for this hospital stay. The provider can only be paid if they submit a corrected claim.
The Plan must follow Medicare rules. Medicare rules say that when an enrollee is a registered outpatient, providers must report the outpatient POS code.
We looked at the file and Medicare rules. You received outpatient hospital services from November 3, 2018, through November 6, 2018. This provider incorrectly reported an inpatient POS code. Neither the Plan nor you are obligated to pay for these services which were billed incorrectly. Based on this information, we decided that Medicare rules for coverage of the inpatient physician consultation have not been met. Therefore, we decided that the Plan does not have to pay for the initial inpatient physician consultation billed for date of service November 5, 2018, billed with code 99222.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on March 31, 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 claim was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on March 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a telehealth visit (99214) provided on January 5, 2021.
You asked the Plan to pay for a telehealth visit. You say that POS 12 is correct for Medicaid home health claims. The Plan denied your request. The Plan says this was not billed with the correct POS.
The Plan must follow Medicare rules. Medicare rules say that providers should submit telehealth services claims using Place of Service (POS) 02-Telehealth to indicate they furnished the billed service as a professional telehealth service from a distant site.
We looked at the file and Medicare rules. The telehealth service at issue was not billed with POS 02. Based on this information, we decided that Medicare rules for coverage of a telehealth visit have not been met. Therefore, we decided that the Plan does not have to pay for a telehealth visit (99214) provided on January 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services provided on December 16, 2020.
You asked the Plan to pay for the chiropractic services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. The rules say for Medicare purposes, a chiropractor must place an AT modifier on a claim when providing active/corrective treatment to treat acute or chronic subluxation. We looked at the file and Medicare rules. The file shows that the provider did not bill the claims with the
Medicare required AT modifier. Therefore, we decided that the Plan does not have to pay for the chiropractic services provided on December 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital outpatient clinic visit for assessment and management of a patient (G0463) provided on December 8, 2020, by an out of network (OON) provider.
You asked the Plan to pay for the hospital outpatient clinic visit for assessment and management of a patient. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON provider.
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 hospital outpatient clinic visit for assessment and management of a patient (G0463) provided on December 8, 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 oral exam (D0120), the periapical x-ray (d0220), the bitewing x-rays (D0274), and prophylaxis (D1110) provided on January 11, 2021.
You asked the Plan to pay for the dental services. You say that you were not advised that the provider was non-participating with the plan. You also say that you added dental coverage to your insurance to ensure that you had coverage. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan says that this provider is not permitted to submit claims to Medicare or Medicare Advantage plans. The Plan also says that you did not contact the Plan prior to the date of service to verify benefits and provider eligibility.
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 provider in this case is not in network with the Plan. The Evidence of Coverage clearly states that Services received from an out of network dentist are not covered benefits. Therefore, we decided that the Plan does not have to pay for the oral exam (D0120), the periapical x-ray (d0220), the bitewing x-rays (D0274), and prophylaxis (D1110) provided on January 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on January 21, 2021 by a non-participating provider.
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 were rendered by a non-participating 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 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 physician services provided on January 21, 2021 by a non-participating provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuation of skilled nursing facility (SNF) services provided on December 1 - December 25, 2020.
You asked the Plan to pre-approve the SNF services. You say that the records provided support that the SNF services in dispute were medically necessary. The Plan denied your request. The Plan says a continuation of SNF services was not medically necessary. The Plan says that continued assistance with routine daily activities could have been safely provided at the custodial level of care, as it had been before.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral and inhaled medications. The enrollee had stable vital signs and was monitored for COVID-19 symptoms. The enrollee used CPAP. The enrollee received a course of occupational therapy in the SNF, prior to the dates in question. As of the dates of service in dispute, the enrollee had no identifiable skilled nursing service needs or skilled therapy service needs. The enrollee did not meet the severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuation of skilled nursing facility (SNF) services provided on December 1 - December 25, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic procedure (97110) provided on January 18, 2020.
You asked the Plan to pay for the therapeutic procedure. 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.
We find that CPT code 97110 is not supported in the record. Specifically, the documentation does not support any services being rendered by the billing provider on this date of service. Based on this information, we decided that Medicare rules for coverage of the therapeutic procedure have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic procedure (97110) provided on January 18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the infectious agent detection panel by nucleic acid with 3-5 targets provided on January 12, 2021 billed with code 87631.
You asked the Plan to pay for the genetic testing. You say that this is medically necessary and payable as billed. The Plan denied your request. The Plan says all codes aside from 87631 were paid. This code is 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 87631 is infectious agent detection by nucleic acid (DNA or RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza virus, respiratory syncytial virus, rhinovirus), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 3-5 targets.
We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the genetic testing. Our reviewer says that the testing billed is not supported in the record. Our coding reviewer found the medical records provided do not include sufficient documentation to validate that service 87631 was 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 genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for the infectious agent detection panel by nucleic acid with 3-5 targets provided on January 12, 2021 billed with code 87631.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoperative neurophysiologic monitoring services (95861, 95868, 95927, 95938) provided on August 28, 2020.
You asked the Plan to pay for intraoperative neurophysiologic monitoring. You say that this was billed with the correct POS because the hospital did not provide the equipment or services at issue. The Plan denied your request. The Plan says this was not billed with the correct POS.
The Plan must follow Medicare rules. Medicare rules say that if a mobile unit is serving an entity for which another POS code already exists, providers should use the POS code for that entity.
We looked at the file and Medicare rules. The services at issue were billed with the Mobile Unit POS code 15, but the records show that they were provided to serve an entity for which another POS code exists. Based on this information, we decided that Medicare rules for coverage of intraoperative neurophysiologic monitoring have not been met. Therefore, we decided that the Plan does not have to pay for intraoperative neurophysiologic monitoring services (95861, 95868, 95927, 95938) provided on August 28, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram (93010) provided on July 21, 2020.
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 CPT code 93010 is a column II code to a column I code which was billed by the same billing provider on the same date of service.
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 the electrocardiogram has a bundled relationship with code 93460 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 the electrocardiogram (93010) provided on July 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on June 17, 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 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 laboratory services rendered on June 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate for the limited oral evaluation (D0140), and the scaling and root planing (D4341) for the lower left and lower right quadrants provided on March 2, 2021.
You asked the Plan to pay the in network rate for the limited oral evaluation and scaling and root planing. You say that you were under the impression that you had proper dental coverage. You say that you made sure you had periodontal cleanings on your coverage last year. You say that you received an email from the plan stating "if you would like the same coverage as last year, you do not need to do anything." You also say that you are now stuck with a large bill. The Plan denied your request. The Plan says that limited oral evaluation is not listed as a covered service. The Plan says that scaling and root planing are not listed as covered services either.
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 the in network rate for the limited oral evaluation (D0140), and the scaling and root planing (D4341) for the lower left and lower right quadrants provided on March 2, 2021.
Your complaint about being misinformed by the plan 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.