Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the SNF stay.

You asked the Plan to waive the copayment for the SNF stay. You say that there is no copayment for days 1-20 in a skilled nursing facility. The Plan denied your request. The Plan says the copayment 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 $0 per day, days 1-20 and $178 per day, days 21-100 for each SNF stay. A benefit period begins the day you go into a hospital or skilled nursing facility. The benefit period ends when you haven't received any inpatient hospital care (or skilled care in a SNF) for 60 days in a row.

You have been asked to pay a total of $712 for the SNF stay.

The SNF stay falls within the "Skilled nursing facility (SNF) care" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the SNF stay.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation and set-up of a portable x-ray (Q0092, R0070).

You asked the Plan to pay for the transportation and set-up of a portable x-ray. You say that you would like reconsideration because this service was billed with the correct place of service code. The Plan denied your request. The Plan says this service was not authorized.

The Plan must follow Medicare rules. Medicare rules say that if the patient is in a Part A Skilled Nursing Facility stay, the transportation and set up costs are subject to consolidated billing and not separately billable to Medicare Part B.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the transportation and set-up of a portable x-ray have not been met. Specifically, the claim was billed with place of service code 31, indicating that the member was in a Part A covered Skilled Nursing Facility stay. When the member is in a Part A covered stay, the costs for this service is subject to consolidated billing and not separately reimbursable. Therefore, we decided that the Plan does not have to pay for the transportation and set-up of a portable x-ray (Q0092, R0070).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a routine venipuncture.

You asked the Plan to pay for the routine venipuncture. The Plan denied your request. The Plan says you must receive your care from a network provider. In most cases care you receive from an out of network provider will not be covered. If you need medical care that Medicare requires our plan to cover and the providers in our network cannot provide this care, you can get this care from an out of network provider. You, or your PCP must obtain authorization prior to seeking 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 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 a routine venipuncture.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye exam (92014) provided on September 8, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the eye exam. You say that you were unaware of the plan enrollment and therefore did not obtain pre-authorization. The Plan denied your request. The Plan says prior authorization was not obtained. The service was not urgent or emergent.
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 eye exam (92014) provided on September 8, 2020 by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation visit provided on August
20, 2019, by an OON provider.
You asked the Plan to pay for evaluation visit. You say that your provider depends upon the facility to verify
eligibility and obtain the proper authorization. The Plan denied your request. The Plan says the denial of
payment for this service is correct, because this provider is out-of-network with the Plan and authorization 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 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 a psychiatric diagnostic evaluation visit provided
on August 20, 2019, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the oral exam (D0120), prophylaxis (D1110), and the filling (D2330) provided from June 11, 2020, to September 15, 2020.
You asked the Plan to reimburse you for the dental services. You say that you paid out of pocket for the services. You also say that you should be reimbursed. The Plan denied your request. The Plan says there is an allowance of $1,000 every year for covered preventive and comprehensive dental services. The Plan also says that the allowance has been exhausted.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the allowance of $1,000 every year for covered preventive and comprehensive dental services has been exhausted. The record shows that the Plan paid $348 for dental services that you received on February 6, 2020, and $652 for dental services that you received on March 2, 2020, thus exhausting the allowance. Therefore, we decided that the Plan does not have to reimburse you for the oral exam (D0120), prophylaxis (D1110), and the filling (D2330) provided from June 11, 2020, to September 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services.

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 29823 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 29823 is arthroscopy, shoulder, surgical; debridement, extensive, 3 or more discrete structures (eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, subacromial bursa, foreign body[ies]).

We find that CPT code 29823 is not supported in the medical record. Specifically, there is no documentation of extensive surgical debridement of three or more discrete structures. 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 surgical services.
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 the records provided support the need for IRF care. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee could receive the care needed in another setting.
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 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 was admitted for falling times two from March 4 - March 7, 2021. She was discharged home with home health services. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that the enrollee 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical services to be provided by a pain specialist.
You asked the Plan to pre-approve the requested services. You say that you have a lot of severe injuries. The
Plan denied your request. The Plan says the records do not show that you have been evaluated by your primary
care physician.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at the file, and Medicare rules. In this case, there are insufficient medical records, including signs,
symptoms, or a physical exam, that indicate a pain specialist is necessary. Based on this information, we
decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have
to pre-approve medical services to be provided by a pain specialist.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments for the vena cava ultrasound, the blood flow ultrasound, and the heart ultrasound provided on June 17, 2020.
You asked the Plan to reduce the copayments for the ultrasounds. You say that you are being overcharged by insurance. You say there was a significant increase in the cost of a sonogram from 2019 to 2020. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing 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 $110 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a freestanding facility (such as a radiology center or medical clinic). You have been asked to pay a $110 copayment for each of the ultrasounds. The ultrasounds fall within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" 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 reduce the copayments for the vena cava ultrasound, the blood flow ultrasound, and the heart ultrasound provided on June 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite (D2392).

You asked the Plan to pay for the resin-based composite. You say that you would like this service to be covered. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan. The Plan also says that you did not purchase a dental rider for additional 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 resin-based composite (D2392).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the needle electromyography (95867) provided October 7,
2020
You asked the Plan to pay for the needle electromyography. You say that you are asking that this claim be
processed under any authorizations obtained by the operating surgeon based on your rendering provider was
requested to participate in this enrollee's surgery. The Plan denied your request. The Plan says the diagnosis
code reported on the claim I65.22 does not support the medical necessity of bill code 95867.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at this the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the needle electromyography have not been met. Therefore, we decided that the Plan does not have
to pay for the needle electromyography (95867) provided October 7, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of torus mandibularis (D7473).

You asked the Plan to pay for the removal of torus mandibularis. You say that this procedure was performed in preparation for a partial denture. The Plan denied your request. The Plan says this service is not covered.

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 removal of torus mandibularis (D7473).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound of the breast (76642) provided on October 20, 2020.
You asked the Plan to waive the copayment for the ultrasound. You say that you went in for just a screening mammogram and should have no copayment. The Plan denied your request. The Plan says that you did receive a screening at no cost to you, but then you received other services which do require a copayment. Medical records were provided.
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 copayment for x-rays and ultrasounds. You have been asked to pay a $20 copayment for an ultrasound. According to the medical records, you went in for a screening mammogram. The screening showed there may be cause for concern, so other tests, including a diagnostic mammogram (77066) and an ultrasound of the breast (76642), were provided. The applicable cost-sharing will apply to any non-preventative services you receive during a visit, even if you only went in for a screening. Both screening and diagnostic mammograms require a $0 copayment according to your Plan's contract, however you also received an ultrasound which falls within the x-rays and ultrasounds 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 the ultrasound of the breast (76642) provided on October 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and X-rays (99212, 73630, 73560) provided on October 13, 2020, by an out of network (OON) provider.
You asked the Plan to pay for the office visit and X-rays. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were provided without a referral and OON criteria were not met.
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 office visit and X-rays (99212, 73630, 73560) provided on October 13, 2020, by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to
the enrollee on May 21, 2018.
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request.
The Plan says this should be reported with CPT 81479.
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare
rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay
for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on May 21, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision services provided on January 24, 2019.
You asked the Plan to pay for the vision services. You say that the claim was timely. The Plan denied your request. The Plan says the claim was untimely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the vision services was not filed until February 13, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the vision services provided on January 24, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient hospital admission for the right shoulder arthroplasty.
You asked the Plan to pre-approve an inpatient hospital admission. You say that the records provided support the need for an inpatient level of care. The Plan denied your request. The Plan says the enrollee is medically stable and has been approved to undergo this elective procedure. The Plan says that there is no documentation to support the expectation that the enrollee will require a greater than 2 midnight 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 pre-approve an inpatient hospital admission. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found detailed documentation is not evident regarding increased risks for post-operative complications that would require inpatient stay over observation post-op. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. The records do not show that the admitting physician reasonably expects the enrollee's necessary hospital care would span two 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 an inpatient hospital admission have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient hospital admission for the right shoulder arthroplasty.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Denosumab injection provided on December 10, 2019.
You asked the Plan to waive the coinsurance for the Denosumab injection. You say that you have a prior authorization so you should not have a coinsurance. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing 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 20% of the cost for Medicare Part B chemotherapy drugs and other Medicare Part B drugs. You have been asked to pay $843.64 which is 20% of the allowed amount for the Denosumab injection. The allowed amount is $4,218.20. ($4,218.20 x 20% = $843.64). The Denosumab injection falls 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 coinsurance for the Denosumab injection provided on December 10, 2019.