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

We decided that the Plan does not have to pay for the laboratory services rendered on August 4, 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 the services were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in a skilled nursing facility setting and should have been billed with POS code 31. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on August 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-ray (D0270) and one first intraoral periapical x-ray (D0220) provided on September 1, 2020, and September 2, 2020.
You asked the Plan to pay for the bitewing x-ray and additional intraoral periapical x-ray. You say that you feel the Plan should pay the remaining $829 because of the mistakes they have made. The Plan denied your request. The Plan says you have exceeded the benefit limit for the bitewing x-ray. The Plan also says that first intraoral periapical x-ray 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, intraoral x-rays are not among those covered under this benefit. The contract also says that bitewing x-rays are limited to one procedure per calendar year. The record shows that you received bitewing x-rays (D0274) on August 26, 2020 and your bitewing x-rays benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the bitewing x-ray (D0270) and one first intraoral periapical x-ray (D0220) provided on September 1, 2020, and September 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation, panoramic xray,
extractions, and inhalation of nitrous oxide/analgesia provided on November 23, 2020 by an OON
provider.
You asked the Plan to pay for the problem focused limited oral evaluation, panoramic x-ray, extractions, and
inhalation of nitrous oxide/analgesia. You say that you think this bill should be covered because you needed the
extractions due to radiation. The Plan denied your request.
The Plan says the problem focused limited oral evaluation is not a covered service. The Plan says that your
benefits for the panoramic x-ray and extractions have been satisfied and the frequency limitations have been
exceeded. The Plan also says that the use of nitrous oxide is not a covered benefit when administered in
conjunction with non-covered services, so no payment can be made for this 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 problem focused limited oral
evaluation is not among those covered under this benefit. The contract says that full mouth or panoramic x-rays
are limited to one procedure code every five years. The record shows that you received a complete series of xrays
on November 9, 2020, and your full mouth or panoramic x-rays benefit has been exhausted. Extractions
are limited to two procedure codes per calendar year, and you must pay a 55% coinsurance for each extraction
received out-of-network. The record shows that you received 13 extractions on November 23, 2020, two of
which were covered at the OON benefit rate by the Plan, and your extractions benefit has been exhausted. The
nitrous oxide/analgesia is not covered because your extractions benefit has been exhausted. Therefore, we
decided that the Plan does not have to pay for the problem focused limited oral evaluation, panoramic x-ray,
extractions, and inhalation of nitrous oxide/analgesia provided on November 23, 2020 by an OON provide
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for diagnostic mammography, including computer-aided detection (CAD) when performed; unilateral (77065) diagnostic digital breast tomosynthesis, unilateral or bilateral (G0279) ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete (76641-LT, RT) provided February 9, 2021.
You asked the Plan to waive the copayment for the diagnostic services. You say that you do not believe you should have responsibility for the mammogram. The Plan denied your request. The Plan says the claim was processed with the correct copayment applied per the Evidence of Coverage.
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 $10 copayment for most x-rays and ultrasounds.
You have been asked to pay $40 ($10 x 4) for the diagnostic services. The diagnostic service falls 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 diagnostic mammography, including computer-aided detection (CAD) when performed; unilateral (77065) diagnostic digital breast tomosynthesis, unilateral or bilateral (G0279) ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete (76641-LT, RT) provided February 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound study of arm and leg arteries (93922) provided on March 12, 2021.
You asked the Plan to waive the copayment for an ultrasound study of arm and leg arteries. You say that the service at issue was performed at your annual wellness visit and there should be no copayment for this visit, nor were you told there would be a copayment for the service at issue. The Plan denied your request. The Plan says the correct copayment was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for Medicare-covered diagnostic procedures and tests (excepting diagnostic bone mass measurement, diagnostic colonoscopy, and diagnostic mammography).
You have been asked to pay a $50 copayment for an ultrasound study of arm and leg arteries. an ultrasound study of arm and leg arteries falls 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 an ultrasound study of arm and leg arteries (93922) provided on March 12, 2021.
Your complaint about receiving incomplete information from your provider about your cost-sharing responsibility 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the specialist office visit provided on February 25, 2021.
You asked the Plan to waive the copay for the services provided. You say that you had issues getting in touch with the doctor. The Plan denied your request. The Plan says the copay was 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 $40 copay per specialist visit. The medical records show that a follow up for blood work was provided. You have been asked to pay a $40 copay for the services provided. The services fall within the physician services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copay for the specialist office visit provided on February 25, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90832) provided on October 2, 2020, by an out-of-network provider.
You asked the Plan to pay for psychotherapy services. You say that the medically necessary services at issue were rendered to the enrollee in good faith that they would be reimbursed. The Plan denied your request. The Plan says rules for out-of-network care have not been 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 psychotherapy services (90832) provided on October 2, 2020, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided on March 5, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the OON services. You say that the tests are used when decisions are to be made to treatment. 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 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 drug testing services provided on March 5, 2021 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 psychotherapy provided on September 2, 2020 by an out-of-network provider.
You asked the Plan to pay for the psychotherapy (90837). You say that you did not have time to get authorization. The Plan denied your request. The Plan says you did not request prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the service 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 the service. Therefore, we decided that
the Plan does not have to pay for psychotherapy provided on September 2, 2020 by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care.
You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient admission are met in this
case. Our physician reviewer found the procedure is currently approved as an ambulatory procedure. There is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. The record does not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (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 acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the guided tissue regeneration and bone replacement graft provided on August 13, 2020.
You asked the Plan to pay for the guided tissue regeneration and bone replacement graft. You say that you were told you had a loose molar which needed to be removed and you needed an implant. You say that you were left with a big dental bill that you cannot take care of and you want a refund. The Plan denied your request. The Plan says the services are not covered 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 guided tissue regeneration and bone replacement graft provided on August 13, 2020.
Your complaint about the dental office disregarding the needs of their clients and this being unfair 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 pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary for the enrollee's
condition. The Plan denied your request. The Plan says rules for IRF care have not been met.
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 patient was admitted for a stroke. Medical conditions are stable. There are no
complex nursing or rehabilitation needs.
The patient does not require treatment by multiple therapies, including either physical therapy or occupational
therapy, and an intensive rehabilitation therapy program. The patient does require physical and occupational
therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services
can be provided in a different level of care. In conclusion, there is not a reasonable expectation that this patient
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
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 daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. 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 SNF care
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the infusion therapy services provided on January 21, 2021 by an out-of-network provider.
You asked the Plan to pay for the infusion therapy services. You say that the Plan should pay this claim. The Plan denied your request. The Plan says you did not request prior authorization for the out-of-network services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 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 infusion therapy services provided on January 21, 2021 by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services coded 99153 provided on January 25, 2021.
You asked the Plan to pay for the moderate sedation services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as 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. In this case, the CPT Code Manual definition of code 99153 is moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List separately in addition to code for primary service).
We find that CPT code 99153 is not supported in the medical record. Specifically, this code has a Professional Component (PC)/Technical Component (TC) indicator of 3 per the January 2021 National Physician Fee Schedule Relative Value File. This indicator identifies stand-alone codes that describe the technical component (i.e., staff and equipment costs) of selected diagnostic tests for which there is an associated code that describes the professional component of the diagnostic tests only. It also identifies codes that are covered only as diagnostic tests and therefore do not have a related professional code. Based on this information, we decided that Medicare rules for coverage of the moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services coded 99153 provided on January 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an obstetrics/gynecology (OB/GYN) office visit provided on January 12, 2021.
You asked the Plan to waive the copayment for specialist visit. You say that you only went to this provider for a referral. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 $45 copayment for specialist visit. You have been asked to pay $45 copayment for specialist visit. 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 an obstetrics/gynecology (OB/GYN) office visit provided on January 12, 2021