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

 
We decided that the Plan does not have to pay for the medical services provided on February 18, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that these services were medically necessary and 
you were unable to get prior authorization. The Plan denied your request. The Plan says unauthorized, non-plan 
care is not covered. 
 
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 was not a network provider with the Plan on the date of service. 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 
February 18, 2020 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from January 24, 2020 
to January 31, 2020. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's 
condition no longer required daily skilled services at an inpatient SNF level of care. 
 
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 pay for the skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily 
skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from January 24, 2020 to January 31, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF stay provided from March 17, 2020 
to March 20, 2020. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that the stay should be fully covered. 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 $0 
copayment each day for days 1-20 and a $160 copayment for days 21-62, per benefit period, for SNF care.  
 
You had a SNF stay from March 17, 2020 to March 20, 2020. The record shows that you had a previous SNF 
stay within the same benefit period for a total of 20 days. Therefore, you are responsible to pay a $160 
copayment for days 21-23 (March 17, 2020 to March 19, 2020). $160 (copayment) x 3 (SNF days) = $480. 
 
You have been asked to pay the total copayment amount of $480 for a SNF stay. A SNF stay falls within the 
SNF 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 a SNF stay provided from 
March 17, 2020 to March 20, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 80050) provided on January 30, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "N" under the Physician Fee 
Schedule indicates that the code in question is non-covered. 
 
We looked at the file and Medicare rules. CPT code 80050 is assigned a status indicator of "N" under the 
Physician Fee Schedule. This means that this code is non-covered and payment cannot be made for the service 
in question. Based on this information, we decided that Medicare rules for coverage of the services have not 
been met. Therefore, we decided that the Plan does not have to pay for the services (CPT 80050) provided on 
January 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on February 25, 2020. 
 
You asked the Plan to pay for lab tests. You say that you are appealing with records. The Plan denied your 
request. The Plan says the denial of payment for these services is correct, because the documentation submitted 
does not support the Place of Service (POS) code billed on this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place 
where the sample was taken is reported as the Place of Service (POS).  
 
We looked at the file and Medicare rules. The documentation submitted shows that the sample for this testing 
was taken in an office setting, therefore; the Place of Service (POS) code 81 ? indicating an independent 
laboratory setting ? is not appropriate for this claim. Based on this information, we decided that Medicare rules 
for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for 
laboratory testing provided on February 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the three extractions, first 15 minutes of deep 
sedation/general anesthesia, additional 15 minute increment of deep sedation/general anesthesia, and adjunctive 
procedure provided on January 30, 2020. 
 
You asked the Plan to pay more for the dental procedures. You say that these services needed to be provided 
due to an infection. You also say that you are on a fixed income. The Plan denied your request. The Plan says 
you are responsible for the remaining $1,276 because your $300 allowable has been exhausted. 
 
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 Plan will reimburse you for non-
Medicare covered dental services up to a maximum of $300 annually combined with non-Medicare covered 
vision care. The record shows that you met the annual maximum benefit while processing this claim for the 
January 30, 2020 date of service, and your annual maximum benefit has been exhausted. Therefore, we decided 
that the Plan does not have to pay more for the three extractions, first 15 minutes of deep sedation/general 
anesthesia, additional 15 minute increment of deep sedation/general anesthesia, and adjunctive procedure 
provided on January 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on May 14, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require 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 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 May 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the porcelain crown and provisional crown (D2799) for tooth 
#'s 12 and 13 provided on February 18, 2020. 
 
You asked the Plan to pay for the porcelain crown and provisional crown for tooth #'s 12 and 13. You say that 
there was no information regarding dental codes and how your benefits work. The Plan denied your request. 
The Plan says the services are not covered benefits. 
 
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 the 
porcelain crown and provisional crown (D2799) for tooth #'s 12 and 13 provided on February 18, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 testing provided on December 11, 2019. 
 
You asked the Plan to pay for genetic testing. You say that the enrollee's treating physician ordered this testing 
to determine if there was a more effective therapy to treat the enrollee's condition. The Plan denied your 
request. The Plan says the denial of payment for this testing is correct, because this testing was not billed with 
the appropriate coding. 
 
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be billed with 
procedure code 81479 for date of service December 11, 2019.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for 
Guardant360 testing provided on December 11, 2019.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from March 3, 2020 to 
March 8, 2020 and from March 12, 2020 to March 17, 2020. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's 
condition no longer required daily skilled services at an inpatient SNF level of care. 
 
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 pay for the skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse.  
The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and 
judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled 
therapy on an inpatient basis in a SNF 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 skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from March 3, 2020 to March 8, 2020 and 
from March 12, 2020 to March 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient mental health care provided to the enrollee from 
August 16, 2019 through September 27, 2019 by an out-of-network provider. 
 
You asked the Plan to pay for inpatient mental health care. You say that the stay was medically necessary. The 
Plan denied your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient mental health care. Our physician 
reviewer found based upon review the records provided it was not expected this enrollee would improve in a 
reasonable period of time as the enrollee did not have dangerousness to self or others, auditory or visual 
hallucinations, delusions and was not showing any behavioral issues. It did not appear medically necessary and 
reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care 
as the enrollee did not have dangerousness to self or others, perceptual disturbance including auditory or visual 
hallucinations.  
 
The health plans denial of inpatient psychiatric services appears appropriate. This enrollee did not appear to 
require inpatient mental health treatment as he was not a danger to himself or others and was cooperative and 
compliant. It did not appear that active treatment was taking place. It did not appear that the services were 
reasonably expected to improve the patients condition or for the purpose of diagnosis. This patient was treated 
under an individualized treatment plan found in the record. It did appear that the records were supervised and 
evaluated by a physician. Based upon review the records provided, for the admission of this patient does not 
meet the criteria for acute inpatient mental health treatment as this patient was not shown to be a danger to 
themselves or others but was without agitation or aggression without perceptual disturbance including auditory, 
visual hallucinations or delusions. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the 
Plan does not have to pay for inpatient mental health care provided to the enrollee from August 16, 2019 
through September 27, 2019 by an out-of-network provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transportation services (A0427 and A0425) provided on 
December 25, 2019. 
 
You asked the Plan to pay for the transportation services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says this service was not medically necessary. 
 
Medicare pays for ambulance services only when an emergency exists or when other means of transport would 
endanger the patients 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 transportation services. Our reviewer 
says that the ambulance transportation at issue in this case was not medically reasonable or necessary. Our 
physician reviewer found the member was hemodynamically stable with stable vital signs. The member could 
have been safely transported by another type of motor vehicle, possibly a van transport vehicle. 
 
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 transportation services have not been met. Therefore, we decided that the 
Plan does not have to pay for transportation services (A0427 and A0425) provided on December 25, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 81225, 81226, 81227,81230, 
81231, 81240, 81241, 81328, 81335, 81355, 81232, 81283, and 81408 provided on February 6, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 codes 81225, 81226, 81227,81230, 81231, 81240, 81241, 81328, 81335, 81355, 81232, 
81283, and 81408 are not supported in the medical record. Specifically, the documentation did not include 
laboratory results from the billing provider for the billed date of service. Based on this information, we decided 
that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory services coded 81225, 81226, 81227,81230, 81231, 81240, 81241, 
81328, 81335, 81355, 81232, 81283, and 81408 provided on February 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery and coinsurance for 
an injection provided by a participating provider on January 30, 2020. 
 
You asked the Plan to waive the copayment and coinsurance for an outpatient surgery and an injection. You 
say that you should only have a $95 copayment. The Plan denied your request. The Plan says the correct 
copayment and coinsurance 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 $95 
copayment and a 20% coinsurance for outpatient surgery/in-network and Medicare Part B prescription 
drugs/in-network.  
 
You have been asked to pay a $95 copayment for an outpatient surgery and a 20% coinsurance of the allowed 
amount for an injection. The allowed amount is $166.25. The amount you are being asked to pay for an 
injection is $33.25 ($166.25 x 20% = $33.25). The total amount you are being asked to pay is $128.25 ($95 + 
$33.25 = $128.25). An outpatient surgery falls within the outpatient surgery/in-network benefit category and an 
injection falls within the Medicare Part B prescription drugs/in-network 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 and coinsurance for an outpatient surgery and an injection provided by a 
participating provider on January 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for orthoses (L1851, L2397) provided April 13, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the items were medically necessary. The Plan denied 
your request. The Plan says rules for telehealth services were not met. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. There is no record showing an established relationship between the physician and 
patient. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. 
Therefore, we decided that the Plan does not have to pay for orthoses (L1851, L2397) provided April 13, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on March 18, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that the doctor should not be penalized for the 
hospital's failure to get authorization. The Plan denied your request. The Plan says unauthorized, non-plan care 
is not covered. 
 
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. 
 
Neither the provider in this case nor the facility where these services were rendered is 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 March 18, 2020 by an out of network (OON) provider.