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

We decided that the Plan does not have to pay for radiology services provided to the enrollee.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says based on the member/claims history, the claim was billed with an inappropriate place of 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 the denied codes is:

CPT 50432:

Placement of nephrostomy catheter, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (e.g., ultrasound and/or fluoroscopy) and all associated radiological supervision and interpretation.

CPT 99153:

Moderate sedation services provided by the same physician or other qualified healthcare professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent, trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; each additional 15 minutes of intra-service time (List separately in addition to code for primary service.

CPT 99152:

Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older.

We asked our coding 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found the provider billed place of service 22 On Campus - Outpatient Hospital, with an off-campus address. Therefore, place of service 22, would not be the correct place of service to report.

We looked at this coder's review, the file, and Medicare rules. 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 radiology services provided to the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the $40 copayment for crisis mental health services provided on December 17, 2020.
You asked the Plan to waive this copayment. You say that you did not call these people and now you have to pay this bill. The Plan denied your request. The Plan says this copayment was charged based on the services provided and the Plan contract agreement.
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 $40 copayment for outpatient mental health care. 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 $40 copayment for crisis mental health services provided on December 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided out of network by the Clinic.

You asked the Plan to pay for this service. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says the provider was told by the Plan to submit a corrected claim and did not. This is a non-plan provider for which no prior authorization is giving. The non-plan provider is balance billing incorrectly. The Plan has no jurisdiction over a non-plan clinic that is not overseen by physicians. The Plan suggests you contact Medicare for further direction on this provider and inappropriate balance billing.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the 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 services provided out of network by the Clinic
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the unclassified biologics coded J3590 provided on August 21, 2020.

You asked the Plan to pay for the unclassified biologics. 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.

In this case, the CPT Code Manual definition of code J3590 is unclassified biologics.

We find that CPT code J3590 is not supported in the medical record. Specifically, two units of this code were billed. The documentation submitted does not support the units billed. Only one unit is appropriate to bill for this code. Based on this information, we decided that Medicare rules for coverage of the unclassified biologics have not been met. Therefore, we decided that the Plan does not have to pay for the unclassified biologics coded J3590 provided on August 21, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on October 8, 2020.
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. 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 October 8, 2020. 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 for the ambulance services provided on October 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and the initial periapical x-ray (D0220).

You asked the Plan to pay for the dental services. You say that you have an authorization and a letter that explains the x-ray should be covered. The Plan denied your request. The Plan says 1 limited oral evaluation is covered per calendar year. The Plan says 1 initial periapical x-ray is covered per calendar year. The Plan also says that the frequency limitations for these services have been exceeded.

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 the services are listed as covered, the frequency limitations have been exceeded. The record shows that the Plan paid for a limited oral evaluation and an initial periapical x-ray. The record shows that the authorization mentioned in the appeal was referring to an additional periapical x-ray, rather than the initial periapical x-ray that was provided. The Dental Handbook clearly states that you will be responsible for the cost of any services over the benefit year maximum, frequency limit or not covered. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) and the initial periapical x-ray (D0220).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for medical supplies provided by a participating provider on June 29, 2020.
You asked the Plan to waive the coinsurance for medical supplies. You say that these supplies were defective, and you should not have to pay for them. The Plan denied your request. The Plan says the correct 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 20% coinsurance for durable medical equipment. You have been asked to pay a 20% coinsurance of the allowed amount for medical supplies. The total allowed amount is $184.50. The total amount you are being asked to pay is $36.90 ($184.50 x 20% = $36.90). Since supplies were provided, the correct copayment has been applied. Medical supplies falls within the durable medical equipment 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 medical supplies provided by a participating provider on June 29, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on October 17, 2020.
You asked the Plan to pay for this service. 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 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 physician services provided to the enrollee on October 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for nuclear medicine services provided by a participating provider on October 30, 2020.
You asked the Plan to waive the copayment for nuclear medicine services. You say that you were told that this would be 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 $290 copayment for outpatient diagnostic tests/nuclear medicine services/outpatient hospital. You have been asked to pay a $290 copayment for nuclear medicine services. The correct copayment has been applied to the services that were provided. Nuclear medicine services fall within the outpatient diagnostic tests/nuclear medicine services/outpatient hospital 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 nuclear medicine services provided by a participating provider on October 30, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the lab services provided on August 19, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says that the services were billed incorrectly.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan references several Local Coverage Articles (LCAs) and Local Coverage Determinations (LCDs) to support its denial. However, the referenced LCAs and LCDs are not applicable to the jurisdiction in which the services were rendered. Without applicable supporting documentation, the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the lab services provided on August 19, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient rehabilitation services provided from December 23, 2020, to December 31, 2020.
You asked the Plan to waive the copayments for outpatient rehabilitation services. You say that you needed rehabilitation due to COVID-19 and disagree with the charges. 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 $40 copayment for outpatient rehabilitation services. You received outpatient rehabilitation services provided from December 23, 2020, to December 31, 2020 for a total of 3 visits. Therefore, you are responsible to pay a $40 copayment per each visit. Therefore, you are responsible to pay a $30 copayment per each visit. Therefore, the total amount you owe is: $120. You have been asked to pay the total copayment amount of $120 for outpatient rehabilitation services. Outpatient rehabilitation services fall within the outpatient rehabilitation services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for outpatient rehabilitation services provided from December 23, 2020, to December 31, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (S9328).

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 "I" under the Physician Fee
Schedule indicates that the code in question is not valid for Medicare purposes.

We looked at the file and Medicare rules. Code 99242 is assigned a status indicator of "I" under the Physician
Fee Schedule, which means that this code is not valid for Medicare purposes. Medicare uses another code for
reporting of, and payment for, these services. 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 (S9328).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dermatology services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve dermatology services. You say that you would like these services to be provided by an out-of-network provider. The Plan denied your request. The Plan says there are in-network providers available 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 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 dermatology services to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiac device monitoring.

You asked the Plan to pay for the cardiac device monitoring. 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 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 cardiac device monitoring.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided from June 18, 2020, through June 24, 2020.
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider such as an urgent or an emergent situation that 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 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 psychotherapy services provided from June 18, 2020, through June 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the mandibular partial denture.

You asked the Plan to pay for the mandibular partial denture. You say that this service was approved for coverage prior to being rendered. The Plan denied your request. The Plan says this service was rendered before the 5 year period.

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 replacement of a removable prosthesis will be covered 5 years after the initial insertion. The record shows that you received a mandibular partial denture, and your mandibular partial denture benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the mandibular partial denture.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray.

You asked the Plan to pay for the panoramic x-ray. You say that you would like this service to be covered. The Plan denied your request. The Plan says this procedure is not a benefit under your dental plan.

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. Bitewing x-rays are the only x-rays covered under your dental benefit. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoral periapical radiographic images (D0220, D0230),
and does not have to pay an additional amount for teeth cleaning (D1110), a comprehensive oral evaluation
(D0150), bitewing radiographic images (D0274), and topical application of fluoride (D1206) provided on
November 10, 2020.
You asked the Plan to pay for intraoral periapical radiographic images, and pay an additional amount for teeth
cleaning, a comprehensive oral evaluation, bitewing radiographic images, and topical application of fluoride.
You say that you were not aware that the provider was out-of-network. The Plan denied your request. The Plan
says periapical radiographic images are a non-covered benefit. You are responsible for the difference in cost
between the provider's fee and the allowed amount for the teeth cleaning, comprehensive oral evaluation,
bitewing radiographic images, and topical application of fluoride.
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.
We looked at the file, and Medicare rules. Based on this information, we decided the Plan does not have to pay
for intraoral periapical radiographic images, or pay an additional amount for teeth cleaning, a comprehensive
oral evaluation, bitewing radiographic images, and topical application of fluoride. Specifically, the plan paid an
allowed amount for the teeth cleaning, comprehensive oral evaluation, bitewing radiographic images, and
topical application of fluoride.
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. Intraoral periapical radiographic
images are not a covered benefit. Therefore, we decided that the Plan does not have to pay for intraoral
periapical radiographic images (D0220, D0230), and to pay an additional amount for teeth cleaning (D1110), a
comprehensive oral evaluation (D0150), bitewing radiographic images (D0274), and topical application of
fluoride (D1206) provided on November 10, 2020.