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

We decided that the Plan does not have to waive the copayment for urgent care services provided by a participating provider on September 6, 2020.You asked the Plan to waive the copayment for urgent care services. You say that your issue was not resolved so you feel like you should not have to pay for this. The Plan denied your request. The Plan says the correct copayment has been applied.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $60 copayment for urgently needed services. You have been asked to pay a $60 copayment for urgent care services. Since urgent careservices were provided, the correct copayment has been applied. Urgent care services fall within the urgently needed 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 urgent care services provided by a participating provider on September 6, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home infusion therapy rendered from February 6, 2020 to July 2, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies.We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe home infusion therapy rendered from February 6, 2020 to July 2, 2020.Benefits for these servicesmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 13, 2020 to 
October 7, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says prior 
authorization is required, but 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 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 medical services provided on January 13, 2020 to October 7, 2020 by an out 
of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on September 28, 2020.You asked the Plan to pay forthe services. The Plandenied your request. The Plan says the services were not 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 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 forthe medical services provided to the enrollee by an out-of-network provider on September 28, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 20, 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 screening tests 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, magnesium testing, 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 July 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services (D6980) provided to the enrollee on April 24, 
2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for dental 
services (D6980) provided to the enrollee on April 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on January 20, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says services rendered 
by non-participating providers 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 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 medical services provided on January 20, 2020 by an out of network (OON) 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe gingivectomy or gingivoplasty (D4212 x 2) provided on September 14, 2020.You asked the Plan to pay forthe dental service. You say that the dentist got approval from the plan for all of the services that would be part of your procedure. You say that you had the procedure done for this reason. You say that you were lied to about what services were covered. You also say that you went for a second opinion.The Plan denied your request. The Plan says gingivectomy or gingivoplasty is 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 requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe gingivectomy or gingivoplasty (D4212 x 2) provided on September 14, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lead wires provided to the enrollee.

You asked the Plan to pay for the lead wires. You say that these should be covered by the Plan.The Plan denied your request. The Plan says that records supporting the medical necessity of the additional lead wires were not submitted.

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 does not contain relevant medical records which support medical necessity for the supplies provided in this case. The file indicates the enrollee has previously received lead wires within 12 months. The record shows that the Plan made several attempts to obtain the necessary documentation without success.Therefore, we decided that the Plan does not have to pay for the lead wires provided to the enrollee.
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 is medically stable and ready to discharge to a LTACH. You also say that the enrollee is expected to require at least another 25 day length of stay in an acute care facility for optimal recovery. The Plan denied your request. The Plan says criteria for admission to the LTACH have not been met.
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 reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee appears to be improving and requires only short term additional acute care services which can be safely completed at the current facility. The enrollee does not require services at the LTACH that are not already available at the current facility. Our reviewer found that there are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Our physician reviewer also found that transfer to a lower level of care may be considered when appropriate and when treatment had completed. 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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient hospital services provided from January 11, 2020, to 
January 14, 2020. 
 
You asked the Plan to pay for the inpatient hospital services. You say that you should not be responsible for 
these charges. The Plan denied your request. The Plan says that that these services were medically necessary. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the inpatient hospital services by a contract provider. The file does not show that the 
Plan provided notice that the inpatient hospital services would not be covered. Under Medicare rules, this 
means the inpatient hospital services is considered approved by the Plan. Therefore, we decided that the Plan 
has to pay for the inpatient hospital services provided from January 11, 2020, to January 14, 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 February 14, 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. The Plan says that there is no 
referring 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 specialist services provided on February 14, 2020, 
by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe imaging services rendered on June 1, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure codes 77062 and 77066 are not covered.The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes.In this case, the MUE for CPT code 77066 is 1. You billed 2 units of this code, exceeding the MUE. Billed procedure code 77062 has a status indicator of I and is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe imaging services rendered on June 1, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on July 27, 2020.You asked the Plan to pay for the laboratory services.The Plan denied your request. The Plan says the enrolleemust receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.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 Plandid 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 July 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from July 8, 
2020, to July 15, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were waiting for 
results and they would not release you until they came in. The Plan denied your request. The Plan says the 
claims were processed correctly and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 
copayment for days 1-6 for inpatient hospital care.  
 
The medical records show that you had an inpatient hospital stay from July 8, 2020, to July 15, 2020. 
Therefore, you are responsible to pay a $275 copayment for days 1-6 (July 8, 2020, to July 13, 2020). $275 
(copayment) x 6 (inpatient days) = $1,650.  
 
You have been asked to pay the total copayment amount of $1,650 for an inpatient hospital stay. An inpatient 
hospital stay falls within the inpatient hospital 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 inpatient hospital stay from July 8, 2020, to July 15, 2020.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pay for the extremity study (93971) provided on September 9, 2020.

You asked the Plan to pay for the extremity study. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that CPT code 93971 is a column II code to CPT code 93970.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The rules also say that MACs subject all line items for the same beneficiary, same NPI, and same date of service to NCCI edits. 

We find that CPT code 93971 is supported in the record. Specifically, the record indicates that CPT codes 93971 and 93970 were rendered and billed by different providers. NCCI edits do not apply to claims with different NPIs. Based on this information, we decided that Medicare rules for coverage of the extremity study have been met. Therefore, we decided that the Plan has to pay for the extremity study (93971) provided on September 9, 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 the medical services provided on September 8, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the outpatient services. You say that you would like reconsideration because 
there was a miscommunication regarding the member's insurance. The Plan denied your request. The Plan says 
the services rendered were not urgent or emergent and 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 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 medical services provided on September 8, 
2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe psychiatric diagnosis interview examination (90792) provided July 10, 2019.You asked the Plan to pay forthe psychiatric diagnosis interview examination. You say that you did not receive proper notice of this enrollee's benefit determination, hence, the untimely submission of the claim.The Plan denied your request. The Plan says this claim was submitted after timely filing limitations.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 psychiatric diagnosis interview examination was not filed until August 31, 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 psychiatric diagnosis interview examination (90792) provided July 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on April 23, 2020. 
 
You asked the Plan to pay for the services provided. You say that the appropriate modifiers have been applied. 
The Plan denied your request. The Plan says the procedure code is inconsistent with the modifier used. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
In this case, the CPT Code Manual definition of code 31500 is intubation, endotracheal, emergency procedure.  
CPT code 31500 was billed with an AA modifier. This modifier is for anesthesia services performed personally 
by an anesthesiologist. We find that the billed modifier was not billed in association with an anesthesia service. 
Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the medical services provided on April 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay fora topical application of fluoride (D1208) performed on September 30, 2020.You asked the Plan to pay fora topical application of fluoride. You say that you cannot afford this bill as you have no money coming in.The Plan denied your request. The Plan says rules for payment have not been met.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 itemor serviceis not among those covered under thisbenefit.Therefore, we decided that the Plan does not have to pay fora topical application of fluoride (D1208) performed on September 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation, bitewings, prophylaxis, and 
preventive procedure provided on October 12, 2020 by an OON provider. 
 
You asked the Plan to pay for the periodic oral evaluation, bitewings, prophylaxis, and preventive procedure. 
The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also 
says that OON providers are allowed to balance bill enrollees for the difference between the provider's billed 
amount and the Plan's paid amount. 
 
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, you are responsible for the difference 
between the billed amount and allowed amount. Therefore, we decided that the Plan does not have to pay for 
the periodic oral evaluation, bitewings, prophylaxis, and preventive procedure provided on October 12, 2020 
by an OON provider.