Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for
the enrollee.

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says the services can be safely offered in other settings.

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 based on the medical records provided, the complexity of the enrollee's nursing,
medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary
approach to rehabilitation care. The enrollee does not requite an intensive therapy program. Care at the skilled nursing facility level appears to be appropriate in this case. 

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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that inpatient skilled nursing facility (SNF) care is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of inpatient skilled nursing facility care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 pre-approve SNF care. Our reviewer says that inpatient skilled nursing facility care is not medically necessary. Our physician reviewer found that the enrollee does not have documented skilled nursing or skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point are custodial and, as a practical matter, can be provided at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for magnetic resonance imaging (MRI) brain, including brain stem (70553) provided on February 2, 2021 by an out of network (OON) provider.

You asked the Plan to pay for the MRI. You say that please review the attached documentation for patient medical necessity and reprocess claim without the authorization. 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 magnetic resonance imaging (MRI) brain, including brain stem (70553) provided on February 2, 2021 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit, lesion removal and nail debridement provided
by an out-of-network provider on August 19, 2020.
You asked the Plan to pay for the home visit, lesion removal and nail debridement. You say that authorization
was impossible with the incorrect insurance information. You say that the patient required the medical care
received and the claim should be reprocessed for payment. 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 the home visit, lesion removal and nail
debridement provided by an out-of-network provider on August 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoral - complete series of radiographic images (D0210) received February 5, 2020.
You asked the Plan to pay for intraoral - complete series of radiographic images. You say that you are not able to pay for these charges. The Plan denied your request. The Plan says the requested service is limited to one procedure every five years.
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 services frequency was exhausted on this date of service. The Plan contract limits panoramic or diagnostic X-rays to one procedure every five years. The Plan has submitted evidence that you last received this service on September 14, 2016.
Therefore, we decided that the Plan does not have to pay for intraoral - complete series of radiographic images (D0210) received February 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on February 3,
2021.

You asked the Plan to waive the copayment for a specialist visit. You say that you 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 $25
copayment for specialist visits.

You have been asked to pay a $25 copayment for a specialist visit. A specialist visit falls within the
physician/practitioner services, including doctor's office visits 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 specialist visit provided on February 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0483 provided on August 10, 2020.
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.
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 G0483 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed. We find that CPT code G0483 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0483 provided on August 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided on May 28, 2020 by an out of
network provider.

You asked the Plan to pay for chiropractic services provided by an out of network provider. You say that the
chiropractor has always been in-network. The Plan denied your request. The Plan says you did not request prior
authorization for the non-urgent service.

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 chiropractic services provided on May 28, 2020 by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on February 3, 2021.
You asked the Plan to pay for the dental service. You say that although the service was provided for the same tooth, it was 2 completely different issues. The Plan denied your request. The Plan says 1 limited oral evaluation is covered per plan year. The Plan also says that the frequency limit has 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 limited oral evaluation is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for this service that you received on January 27, 2021. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on February 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided on September 2, 2020, by an OON
provider.

You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says services rendered
by non-participating 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 file shows that the enrollee was seen for a new patient visit. The 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 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 lab services
provided on September 2, 2020, by an OON provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy provided on
February 5, 2021.

You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that you were told you
would only have to pay the copayment. The Plan denied your request. The Plan says the claim was processed
accordingly with your 2021 EOC benefits.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).

Review of the file show that you received a diagnostic colonoscopy on February 5, 2021. You were asked to
pay a $250 copayment for the colonoscopy. Your 2021 EOC states that enrollees must pay a $250 copayment
for each ambulatory surgical center visit. 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 the diagnostic colonoscopy provided on February 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for the specialist services provided on June 24, 2020.

You asked the Plan to waive the co-payment for the specialist services. You say that you were not told that you would owe a separate facility copay of $10. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance).

Review of the file show that you received specialist services provided on June 24, 2020. You are asked to pay a $10 copayment for the in-network services. Your 2020 EOC states that enrollees must pay a $10 co-payment per visit for in-network primary care physician (PCP) and a $10 co-payment per visit for in-network specialist. 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 co-payment for the specialist services provided on June 24, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services provided on July 21, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that treatment was rendered in good faith. The Plan denied your request. The Plan says authorization for out-of-network services was 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 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 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 the outpatient mental health services provided on July 21, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on February 24, 2021.
You asked the Plan to pay for the dental service. You say that all that the dentist did was look in your mouth.
You say that you thought the dentist was in network. You also say that your primary care physician (PCP)
advised you to go see a dentist for your headaches. The Plan denied your request. The Plan says panoramic xray
is not listed as a covered service.
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
panoramic x-ray (D0330) provided on February 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the injection provided on February 17, 2021.

You asked the Plan to waive the cost share for the services provided. You say that you did not know the
medication was charged separately. The Plan denied your request. The Plan says the coinsurance applied
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% of
the cost for Medicare Part B prescription drugs.

The file shows that you received a perflutren lipid microspheres injection. You have been asked to pay 20% of
the cost for the services provided. The services fall within the Medicare Part B prescription drugs 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 cost share for the injection provided on February 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and laboratory tests provided by an out-of-network provider on May 14, 2020.

You asked the Plan to pay for the office visit and laboratory tests. You say that you requested enrollment with the Plan but didn't receive any response. You say that you are losing out on reimbursement and the claim should be processed at the contracted rate. 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 office visit and laboratory tests provided by an out-of-network provider on May 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on October 15, 2020.
You asked the Plan to pay for lab tests. You say that you have added diagnosis codes and are submitting supporting records. The Plan denied your request. The Plan says this testing is not covered for the diagnosis code billed and was performed for screening purposes.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The tests at issue in this appeal, lab tests, were requested for screening purposes. Medicare does not cover these tests for screening purposes. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on October 15, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the Covid testing coded U0004 and the Streptococcus assay coded 87880 provided on November 1, 2020 and November 2, 2020.
You asked the Plan to pay for the Covid testing and the Streptococcus assay. 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 payable.
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 U0004 and 87880 is not supported in the medical record. Specifically, these services were billed with modifier CS. The reporting of modifier CS indicates that the line(s) is a COVID-19 visit with testing-related services, deductible and coinsurance is not applicable for the visit. Additionally, modifier CS should only be reported when the item or service is identified by CMS as being eligible for a coinsurance and deductible waiver. Based on this information, we decided that Medicare rules for coverage of the Covid testing
and the Streptococcus assay have not been met. Therefore, we decided that the Plan does not have to pay for the Covid testing coded U0004 and the Streptococcus assay coded 87880 provided on November 1, 2020 and November 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the dental services provided from February 4, 2021 through February 19, 2021.
You asked the Plan to provide additional payment for the dental services. You say that you believed this was covered by the Plan. The Plan denied your request. The Plan says that if you choose to see an Out-of-Network dentist, you might be billed for any amount greater than what the plan pays.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan says that if you choose to see an Out-of-Network dentist you might be billed for charges above what the plan pays, even for services listed as $0 copayment.
We looked at the file and Medicare rules. The file indicates you went to an Out-of-Network dentist and the Plan paid up to the maximum benefit amount. You are responsible for any charges over that amount. Therefore, we decided that the Plan does not have to provide additional payment for the dental services provided from February 4, 2021 through February 19, 2021.