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

We decided that the Plan does not have to pay for domiciliary or rest home visit (99334) provided on December 12, 2020 by an out of network (OON) provider.
You asked the Plan to pay for domiciliary or rest home visit. You say that the rendering physician, is a Hospitalist physician with the group and depends on the hospital staff to verify eligibility and obtain the proper authorizations from insurance companies. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for domiciliary or rest home visit (99334) provided on December 12, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on August 5, 2020.
You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because Medicare denies coverage when a laboratory test assays two or more genes in a patient in parallel.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a physician order or clear intent to order the specific lab services billed on this claim. Without an order, it has not been shown that this testing was requested for covered purposes. 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 August 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for wound supplies provided by an out-of-network provider on August 27, 2020.
You asked the Plan to pay for the wound supplies. You say that the member is entitled to receive surgical dressings as a covered benefit just as they would under Medicare Part B. You say that the provider has an exclusive wound care supply agreement and is unable to receive the medically necessary treatment because of the denial. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the service was 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 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 wound supplies provided by an out-of-network provider on August 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on December 15, 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 procedure code 87150 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 87150 is culture, typing; identification by nucleic acid (DNA or RNA) probe, amplified probe technique, per culture or isolate, each organism probed.
We find that CPT code 87150 is not supported in the medical record. Specifically, there is no documentation of culture typing by DNA or RNA probe. 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 for the laboratory services rendered on December 15, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the diagnostic imaging provided on February 10, 2021.
You asked the Plan to waive the coinsurance for the diagnostic imaging. You say that your physician never received the images. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for Outpatient Diagnostic Tests.
You have been asked to pay 20% coinsurance for the diagnostic imaging. The diagnostic imaging falls within the Outpatient Diagnostic Tests 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 the diagnostic imaging provided on February 10, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services rendered on January 15, 2021.
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 procedure code 97530 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 97530 is therapeutic activities, direct (one-on-one)
patient contact (use of dynamic activities to improve functional performance), each 15 minutes.
We find that CPT code 97530 is not supported in the medical record. Specifically, the records show that the
services were performed in the home setting and there is a more appropriate code for these services. 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 for the physical therapy services rendered on January 15, 2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital care (99222, 99232) provided on September 25, 2020 and October 11, 2020 through October 12, 2020.
You asked the Plan to pay for these services. You say that you would like payment for these services. The Plan denied your request. The Plan says that the medical records did not support these services.
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. The file does not include medical records to support these services. 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 for the inpatient hospital care (99222, 99232) provided on September 25, 2020 and October 11, 2020 through October 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a speech generating device (E2508).
You asked the Plan to pre-approve a speech generating device. You say that it is medically necessary for the enrollee to receive this device because other individuals do not know American Sign Language. The Plan denied your request. The Plan says the enrollee is able to communicate effectively with American Sign Language.
The Plan must follow Medicare rules. Medicare rules say that in order for a speech generating device to be covered your needs must not be able to be met using natural communications methods. We looked at the file and Medicare rules. In this case, it is noted that you are able to communicate effectively with American Sign Language. Based on this information, we decided that Medicare rules for coverage of a speech generating device have not been met. Therefore, we decided that the Plan does not have to pre-approve a speech generating device (E2508).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for wound debridement provided from September 25, 2020, to December 24, 2020.
You asked the Plan to waive the copayments for wound debridement. You say that the enrollee did not receive bills until much later and was under the impression that the Plan was covering the charges. You state that you disagree with how the services were processed as surgical procedures. The Plan denied your request. The Plan says the claims were processed correctly, and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $295 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers.
The enrollee received wound debridement at an outpatient hospital facility, from September 25, 2020, to December 24, 2020, for a total of 12 visits. Wound debridement is considered an outpatient surgical procedure. Therefore, the enrollee is responsible to pay a $295 copayment per each visit. However, the enrollee is only being asked to pay the total amount of $2,541.72, which is less than the total copayment amount. The enrollee has been asked to pay the total amount of $2,541.72 for wound debridement. Wound debridement falls within the outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for wound debridement provided from September 25, 2020, to December 24, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the $220.99 copayment charged for ambulance transport provided on January 12, 2021.
You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The Plan denied your request. The Plan says in this case you are actually being charged less than the normal copayment amount for this service.
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 $250 copayment for each one-way ambulance transport. You are only being charged $220.99. 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 $220.99 copayment charged for ambulance transport provided on January 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the periodic oral evaluation, bitewing x-rays, and prophylaxis provided on February 25, 2021 by an OON provider.
You asked the Plan to pay more for the periodic oral evaluation, bitewing x-rays, and prophylaxis. You say that you were advised you could appeal if the coverage was not accurate. The Plan denied your request. The Plan says the total liability amount of $105.00 was applied correctly. The Plan also says that the enrollee liability is a contractual obligation under the Plan and cannot be waived.
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 more for the periodic oral evaluation, bitewing x-rays, and prophylaxis provided on February 25, 2021 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the occlusal adjustment - limited (D9951) received January
5, 2021.
You asked the Plan to pay for the occlusal adjustment. You say that this is a covered benefit that you are
entitled to. The Plan denied your request. The Plan says this is not a covered service under your supplemental
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 the
occlusal adjustment - limited (D9951) received January 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network home health services provided to the enrollee on November 17, 2020.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
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 Plan contract also states that home health services require prior authorization. The 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 out of network home health services provided to the enrollee on November 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ankle orthosis, soft interface and lacer provided by an out-of-network provider on April 27, 2020.
You asked the Plan to pay for the ankle orthosis, soft interface and lacer. You say that the patient only provided Medicare information at the time of service. The Plan denied your request. The Plan says the services could have been provided by an in-network provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the ankle orthosis, soft interface and lacer provided by an out-of-network provider on April 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the implant removal (D6100), and the non-intravenous conscious sedation (D9248) received February 18, 2021.
You asked the Plan to pay for the implant removal and the non-intravenous conscious sedation. You say that these services were provided for health reasons, not cosmetic reasons, and should therefore be covered. The Plan denied your request. The Plan says the requested services are not covered under your supplemental 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 the implant removal (D6100), and the non-intravenous conscious sedation (D9248) received February 18, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee from November 6, 2020, to November 10, 2020.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says due to the enrollee's hospice election at the time of service, this claim should be submitted to Original Medicare.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee from November 6, 2020, to November 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible applied to the walker provided on January 8, 20201.
You asked the Plan to waive this cost share. You say that you do not believe this cost share is correct. The Plan denied your request. The Plan says the deductible had not been met at the time of service.
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 $146 deductible for 20201. This cost sharing is a contractual obligation that had not been met at the time this walker was purchased. Therefore, we decided that the Plan does not have to waive the deductible applied to the walker provided on January 8, 20201.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the periodic oral evaluation -
established patient (D0120), the prophylaxis (D1110), the intraoral - periapical first radiographic image
(D0220) the intraoral - periapical each additional radiographic image (D0230) and the unspecified preventive
procedure (D1999) received March 1, 2021, from the out-of-network provider.
You asked the Plan to pay an additional amount for the dental services. You say that you thought your Plan
provided better services for a lower cost. The Plan denied your request. The Plan says the correct cost share
applied to the claims.
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 or are subject to frequency limitations.
The Plan does not offer coverage for the unspecified preventive procedure (D1999). The Plan provides
coverage for periapical radiographic images, one procedure every three years. The Plan agreed to cover the first
periapical radiographic image received on March 1, 2021; therefore, the remaining procedures (D0230) exceed
the frequency limitation and cannot be covered.
The Plan requires 80% coinsurance for non-Medicare covered, routine dental services when received from an
out-of-network provider. When you receive services from an out-of-network provider the Plan calculates
reimbursement based off the Plan's maximum allowable charge for each service. You are responsible for the
difference between the maximum allowable charge and the amount billed by the out-of-network provider. You
have been asked to pay $47.06 ($19.73 (coinsurance) + $27.33) for the periodic evaluation (D0120); $80.39
($38.40 (coinsurance) + $41.99) for the prophylaxis (D1110); $24.10 ($11.56 (coinsurance) + $12.54) for the
first periapical radiographic image (D0220); and $24.52 ($5.92 (coinsurance) + $18.60) for the periapical
additional radiographic image (D0230). You have been asked to pay the correct amount based on your contract
with the Plan. Therefore, we decided that the Plan does not have to pay an additional amount for the periodic
oral evaluation - established patient (D0120), the prophylaxis (D1110), the intraoral - periapical first
radiographic image (D0220) the intraoral - periapical each additional radiographic image (D0230) and the
unspecified preventive procedure (D1999) received March 1, 2021, from the out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you need IRF care. The Plan denied your request. The Plan says rules for IRF care have not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 you were admitted for surgical treatment of a hip fracture after a fall. Medical conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. Although you do require physical and occupational therapy, there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. In conclusion, there is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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 acute inpatient rehabilitation facility (IRF) admission and services.