Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0676).
You asked the Plan to pay for a pneumatic compression device. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0676).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member's needs are purely custodial in nature.
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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the dental services (D1110, D0274, D0150) received October 14, 2020 from an out-of-network (OON) provider.
You asked the Plan to pay an additional amount for the dental services (D1110, D0274, D0150). You say that the out-of-network (OON) provider was highly recommended. The Plan denied your request. The Plan says enrollees are responsible for the difference between the maximum allowable charge and dentists' charged fees when visiting an OON provider.
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 payment is in excess of that covered under this benefit. You have been charged OON coinsurance amount plus the difference between the average negotiated in-network fee schedule rate and the out-of-network provider's charged fees. Therefore, we decided that the Plan does not have to pay an additional amount for the dental services (D1110, D0274, D0150) received October 14, 2020 from an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided on July 7, 2020, by an OON provider.
You asked the Plan to pay for lab services. You say that you would like this claim reprocessed and paid. You
say that your lab performed all the tests that were ordered by the referring physician. The Plan denied your
request. The Plan says the referring provider is out-of-network. The Plan says that prior authorization was not
obtained by the member's primary care physician.
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 lab services provided on July 7, 2020, by an OON
provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services (A0428 and A0425) provided on July 12, 2020.
You asked the Plan to pay for the ambulance services. You say that you would like reconsideration because this is not a duplicate claim. The Plan denied your request. The Plan says this claim should have been billed with place of service code 41 for ambulance services.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT code A0428 and A0425 is not supported in the record. Specifically, this claim was not billed with a required place of service code. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance services (A0428 and A0425) provided on July 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care rendered on December 27, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says procedure code 99223 is not payable.
The Plan must follow Medicare rules. The rules say that it is not appropriate to report a discharge from
outpatient hospital observation care (CPT code 99217) when a patient is admitted to hospital inpatient status on
the same day.
We looked at the file and Medicare rules. Billed procedure code 99223 (initial hospital care) is not covered
because code 99217 (observation care discharge) was billed for the following date and paid by the Plan.
Therefore, we decided that the Plan does not have to pay for the initial hospital care rendered on December 27,
2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation with medical services provided on November 4, 2020 by an OON provider.
You asked the Plan to pay for the psychiatric diagnostic evaluation. You say that the service provided was medically necessary. The Plan denied your request. The Plan says this service was rendered by a non-participating provider. The Plan also says that prior 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 the psychiatric diagnostic evaluation with medical services provided on November 4, 2020 by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve three levels of facet joint injections (64494, 64493,
64495).
You asked the Plan to pre-approve three levels of facet joint injections. You say that this is a necessary second
diagnostic procedure. The Plan denied your request. The Plan says this request exceeds the frequency
limitations for this service.
The Plan follows Medicare rules. Medicare rules say that one to two levels, either unilateral or bilateral, are
allowed per session per spine region. The need for a three or four-level procedure bilaterally may be considered
under unique circumstances and with sufficient documentation of medical necessity on appeal.
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 three levels of facet joint injections.
Our reviewer says that the requested facet joint injections are not medically reasonable and necessary. Our
physician reviewer found the documentation of pathology at a third level bilaterally is lacking and the request
exceeds utilization criteria.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of three levels of facet joint injections have not been met. Therefore, we decided
that the Plan does not have to pre-approve three levels of facet joint injections (64494, 64493, 64495).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy provided by an out-of-network provider on
May 19, 2020.
You asked the Plan to pay for the psychotherapy. You say that the physician renders medical care as requested
by the facility. You say that you attached medical records which show the medical necessity for the claim. 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 psychotherapy provided by an out-of-network
provider on May 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and first intraoral periapical x-ray (D0220) provided on December 15, 2020.
You asked the Plan to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray. You say that you believe these services should be covered. The Plan denied your request. The Plan says these 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 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 problem focused limited oral evaluation (D0140) and first intraoral periapical x-ray (D0220) provided on December 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing provided on September 16, 2020.
You asked the Plan to pay for the drug testing. The Plan denied your request. The Plan says the drug testing is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that definitive drug testing is covered for the indications established in the applicable LCD. 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 drug testing. Our reviewer says that the requested drug testing was not medically reasonable and necessary. Our physician reviewer found that the enrollee is maintained on chronic opiate therapy for her cancer pain. The information sent shows that she has been taking the medicine as prescribed. She has not had inconsistent drug tests and her doctor has not stated a reason why she would need 22+ classes of drugs tested. Her doctor wants to perform drug testing to see how much of a certain kind of drug is present in her system, however, it is not necessary to perform a quantitative drug screen for more than 22 classes.
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 drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the definitive drug testing provided on September 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (G0483) provided July 9, 2019.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.
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 G0483 is not supported in the medical record. Specifically, the claim shows a place of service 81, laboratory. The records provided show the specimen was obtained at place of service 11, office setting. Additionally, the date of service on the claim does not match the date the specimen was collected on the records. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (G0483) provided July 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower denture (D5120).
You asked the Plan to pre-approve the dental items. You say that you lost your lower denture. You say that you cannot eat without them. You say that your top denture has been cutting your lower gum. You say that you cannot find your denture anywhere. You also say that you understand the rules but are asking for an exception. The Plan denied your request. The Plan says dentures are covered once every 5 plan years. The Plan says that the frequency limit has been reached.
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 dentures are listed as covered, the frequency limit has been reached. The record shows that the Plan paid for dentures that you received on January 14, 2020. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal scaling and root planing - four or more teeth
per quadrant (D4341 x2) received January 21, 2021.
You asked the Plan to pay for the periodontal scaling and root planing. You say that you signed up for the
enhanced benefit, so the requested service should be covered. The Plan denied your request. The Plan says you
were not signed up for the enhanced benefit at the time of 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
periodontal scaling and root planing - four or more teeth per quadrant (D4341 x2) received January 21, 2021.
Your complaint about being signed up the enhanced benefit at the time of service is not a valid appeal for
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does
not permit us to make a decision about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from November 26, 2020, to November 27, 2020.
You asked the Plan to pay for the acute inpatient hospital care. The Plan denied your request. The Plan says the inpatient care was not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation 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 the acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from November 26, 2020, to November 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible forthe inpatient hospital stay provided from February 3, 2019, to February 6, 2019.You asked the Plan to waive the deductible forthe inpatient hospital stay. You say that you have been to this provider numerous times and have never had to pay a deductible. 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. Your contract with the Plan says that there is a $300 deductible per calendar year for covered services received in a general acute care hospital. You will not pay more than $300 for inpatient hospital covered services in a calendar year. The inpatient hospital stay you asked the Plan to waive the deductible for falls within the "Inpatient hospital care" benefit category. You will not pay more than $300 for inpatient hospital covered services in a calendar year. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $300 deductible per calendar year for covered services received in a general acute care hospital. This cost sharing is a contractual obligation that had not been met at the time the inpatient hospital stay was received on February 3, 2019 to February 6, 2019. Therefore, we decided that the Plan does not have to waive the deductible forthe inpatient hospital stay provided from February 3, 2019, to February 6, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services (99212) provided to the enrollee on October 22, 2020.
You asked the Plan to pay for the chiropractic services. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the chiropractic services (99212) provided to the enrollee on October 22, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient services provided on September 30, 2020, through October 1, 2020.
You asked the Plan to pay for the outpatient services. You say that you would like reconsideration because this claim was billed correctly. The Plan denied your request. The Plan says the claim was billed with a new diagnosis code R51.9 which became effective October 01, 2020, after the claim date of service of September 30, 2020.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the outpatient services have not been met. Specifically, diagnosis code R51.9 was not valid on September 30, 2020. Therefore, we decided that the Plan does not have to pay for the outpatient services provided on September 30, 2020, through October 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the surgery services provided on November 9, 2020 and November 12, 2020.
You asked the Plan to waive the copayment for the surgery services. You say that you were sent a bill saying you owed for services and the hospital stated the coding is incorrect. You say that you were informed you only owe $175. 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 $175 for surgery services at an in-network outpatient hospital. You have been asked to pay a $175 copayment for the surgery services. The surgery services fall within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 surgery services provided on November 9, 2020 and November 12, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for ultrasounds provided on October 21, 2020.
You asked the Plan to waive the copayments for ultrasounds. You say that you feel that you should only owe a
copayment for one ultrasound. 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 $110
copayment for each ultrasound.
You received an ultrasound on October 21, 2020. Therefore, you are responsible to pay the allowed amount of
$106.78, which is less than the $110 copayment.
You received a second ultrasound on October 21, 2020. Therefore, you are responsible to pay the allowed
amount of $106.78, which is less than the $110 copayment.
The total amount you owe is: $213.56.
You have been asked to pay the total copayment amount of $213.56 for ultrasounds. 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 waive the copayments for ultrasounds provided on October 21, 2020.