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

We decided that the Plan does not have to pay for the medical services provided on October 24, 2019 by an out of network (OON) provider. You asked the Plan to pay for the OON services. You say that the providers office informed you they accepted your insurance. The Plan denied your request. The Plan says you did not receive authorization prior to receiving services.
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 OON services. Therefore, we decided that the Plan does not have to pay for the medical services provided on October 24, 2019 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 observation care (CPT 99225) provided on September 15, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not payable for this provider. The Plan must follow Medicare rules. Medicare rules say that payment for a subsequent observation care code is for all the care rendered by the treating physician on the day(s) other than the initial or discharge date. All other physicians who furnish consultations or additional evaluations or services while the patient is receiving hospital outpatient observation services must bill the appropriate outpatient service codes. We looked at the file and Medicare rules. The records show that the services in question were rendered by a provider who was not the ordering provider. Only the ordering provider can bill subsequent observation care codes. 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 observation care (CPT 99225) provided on September 15, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance transport provided on December 6, 2019.You asked the Plan to waive the copayment forthe ambulance transport. You say that you were told you had no copay.The Plan denied your request. The Plan says that you are financially liable for any cost sharing applied, including deductibles, coinsurance and copayments.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 each separate Medicare-covered ambulance service. You have been asked to pay a $225 copayment for the ambulance transport. The ambulance transport falls within the separate Medicare-covered ambulance service 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 forthe ambulance transport provided on December 6, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray provided on July 23, 2019.
You asked the Plan to pay for the limited oral evaluation and intraoral periapical x-ray. The Plan denied your request. The Plan says this provider has chosen not to be part of Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider who has chosen not to be a part of Medicare. This provider has opted out of the Medicare program. The file shows that this provider entered into a private contract with you regarding payment. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray provided on July 23, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

.We decided that the Plan has to pay for the acute inpatient hospital care provided from September 25, 2019 through October 3, 2019. You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says that the stay is not medically necessary. The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review indicates that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from September 25, 2019 through October 3, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and prophylaxis provided on July 25, 2019. You asked the Plan to pay for the dental services. You say that you verified the enrollee's current benefits on the Plan website. You say that you have had claims paid in the past. You also say that you were advised that the office used to be in network with Medicare. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation. The provider in this case has opted out of the Medicare program. The file shows that the provider entered into a private contract with you regarding payment. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and prophylaxis provided on July 25, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the mammography services (77063, 77067) provided on November 22, 2019.
You asked the Plan to pay for the mammography services. You say that the services were medically necessary. The Plan denied your request. The Plan says there were in-network providers who could render the service. The service was not emergent or preauthorized. 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 mammography services (77063, 77067) provided on November 22, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on September 5, 2019. You asked the Plan to waive the copayment for the ambulance transport. The Plan denied your request. The Plan says that the copayment 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 $225 copayment for each one-way Medicare-covered ground trip. You have been asked to pay a $225 copayment for the ambulance transport. The ambulance transport falls within the one-way Medicare-covered ground trip 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 transport provided on September 5, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve varicose vein treatment (36475 and 37766). You asked the Plan to pre-approve varicose vein treatment. You say that this should be covered. The Plan denied your request. The Plan says this is not medically necessary. The Plan follows Medicare rules. Medicare rules say that varicose vein treatment is covered only when medically necessary per the above listed criteria. 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 varicose vein treatment. Our reviewer says that the requested treatment is not medically necessary. Our physician reviewer found there is clear documentation that the patient has symptoms consistent with claudication. There is documentation that the pulse examination is abnormal. There is documentation of significant arterial disease in the lower extremities bilaterally. Therefore, the patient's lifestyle limiting leg complaints may not be attributable to her varicose veins. The medical appropriateness of greater saphenous vein ablation is not supported by the documentation. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of varicose vein treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve varicose vein treatment (36475 and 37766).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided to the enrollee on October 17, 2019. You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening testing is not a Medicare benefit for the diagnoses listed. The Plan must follow Medicare rules. Medicare rules say that providers must produce medical records showing
why the lab services provided were medically necessary. We find that the services are not supported in the medical record. In this case, there were insufficient records provided to show the results of this testing would be used to determine a specific diagnosis or treatment strategy. This testing is not covered for screening purposes. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided to the enrollee on October 17, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for outpatient mental health visits (90833, 99213) provided from  March 11, 2019 to June 3, 2019. You asked the Plan to waive the coinsurance for the outpatient mental health services. You say that the coinsurance should be waived. The Plan denied your request. The Plan says the correct cost sharing was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 40% coinsurance for Outpatient mental health care. You have been asked to pay a 40% coinsurance for the outpatient mental health services. The outpatient mental health services fall within the Outpatient mental health 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 coinsurance for outpatient mental health visits (90833, 99213) provided from March 11, 2019 to June 3, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to the enrollee on April 3, 2019.
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 not billed correctly. 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 an independent laboratory; 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 to the enrollee on April 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure codes L8691 and L8694 provided on July 25, 2019.
You asked the Plan to pay for procedure codes L8691 and L8694. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not support a valid physician's order.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the physician order documentation for the items at issue in this appeal. The record does not contain a valid physician order for the supplies provided in this case. The date the physician signed the written order is almost six months after the date of delivery. Therefore, we decided that the Plan does not have to pay for procedure codes L8691 and L8694 provided on July 25, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. 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 must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above 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 SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found this enrollee does not require skilled nursing
services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and
effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not have a
tracheostomy tube, enteral feedings, complex wound care or other SNF level skilled nursing need. This
enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and
judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable
treatment. The enrollee does not require these skilled nursing or skilled therapy services (or a combination of
these services) on a "daily basis". As a practical matter this enrollee does not require the necessary services on
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 SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the filling (D2393) on tooth #31 provided on November 21, 2019.
You asked the Plan to pay for the dental service. You say that you forgot to add the dental rider to your plan. The Plan denied your request. The Plan says fillings are not listed as a covered service. 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 filling is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the filling (D2393) on tooth #31 provided on November 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-ofnetwork
provider on September 18, 2019. You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are 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 the enrollee by an out-of-network provider on September 18, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the outpatient surgery services you received on February 26, 2019. You asked the Plan to waive the copay for the services provided. You say that you received two copays for one service. The Plan denied your request. The Plan says the copay was applied correctly for services the services provided. 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 $375 copay for outpatient surgery. You have been asked to pay a $375 copay for the services provided. The services fall within the outpatient surgery 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 copay for the outpatient surgery services you received on February 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on September 26, 2018. You asked the Plan to pay for the 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 October 3, 2019. 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 for the services provided on September 26, 2018.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an Emergency Room Visit (80048, 36415, 85025) provided on August 24, 2019. You asked the Plan to waive the copayment for the Emergency Room visit. You say that you received poor care and the copayment should be waived. The Plan denied your request. The Plan says the correct copayment was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copay for Emergency Care. You have been asked to pay a $90 copay for the Emergency Room visit. The 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 (80048, 36415, 85025) provided on August 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network
provider on October 12, 2018. 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 the enrollee by an out-of-network provider on October 12, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a duplex scan provided on October 17, 2019 by an out of network (OON) provider. You asked the Plan to pay for a duplex scan. You say that you would like this claim reprocessed and approved
for payment. The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that no prior authorization was 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 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 a duplex scan provided on October 17, 2019 by an out of network (OON) provider.