Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99217) provided February 21, 2021.
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says this service shares a column I / column II relationship with another service billed and cannot be separately paid.
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, we have confirmed that code 99217 has a bundled relationship with code 99220 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for physician services (99217) provided February 21, 2021
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the office visits provided on October 26, 2020 and October 29, 2020.
You asked the Plan to pay for the office visits. You say that the Plan should pay this claim as primary payer. The Plan denied your request. The Plan says that they reached out to the primary payer for their Evidence of Benefit documentation but did not receive any.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has not met its obligation with regards to coordination of benefits. Specifically, the Plan has not sent the bill to the primary insurer for payment, directed the provider to send the bill to the primary insurer, or payed for the services and submitted a bill to the primary insurer for reimbursement. Therefore, we decided that the Plan has to pay for the office visits provided on October 26, 2020 and October 29, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the peripheral nerve block services provided on March 2, 2021.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says that there was no quantified estimation of benefit from prior injections.
The Plan follows Medicare rules. Medicare rules say that peripheral nerve blocks are only covered under certain medical indications. 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 enrollee has tarsal tunnel syndrome, not trigger points. The diagnosis was confirmed by physical exam. Based on the rules and records provided, the procedure was medically reasonable and necessary to treat the enrollee's condition. 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 been met. Therefore, we decided that the Plan has to pay for the peripheral nerve block services provided on March 2, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided on January 11, 2021.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network 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 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 out of network physician services provided on January 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99223) provided March 9, 2021.
You asked the Plan to pay for physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim cannot be paid 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. We find that CPT code 99223 is not supported in the medical record. Specifically, another evaluation and management service was paid on the same date of service for the same physician group. Based on this information, we decided that Medicare rules for coverage of physician services have not been met. Therefore, we decided that the Plan does not have to pay for physician services (99223) provided March 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit with a specialist (92004) provided on April 15, 2021, by an OON provider.
You asked the Plan to pay for an office visit. You say that the Plan denied your claim but paid your wife's claim with a copayment. You also say you would like to request a refund from the Plan. The Plan denied your request. The Plan says the service was obtained by a provider who opted out of Medicare.
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 confirmed the provider opted out of Medicare on May 29, 2018. The Plan cannot issue payment for services received from a provider who does not participate in Medicare. 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. The records provided for review do not show that the services at issue were urgent or emergent. 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 an office visit with a specialist (92004) provided on April 15, 2021, by an OON provider.
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 inpatient rehabilitation services are necessary. The Plan denied your request. The Plan says the criteria for an IRF are not met, and the necessary services can be provided 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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do require
physical and occupational therapy, but there is no documented need for an intensive rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically necessary services can be provided in a different level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compression device (E0675) and related accessory (E0673) provided February 8, 2021.
You asked the Plan to pay for the pneumatic compression device and related accessory. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says these items are not eligible for coverage.
The Plan must follow Medicare rules. Medicare rules say that a pneumatic compression device coded as E0675 is not eligible for coverage. In addition, the related accessory will not be covered when the base pneumatic compression device is not covered. We looked at the file and Medicare rules. In this case, the pneumatic compression device coded as E0675 is not eligible for coverage based on Medicare rules. Since the pneumatic compression device base is not covered, the accessory will also be denied as not reasonable and necessary. Based on this information, we decided that Medicare rules for coverage of the pneumatic compression device and related accessory have not been met.
Therefore, we decided that the Plan does not have to pay for the pneumatic compression device (E0675) and related accessory (E0673) provided February 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network provider.
You asked the Plan to pre-approve an office visit with an out-of-network provider. You say that you have been seeing the requested therapist for a long time. The Plan denied your request. The Plan says this service is available within the network.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for 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 services at issue in this appeal. Your last visit was January 2021. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction (92015) provided on December 21, 2020.
You asked the Plan to pay for an eye refraction. You say that you are a diabetic and you went in for a follow up on your eyes. You also say you asked for a prescription to get glasses and you did not know you had to go to a specific provider. The Plan denied your request. The Plan says an eye refraction is not covered if performed by a specialist listed in the provider directory.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers these services when it is obtained through one of the Plan's routine vision service
vendors.
We looked at the file and the Plan's rules. An eye refraction is not covered if performed by a provider that is not
part of the Plan's routine vision service vendors. The provider at issue is not one of the Plan's routine vision
service vendors. Based on this information, we decided that the Plan's rules for coverage of an eye refraction
have not been met. Therefore, we decided that the Plan does not have to pay for an eye refraction (92015)
provided on December 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital services provided October 16, 2020 to October 18, 2020.
You asked the Plan to pay for the hospital services. You say that the services were medically necessary. The Plan denied your request. The Plan says this service was already paid under another claim.
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 inpatient services are not supported. Specifically these services were paid under corrected claim 820203250193135. Based on this information, we decided that Medicare rules for coverage of the hospital services have not been met. Therefore, we decided that the Plan does not have to pay for hospital services provided October 16, 2020 to October 18, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (82306) provided December 28, 2020.
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 service is non-covered.
The Plan must follow Medicare rules. Medicare rules say that Medicare considers vitamin assay panels (more than one vitamin assay) a screening procedure and therefore, non-covered. We looked at the file and Medicare rules. The vitamin panel is not a covered service. 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 (82306) provided December 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of skin and tissue (11042) provided on August 12, 2020, to August 26, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the removal of skin and tissue. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON provider.
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 removal of skin and tissue (11042) provided on August 12, 2020, to August 26, 2020 by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) coverage received December 17, 2020 to January 15, 2021.
You asked the Plan to pay for SNF coverage. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are 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 pay for SNF coverage. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was evaluated in the emergency room and transferred to a skilled nursing facility. The documentation does not support that the enrollee required or receive any skilled nursing or therapy services. The enrollee was able to ambulate with a Rollator, independent with transfers, toileting, showering, and dressing. The documentation does not support that the enrollee required skilled therapy services, i.e., are the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment. Therefore, the enrollee did not meet criteria for the services received. 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 coverage have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) coverage received December 17, 2020 to January 15, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room services 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 99285 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 99285 is Level 5 emergency department visit for evaluation and management of patient with problem immediately threatening life, including comprehensive history and physical examination, and medical decision-making of high complexity.
We find that CPT code 99285 is not supported in the medical record. Specifically, the records do not support
the Level 5 complexity of services. 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 emergency
room services rendered on December 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve tracheotomy supplies to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve OON services. The Plan denied your request. The Plan says the requested services are available in-network.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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 at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON items. Therefore, we decided that the Plan does not have to pre-approve tracheotomy supplies to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a below-knee alignable system for a lower limb prosthesis.
You asked the Plan to pre-approve prosthetic component. You say that you meet the criteria for this prosthetic. The Plan denied your request. The Plan says the denial of authorization for this prosthetic component is correct, because you already have an alignable system and the records do not show why this cannot be used for your new prosthesis.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that you have below-knee alignable system. A new below-knee alignable system serves the same purpose as your current below-knee alignable system. Therefore, we decided that the Plan does not have to pre-approve a below-knee alignable system for a lower limb prosthesis.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost shares for the injections services provided from June 8, 2020, to August 11, 2020.
You asked the Plan to waive the cost shares for the services provided. You say that you were told your providers were in-network. The Plan denied your request.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).
The file shows that you received a hyaluronan injection by an out-of-network provider on June 8, 2020, June
23, 2020, July 28, 2020, and August 11, 2020. You were charged a 40% coinsurance for each date of service.
The services fall within the Medicare Part B prescription drugs benefit category.
You received fluoroscopic guidance services by an out-of-network provider on June 8, 2020, June 23, 2020,
July 15, 2020, July 28, 2020, and August 11, 2020. You were charged a 50% coinsurance for each date of
service. The service falls within the outpatient diagnostic tests benefit category.
You received joint injection services by an out-of-network provider on June 8, 2020, June 23, 2020, July 15,
2020, July 28, 2020, and August 11, 2020. You were charged a 30% coinsurance for each date of service. The
service falls within the physician services benefit category.
This means that you have been asked to pay the correct amounts based on your contract with the Plan. This cost
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that
the Plan does not have to waive the cost shares for the injections services provided from June 8, 2020, to
August 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation - per site (D7953) provided December 29, 2020.
You asked the Plan to pay for the bone replacement graft. You say that the bone graft was necessary for dentures. The Plan denied your request. The Plan says this service is not covered because you do not have preventative or comprehensive dental benefits under this plan.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare.
Therefore, we decided that the Plan does not have to pay for the bone replacement graft for ridge preservation - per site (D7953) provided December 29, 2020.