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

We decided that the Plan does not have to pay for ophthalmological services provided on December 10, 2020.

You asked the Plan to pay for the ophthalmological 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 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 ophthalmological services provided on December 10, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services rendered on September 22, 2020 to 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 codes 97116-GP-59 and 97535-GO-59 are not separately payable.
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service. The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural service. Specifically, the records do not support that codes 97116 and 97535 were a separate and distinct service from approved code 97530. Based on this information, we decided that Medicare rules for coverage of services billed with a -59 modifier have not been met. Therefore, we decided that the Plan does not have to pay for the physical therapy services rendered on September 22, 2020 to December 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglasses provided on November 12, 2020.
You asked the Plan to pay for the eyeglasses. The Plan denied your request. The Plan says you last received eyewear on November 13, 2018. Per your EOC, the benefit is administered on a rolling calendar year since your last date of service. You would have been eligible for eyewear on November 13, 2020.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services every two years. We looked at the file and the Plan's rules. The file shows that you received the routine eyewear benefit on November 13, 2018 and you would have been eligible for the eyewear benefit on November 13, 2020. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglasses provided on November 12, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that your medical needs are being met in the current acute setting.
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. You are receiving appropriate care at the present acute care facility. You do not require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. Our physician reviewer found that your condition does not meet Medicare criteria for LTACH services. 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 long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from
January 3, 2021, through January 4, 2021.
You asked the Plan to pay for acute inpatient hospital care. You say that you went to the hospital with chest pain and shortness of breath and the ED physician thought it was serious enough to admit you. The Plan denied your request. The Plan says we are unable to establish that the service requested is medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that you had chest pain. Your cardiac enzymes were normal, the electrocardiogram (ECG) was normal. The CT angiography was without evidence of pulmonary embolism, pneumothorax. Your stress test was normal, and your lungs were clear. You were admitted to the hospital. Based on the initial workup showing no evidence of acute coronary syndrome or other acute conditions warranting inpatient services, it was not expected that you would require hospitalization that would likely cross 2 midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from January 3, 2021, through January 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0483) provided on January 24, 2020.

You asked the Plan to pay for drug testing. You say that this is supported by the medical records. The Plan denied your request. The Plan says this was billed with an incorrect POS.

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 testing at issue was billed with POS 81 for an independent laboratory, but the records show that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (G0483) provided on January 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of radiographic images (D0210) provided January 21, 2021.
You asked the Plan to pay for the complete series of x-rays. You say that the service was medically necessary. The Plan denied your request. The Plan says the x-rays are not a covered service under your dental 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 complete series of radiographic images (D0210) provided January 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from
September 5, 2020 to September 18, 2020.
You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says based on the medical records, this might be an observation stay.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee was transferred for dyspnea, elevated troponins. CXR showed bilateral pulmonary infiltrates, started on antibiotics and dialysis. He underwent coronary catheterization showing severe multivessel disease. CABG was recommended. No evidence of ACS was noted so heparin gtt discontinued. A lower level of care was more appropriate. Based on the provided records, the enrollee was not expected to require hospitalization that would likely cross 2 midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from September 5, 2020 to
September 18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided by an out-of-network provider on January 13, 2021.

You asked the Plan to pay for the laboratory services. You say that the patient does not come to the lab, the participating providers sends the specimens to process. You say that the cost of the test, lab equipment and technicians is expensive, and you can't afford to let claims go unpaid. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and 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 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 laboratory services provided by an out-of-network provider on January 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the crown (D2740) and the core build up (D2950) provided on January 14, 2021.
You asked the Plan to pay more for the dental services. You say that the office clerk did not read your insurance benefits. You also say that you need help to pay this bill. The Plan denied your request. The Plan says there is a 70% coinsurance for crowns performed in network. The Plan says that core build up is not listed as a covered service. The Plan also says that the claim was processed correctly.
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 more for the crown (D2740) and the core build up (D2950) provided on January 14, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a non-emergent ambulance trip provided by a participating provider on December 15, 2020.

You asked the Plan to waive the copayment for a non-emergent ambulance trip. You say that you were transferred from one hospital to another. You say that you were told that this was covered. 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 $250 copayment for ambulance services/non-emergent. 

You have been asked to pay a $222.54 which is less than your copayment amount of $250 for a non-emergent ambulance trip. a non-emergent ambulance trip falls within the ambulance services/non-emergent 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 non-emergent ambulance trip provided by a participating provider on December 15, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray provided by an out-of-network provider on October 29, 2020.

You asked the Plan to pay for the x-ray. You say that the medically necessary service was provided in good faith and the lack of preauthorization should not preclude payment for services. You say that you are requesting retroactive authorization and immediate payment. The Plan denied your request. The Plan says prior authorization was 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 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 the x-ray provided by an out-of-network provider on October 29, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (80307, G0483) provided on October 28, 2020.

You asked the Plan to pay for drug testing. You say that these services were medically necessary. The Plan denied your request. The Plan says these services were billed with an incorrect POS.

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 testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (80307, G0483) provided on October 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extractions (D7210 x 5), the initial 15 minutes of deep sedation (D9222), the additional 15 minutes of deep sedation (D9223), the simple extractions (D7140 x 6), and the therapeutic parenteral drug (D9610) provided on December 23, 2020.

You asked the Plan to pay for the dental services. You say that you needed these services so that you can get dentures. The Plan denied your request. The Plan says there is an annual maximum benefit of $1,000 for covered dental services. The Plan says that the maximum has been exhausted while processing this claim. The Plan also says that deep sedation and therapeutic parenteral drugs are not listed as covered services.

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 and extractions are listed as covered, the annual maximum benefit has been exhausted.

Additionally, deep sedation and therapeutic parenteral drugs are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the surgical extractions (D7210 x 5), the initial 15 minutes of deep sedation (D9222), the additional 15 minutes of deep sedation (D9223), the simple extractions (D7140 x 6), and the therapeutic parenteral drug (D9610) provided on December 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility visit and wound debridement provided by an out-of-network provider on February 4, 2021.
You asked the Plan to pay for the nursing facility visit and wound debridement. You say that the services were provided prior to obtaining authorization to avoid delay in care. You say that the services were medically necessary and the claim should be processed for payment. The Plan denied your request. The Plan says in-network providers were available.
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 the nursing facility visit and wound debridement provided by an out-of-network provider on February 4, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered from June 14, 2020 to October 7, 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 the claims were billed incorrectly.

The Plan must follow Medicare rules. The rules say that the Type of Bill (TOB) code 032x is required for home health services under a plan of treatment. 

We looked at the file and Medicare rules. The file shows that the claims were not billed with the required 032x TOB code. 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 home health services rendered from June 14, 2020 to October 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99243) provided December 3, 2020.

You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan denied your request. The Plan says the code billed is not eligible for Medicare payment.

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 code 99243 is not supported in the medical record. Specifically, Per the National Physician Fee Schedule, this code is marked with a status of "I" which means it is invalid for Medicare payment. A corrected claim is needed from the provider, however, none was submitted. Based on this information, we decided that Medicare rules for coverage of the office visit have not been met. Therefore, we decided that the Plan does not have to pay for an office visit (99243) provided December 3, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the certified nursing assistant (CNA) visit provided on March 20, 2019, billed with code 99347.
You asked the Plan to pay for the medical services as billed. You say that these services should be paid since they were referred by a physician after a recent hospital stay. The Plan denied your request. The Plan says these services cannot be paid as the physician was not physically present in the home.
The Plan must follow Medicare rules. Medicare rules say that a home visit cannot be billed by a physician unless the physician was actually present in the beneficiary's home. Although the note appears to be signed by a physician, only the CNA was actually present in the enrollee's home. Therefore, we decided that the Plan does not have to pay for the certified nursing assistant (CNA) visit provided on March 20, 2019, billed with code 99347.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Domiciliary or rest home visit provided on December 3, 2020 by an out of network provider.
You asked the Plan to pay for Domiciliary or rest home visit (99335). You say that the physician depends upon the hospital staff to verify eligibility and obtain proper authorization. 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 had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service 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 Domiciliary or rest home visit provided on December 3, 2020 by an out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (0012M) provided November 12, 2020.
You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that CxBladder Detect (0012M, 0013M) is not an approved test. We looked at the file and Medicare rules. This is not a covered service. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (0012M) provided November 12, 2020.