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

We decided that the Plan does not have to pay for prolonged evaluation and management or psychotherapy service(s) (beyond the typical service time of the primary procedure) in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour (CPT Code 99354) provided to the enrollee
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are 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. We find that CPT code 99354 is not supported in the medical record. CPT code 99354 is used to report "Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour". This code may only be reported for the time spent in direct face-to-face contact with the patient. To support prolonged services, the documentation must contain a statement by the provider giving the total time of the visit and indicating how much of the time was spent in direct, face-to-face time with the patient. It is only the time spent in direct, face-to-face contact with that patient that may be counted toward the time requirements for prolonged services. Medicare B News, Issue 246, June 24, 2008 states the following: "You must appropriately and sufficiently document in the medical record that you personally furnished the direct face-to-face time with the patient specified in the CPT code definitions." Documentation submitted with the appeal states the provider spent 78 minutes on the visit, but does not state how much of that time was spent in direct, face-to-face time with the patient. In addition, the documentation states that the time spent on the visit includes discussing the enrollee's case with other medical providers and nurses, as well writing orders and documenting and reviewing records; none of which may be considered in the calculation of time to support the prolonged service CPT code 99354. 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 prolonged evaluation and management or psychotherapy service(s) (beyond the typical
service time of the primary procedure) in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour (CPT Code 99354) provided to the enrollee
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient physical therapy services provided from April 16, 2019 to April 25, 2019.You asked the Plan to pay for physical therapy. You say that you are requesting that the Plan review these services for payment.The Plan denied your request. The Plan says the denial of payment for these services is correct, because no medical records were received to support physical therapy services rendered on these dates of service.The Plan must follow Medicare rules. Medicare rules say that services performed outside of the United States and its territories are not covered by Medicare except in specific circumstances. The Plan has worldwide coverage benefits that go beyond Medicare's coverage, therefore the Plan's rules apply to these claims. The Plan covers emergency or urgently needed services worldwide. Enrollees must pay for services upfront and request reimbursement from the Plan. To obtain reimbursement, enrollees must submit proof of payment, medical records, contact information for the rendering providers, and all other supporting documentation to the Plan within 12 months of the date of service.We looked at the file, Medicare rules, and the Plan's rules. You have not submitted medical records to the Plan to support payment of the outpatient physical therapy services provided from April 16, 2019 to April 25, 2019. Without this information, your request for reimbursement does not meet the Plan's rules for worldwide emergent/urgent care benefits.Therefore, we decided that the Plan does not have to pay for outpatient physical therapy services provided from April 16, 2019 to April 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the porcelain or ceramic crown, core buildup, including any pins when required, and porcelain crown fused to noble metal provided on April 25, 2019.
You asked the Plan to pay for the porcelain or ceramic crown, core buildup, and porcelain crown fused to noble metal. You say that you do not agree with the amount you were reimbursed. The Plan denied your request. The Plan says the services are 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 Plan only covers single crowns, abutment supported, and single crowns, implant-supported. The Plan does not cover porcelain or ceramic crowns, core buildups, or porcelain crowns fused to noble metal. Therefore, we decided that the Plan does not have to pay for the porcelain or ceramic crown, core buildup, including any pins when required, and porcelain crown fused to noble metal provided on April 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal scaling and root planings on the upper left,
upper right, lower left, and lower right quadrants provided on June 20, 2019 and July 2, 2019.
You asked the Plan to pay for the scalings and planings. The Plan denied your request. The Plan says this
service is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
periodontal scaling and root planings on the upper left, upper right, lower left, and lower right quadrants
provided on June 20, 2019 and July 2, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from January 21, 2019 through January 27, 2019.You asked the Plan to waive the copayment for the inpatient stay. You say that your stay was extended 36 hours which resulted in additional treatment and charges. You say that the bill should be adjusted.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 a $310 per day copayment for days 1 through 6 at an in-network hospital.You have been asked to pay $1,550 for the inpatient stay. ($310/day x 5 days = $1,550). The inpatient stay falls within the "Inpatient hospital care" benefit category. The records show that you were only charged for 5 days. 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 inpatient stay provided from January 21, 2019 through January 27, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on July 30, 2019.You asked the Plan to waive the copayment for laboratory services. You say that you disagree with the charges because the labs were part of a wellness visit.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 lab services.You received laboratory services on July 30, 2019. Laboratory services are not included in the annual wellness exam. Therefore, you are responsible to pay the $25 copayment.  You have been asked to pay a $25 copayment for laboratory services. Laboratory services 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 waive the copayment for laboratory services provided at on July 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the radiation consultation and planning provided on July 5, 2019 and July 10, 2019.
You asked the Plan to waive the copayments for the radiation consultation and planning. You say that you had ten radiation treatments not 12. You say that you did not receive radiation during the first two visits. The Plan denied your request. The Plan says the copayments 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 a $60 copayment per visit for nuclear medicine and radiation therapy, including but not limited to cancer treatment. You have been asked to pay a total of $120 for the radiation consultation and planning.
Date of Service
Service
Standard Copayment
Member Liability
July 5, 2019
Radiation Consultation
$60
$60
July 10, 2019
Radiation Planning
$60
$60
TOTAL:
$120
The radiation consultation and planning falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. Consultations and planning for radiation treatments apply the radiation therapy copayment. 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 the radiation consultation and planning provided on July 5, 2019 and July 10, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe Unna boot strapping provided fromMay 6, 2019 through May 30, 2019.You asked the Plan to waive the copayments forthe Unna boot strapping. You say that there was no charge for the boot change at your primary care physician's office. You say that the Plan should fully cover this.The Plan denied your request. The Plan says the copayments 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 a $250 copayment for surgery services at an in-network outpatient hospital.You have been asked to pay $132.47, which is less than the standard $250 copayment for each Unna boot strapping. The total amount you owe is $662.35 ($132.47/visit x 5 visits = $662.35). The Unna boot strapping falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. Unna boot strapping is considered a surgical service. 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 forthe Unna boot strapping provided from May 6, 2019 through May 30, 2019.Your complaint about poor coverageis not a valid appeal for medical coverage. This part of your complaint is a grievance thatmust be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe orthotic management and training services provided to the enrollee on June 12, 2019.You asked the Plan to pay forthe services provided. The Plan denied your request. The Plan says the service was billed without an appropriate modifier.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 97760 is Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(ies), lower extremity(ies) and/or trunk, initial orthotic(s) encounter, each 15 minutes.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 the services provided. Our physician reviewer found that the claim was submitted to the health plan without a necessary modifier. Medicare requires that therapy service, including physical therapy, occupational therapy,and speech-language pathology be reported with an appropriate modifier to identify the specific mode of therapy. CPT code 97760 was not billed with the necessary modifier, and as a result, is not eligible for reimbursement consideration.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 services provided have not been met.Therefore, we decided that the Plan does not have to pay forthe orthotic management and training services provided on June 12, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health podiatry services provided on June 21, 2019.You asked the Planto pay for the services. You say that this should be paid for.The Plan denied your request. The Plan says Medicare says non-urgent services should be from network providers who are contracted with the health plan and listed in the Provider Directory 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 has network providers available who can provide 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 home health podiatry services provided on June 21, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital rehabilitation services You asked the Plan to waive the copayment for the inpatient hospital rehabilitation services. You say that you thought you were going to an acute skilled nursing facility and that the stay would be covered in full for day 1-20 per your benefits.The Plan denied your request. The Plan says the correct copay was applied correctly as this facility is a hospital rehabilitation center and is not considered a skilled nursing facility.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 $225 copay each day for days 1-5 for inpatient hospital care. You have been asked to pay $1,125. ($225x5 = $1,125). Per the health plan contract you must pay $225 copay each day for days 1-5 for inpatient hospital care. for the inpatient hospital rehabilitation services. The inpatient hospital rehabilitation services falls within the Inpatient hospital 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 inpatient hospital rehabilitation services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora specialist visit provided by the provider on October 2, 2019.You asked the Plan to waive the copayment fora specialist visit. You say that you disagreewith 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 $45 copayment per specialist visit. You have been asked to pay a $45 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 fora specialist visit provided on October 2, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a diagnostic test provided on July 23, 2019.You asked the Plan to waive the coinsurance fora diagnostic test. You say that you were charged over $500 for this test.The Plan denied your request. The Plan says the correct coinsurance has been applied to the service in question.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 50% coinsurance for Outpatient diagnostic tests/out-of-network/diagnostic procedures and tests. You have been asked to pay a 50% coinsurance of the allowed amount for a diagnostic test. The allowed amount is $231.77. The total amount you are being asked to pay is $115.89 ($231.77 x 50% = $115.89). A diagnostic test falls within the Outpatient diagnostic tests/out-of-network/diagnostic procedures and tests benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the coinsurance fora diagnostic test provided on July 23, 2019.We note your complaint about being charged over $500 for the test. Your complaint is a grievance that must be answered by the health plan and/or provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge services rendered to the enrollee by the doctor on July 10, 2019.
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 99239 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 99239 is hospital discharge day management; more than 30 minutes. We find that CPT code 99239 is not supported in the medical record. Specifically, there is no documentation of more than 30 minutes of discharge services spent on the enrollee. 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 hospital discharge services rendered to the enrollee by the doctor on July 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not haveto pay forDiabetic Supplies (A4253, A4259, A4256, A4235) provided July 27, 2019 to October 15, 2019.You asked the Plan to pay forthe diabetic supplies.. You say that the items were medically necessary.The Plan denied your request. The Plan says there was not valid proof of delivery provided.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The delivery ticket submitted did not include the carrier's tracking number, nor did the proof of delivery include an order number or details to corroborate the delivery ticket submitted.Therefore, we decided that the Plan does not have to pay forDiabetic Supplies (A4253, A4259, A4256, A4235) provided July 27, 2019 to October 15, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe acute inpatient hospital care provided March 15, 2019 to March 17, 2019.You asked the Plan to pay foracute inpatient hospital care. You say that the enrollee required acute care at medical/surgical for the 2 days denied.The Plan denied your request. The Plan says criteria was not met for acute level of care. Original claim was approved for observation level of care only.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 while the enrollee spent two midnights in the hospital, at the time of admission, it was not reasonable to expect that two midnights of inpatient level care would be medicallynecessary. The enrollee could have been safely placed on observation status pending further evaluation.
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 forthe acute inpatient hospital care provided March 15, 2019 to March 17, 2019.