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

We decided that the Plan does not have to pay forthe emergency room services rendered on January 30, 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 six further units of code 99283 are 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 99283 is Level 3 emergency department visit for evaluation and management of patient with problem of moderate severity, including expanded problem-focused history and physical examination, and medical decision-making of moderate complexity.We find that CPT code 99283 is not supported in the medical record. Specifically, the records support the billing of one unit of code 99283 only. 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 emergency room services rendered on January 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvean interspinous and/or interlaminar device for the enrollee.You asked the Planto pre-approvethe device. You say that this is medically necessary.The Plandenied your request. The Plansaysmedical studies have not proven that this device is helpful for treatment of the health problem.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed to show safety and efficacy.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 device have not been met.Therefore, we decided that the Plandoes not haveto pre-approvean interspinous and/or interlaminar device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network orthopedic spine surgeon.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be provided with doctors in the plan's network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network orthopedic spine surgeon.
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 January 2, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says there is no network deficiency for these 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 nota 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 forthe medical services provided to the enrollee by an out-of-network provider on January 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a computerized ophthalmic imaging provided on February 15, 2020.
You asked the Plan to pay for the computerized ophthalmic imaging. The Plan denied your request. The Plan says you must 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 Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for a computerized ophthalmic imaging provided on February 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay forthe GeneSight test provided to the enrollee on December 19, 2019.You asked the Planto pay forthe test. You say that this should be paid for.The Plandenied your request. The Plansaysthere was no authorization for this test.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 rendering 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 Plandoes not haveto pay forthe GeneSight test provided to the enrollee on December 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the ophthalmology services, medical examination and evaluation (92012) provided on February 28, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the ophthalmology services. You say that you received the EOB indicating that the claim has been denied and you would like to appeal., The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to 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 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 ophthalmology services, medical examination and evaluation (92012) provided on February 28, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible and coinsurance for the inpatient hospital care provided to the enrollee from January 9, 2019 to January 22, 2019.
You asked the Plan to waive the deductible and coinsurance for the inpatient hospital care. The Plan denied your request. The Plan says that the services received were subject to the deductible and cost sharing.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $245 deductible and 10% coinsurance for inpatient hospital care. The item or service you asked the Plan to waive the deductible and coinsurance for falls within the benefit category inpatient hospital care. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $245 deductible and 10% coinsurance for inpatient hospital care. The deductible is a contractual obligation that had not been met at the time the inpatient hospital care was received on January 9, 2019 to January 22, 2019. The enrollee has been asked to pay a 10% coinsurance for the inpatient hospital care. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. Therefore, we decided that the Plan does not have to waive the deductible and coinsurance for the inpatient hospital care provided to the enrollee from January 9, 2019 to January 22, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says you do not meet criteria for coverage of an inpatient rehabilitation facility admission.
The Plan must follow Medicare rules. The rules say that an IRF admission is covered only when it is medically reasonable and necessary as described above. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of your nursing, medical, and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The records do not indicate that you have significant, or complex medical/nursing issues that could not be addressed at a skilled nursing level of care. Ongoing pain medication and other medication management, skin care, and daily therapy can be provided at a skilled nursing facility. The intensity of an inpatient rehabilitation facility admission is not warranted. A less intensive, longer duration of therapy is appropriate. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe inpatient hospital stay provided from August 13, 2019 to August 17, 2019.You asked the Plan to waive the copayment forthe inpatient stay. You say that the claim was filed as out-of-network. You say the claim needs to be refiled and corrected. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $300 copayment per day for days 1-5 at for Medicare-covered in-network inpatient hospital stays. You have been asked to pay a $300 copayment for each day the inpatient stay. ($300 x 4 days = $1,200). The inpatient stay falls within the "Inpatient hospital care" benefit category. The record shows this claim was processed at the in-network benefit level.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 inpatient hospital stay provided from August 13, 2019 to August 17, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on December 19, 2019.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says that the health plan requires utilization of network providers when possible and available, and requires authorization for certain services. No necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the laboratory services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for laboratory services provided on December 19, 2019.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay forthe surgical boot provided on March 4, 2020.You asked the Plan to pay forthe surgical boot. You say that your podiatrist put you inthe boot.The Plan denied your request. The Plan says that you do not meet criteria for orthotics.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 surgical boot by a contractprovider. The file does not show that the Plan provided notice that the surgical boot would not be covered. Under Medicare rules, this means the surgical boot is considered approved by the Plan.Therefore, we decided that the Plan has to pay forthe surgical boot provided on March 4, 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography of the heart with quantitative evaluation of coronary calcium (CPT 75571).
You asked the Plan to pre-approve the computed tomography services with quantitative evaluation of coronary calcium. You say that the enrollee needs the requested test due to having artery disease. The Plan denied your request. The Plan says the service being requested is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare rules also say that quantitative calcium scoring (CPT code 75571) is not a covered service and will be denied as not medically necessary. Therefore, we decided that the Plan does not have to pre-approve computed tomography of the heart with quantitative evaluation of coronary calcium (CPT 75571).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services.You asked the Plan to pay forthe ambulance services. You say that on the date of service you fell while taking a shower. You say that you could not get back up so you called the fire department and an ambulance was sent. You stated that when the responders arrived they evaluated you and examined your injuries due to your history of falls. You say that at the conclusion of their exam, they determined that hospitalization was not needed and recommended that you follow up with your doctor instead. You asked the Plan to reconsider their denial based on your history of hospitalizations and medical issues. You say that the ambulance services should be considered to be a preventative measure.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on December 23, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the breast tomosynthesis provided on December 6, 2019.
You asked the Plan to pay for the provided service. The Plan denied your request. The Plan says CPT code 77062 is an invalid procedure code for the 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, the CPT Code Manual definition of code 77062 is diagnostic digital breast tomosynthesis; bilateral. We find that CPT code 77062 is not valid for Medicare purposes. Medicare uses another code for the reporting of, and payment for, these services. 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 breast tomosynthesis provided on December 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder orthosis provided on January 21, 2020 by an out of network provider.
You asked the Plan to pay for the shoulder orthosis (L3670). You say that the orthosis was medically necessary. The Plan denied your request. The Plan says you did not request 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 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 shoulder orthosis provided on January 21, 2020 by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay formassage therapy services (A9270) provided January 1, 2019 to November 20, 2019.You asked the Plan to pay formassage therapy services. You say that you recently submitted a health fitness reimbursement form for 2019 for monthly therapeutic massages provided by a licensed massage therapist. You are appealing the decision.The Plan denied your request. The Plan says massage therapy is not a covered benefit under the wellness allowance benefit.The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers gym benefits only The plan reimburses you up to $150 each calendar year towards your cost for membership in a qualified health club or fitness facility, covered instructional fitness classes, participation in wellness programs such as Matter of Balance, Chronic Disease self-management, diabetes workshop, Healthy Eating for Successful Living, Healthy IDEAS, Powerful Tools for Caregivers, Arthritis Foundation Exercise, Enhance Wellness, Fit For Your Life, AAA Senior Driving, memory fitness activities, acupuncture, and/or covered nutritional counseling sessions with a licensed nutritional counselor or registered dietician. You pay all charges over $150 per calendar year.The Plan's rules for coverage of gym benefits have not been met because massage therapy is not a covered benefit under the wellness allowance benefit..Therefore, we decided that the Plan does not have to pay formassage therapy services (A9270) provided January 1, 2019 to November 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive oral exam (D0150) and complete series x-rays (D0210) and surgical extraction to teeth 3, 15, 21, 22, 29 provided January 22, 2020 to January 29, 2020.
You asked the Plan to pay for the dental services. You say that this dental office is listed as a participating provider. The Plan denied your request. The Plan says enrollee's must receive their dental services from an in-network provider.
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 health plan contract on page 42 specifically says you must receive your care from a network provider. 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 comprehensive oral exam (D0150) and complete series x-rays (D0210) and surgical extraction to teeth 3, 15, 21, 22, 29 provided January 22, 2020 to January 29, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay forthe transportation of a portable x-ray (R0070) provided on January 14, 2020.You asked the Plan to pay forthe transportation of a portable x-ray.. You say that you would like reconsideration because this service was medically necessary.The Plan denied your request. The Plan says that CPT code R0070 has a professional/technical component indicator of 3 and the procedure code is inconsistent with the place of service.The Plan must follow Medicare rules. Medicare rules say that for a Medicare Part B patient, payment would be made under Part B for the share of the transportation fee attributable to that patient. The rules also say that ifthe 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. Based on this information, we decided that Medicare rules for coverage of the transportation of a portable x-ray. have been met. Specifically, the provider transported x-ray equipment to a Medicare Part B patient. The Plan has confirmed that the patient was not in a Part A SNF stay. This means that payment should be made under Part B for the share of the transportation fee attributable to the patient. There is no evidence that more than one patient was serviced. The billing of R0070 with no modifier is supported. Lastly, the POS of 31 is correct, as the facility serviced is a Skilled Nursing Facility (taxonomy code 314000000X).Therefore, we decided that the Plan has to pay forthe transportation of a portable x-ray (R0070) provided on January 14, 2020.