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

We decided that the Plandoes not haveto pre-approveadmission to a skilled nursing facility (SNF).You asked the Planto pre-approvethe admission. You say that this is medically necessary.The Plandenied your request. The Plansaysthere are no daily skilled complex nursing of therapy needs which would meet the guidelines.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 the admission. 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 skilled nursing facility 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 the admission have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadmission to a skilled nursing facility (SNF).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement service provided on May 11, 2020.
You asked the Plan to pay for the wound care. You say that the claim has not been paid in full or under the
terms of the contract for the services provided to the enrollee. The Plan denied your request. The Plan says the
enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits
starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it
is the provider's responsibility to verify the member's coverage before rendering services and to know proper
billing procedures for a Medicare Advantage member on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for the debridement service provided on May 11, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a mammogram provided on October 26, 2020.You asked the Plan to pay for the mammogram. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.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 servicesat issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for a mammogram provided on October 26, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the esophagogastroduodenoscopy, flexible,
transoral; biopsy; single or multiple (43239) provided June 25, 2020.
You asked the Plan to waive the copayment for the esophagogastroduodenoscopy. You say that you have had
this procedure done before and never had to pay $390. You are disabled. The Plan denied your request. The
Plan says the claim processed and the correct copayment was 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 $390
copayment for surgery or other services provided at an outpatient hospital, including but not limited to hospital
or other facility charges and physician or surgical charges.
You have been asked to pay $390 copayment for the esophagogastroduodenoscopy. The
esophagogastroduodenoscopy falls within the Outpatient surgery and other Medical 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 esophagogastroduodenoscopy, flexible, transoral; biopsy; single or multiple
(43239) provided June 25, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transport.

You asked the Plan to pay for the non-emergent ambulance service. You say that the enrollee cannot travel by car and must go by ambulance to safely get to the hospital. The Plan denied your request. The Plan says there is no authorization on file for the service.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules.

We looked at the file and Medicare rules. Prior authorization was not requested. Based on this information, we decided that Medicare rules for coverage of the non-emergent ambulance service have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance transport.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an ultrasound (76770) and an x-ray (71045) provided on August 4, 2020.
You asked the Plan to pay for an ultrasound and an x-ray. You say that these procedures are not specific to a place of service. The Plan denied your request. The Plan says these services were not billed with the correct place of service.
The Plan must follow Medicare rules. Medicare rules say that a physician/practitioner/supplier furnishing services to a patient who is a registered inpatient, shall, at a minimum, report the inpatient hospital POS code 21 irrespective of the setting where the patient actually receives the face-to-face encounter. We looked at the file and Medicare rules. The services at issue were reported with POS 22 for an outpatient hospital, but the record shows that the enrollee was registered as an inpatient at the time of service. Based on this information, we decided that Medicare rules for coverage of an ultrasound and an x-ray have not been met. Therefore, we decided that the Plan does not have to pay for an ultrasound (76770) and an x-ray (71045) provided on August 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copaymentfor the tendon sheath ligament injection (20550) provided on August 18, 2020.You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 copayment for Medicare covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges. You have been asked to pay a $243.22 copayment for the Medicare-covered surgery provided. This is the Plan allowed amount which is less than the applicable 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 copaymentfor the tendon sheath ligament injection (20550) provided on August 18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for COVID-19 testing (G2024, U0003) provided on September 10, 2020.
You asked the Plan to pay for COVID-19 testing. You say that this is supported in the records. The Plan denied your request. The Plan says this was billed with an incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. These services were billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of COVID-19 testing have not been met. Therefore, we decided that the Plan does not have to pay for COVID-19 testing (G2024, U0003) provided on September 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extraction (D7210) provided on October 8, 2020.

You asked the Plan to pay for the surgical extraction. You say that there is not an oral surgeon where you live. You say that you were in pain and did not ask about network. You also say that you would have to drive to another town in pain. You also say that this should not have been denied. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that out of network providers can bill you for the difference between what they charge and what the Plan pays.

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, dental services that you receive out of network may have a higher cost share. The Evidence of Coverage clearly states that out of network providers can bill you for the difference between what they charge and what the Plan pays. Therefore, we decided that the Plan does not have to pay for the surgical extraction (D7210) provided on October 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe radical resection of tumor procedure with current procedural terminology (CPT) code 24077 provided on July 8, 2020.You asked the Plan to pay forCPT code 24077. 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 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 24077 is not supported in the medical record. Specifically, this code was billed with the incorrect place of service code 11 (office). CPT code 24077 has a non-facility indicator identified as "NA", which indicates that this procedure is rarely or never performed in the non-facility setting. Based on this information, we decided that Medicare rules for coverage of CPT code 24077 have not been met.Therefore, we decided that the Plan doesnot have to pay forthe radical resection of tumor procedure with current procedural terminology (CPT) code 24077 provided on July 8, 2020
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on June 28, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that Medicare covers services in freestanding emergency departments only if the emergency clinic is affiliated with a hospital. We looked at the file and Medicare rules. The services in question were provided in a freestanding emergency department that is not affiliated with a hospital. 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 the services provided on June 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for acupuncture services provided by a
participating provider on October 13, 2020.
You asked the Plan to waive the copayment for acupuncture services. You say that you get up to 25 visits a
year and you have only used 17. You say that you do not agree with this copayment. The Plan denied your
request. The Plan says the correct copayment has been 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 $20
copayment for acupuncture.
You have been asked to pay a $20 copayment for acupuncture services. The correct copayment has been
applied to the services that were provided. Acupuncture services falls within the acupuncture 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 acupuncture services provided by a participating provider on
October 13, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe train of four (TOF) monitoring (CPT 95999) provided on June 29, 2020.You asked the Plan to pay forthe TOF monitoring. The Plan denied your request. The Plan says this is a bundled service.The Plan must follow Medicare rules. Medicare rules saythat all services which are integral to accomplishing a procedure are considered a component part of a comprehensive code.IONM services cannot be performed without TOF monitoring. This means that TOF testing is considered integral to the performance of IONM services. As such, this component of the procedure is included in payment for the overall IONM monitoring service which was already paid. No separate payment can be made for this part of the service.Therefore, we decided that the Plan does not haveto pay forthe train of four (TOF) monitoring (CPT 95999) provided on June 29, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services.

You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the continued
SNF stay was 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 above 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 the skilled nursing services. Our reviewer
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily
skilled nursing and/or skilled therapy on 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 the skilled nursing services have not been met. Therefore, we decided that the
Plan does not have to pay for the skilled nursing services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial 15 minutes of deep sedation (D9222), and additional 15 minutes of deep sedation (D9223), and the therapeutic parenteral drugs (D9612) provided on October 27, 2020.

You asked the Plan to pay for the dental services. You say that you had 9 teeth extracted. You also say that you do not understand why the anesthesia was not paid as it was necessary. The Plan denied your request. The Plan says the initial 15 minutes of deep sedation is not listed as a covered service. The Plan says that the additional 15 minutes of deep sedation is not listed as a covered service. The Plan also says that therapeutic parenteral drugs are not listed as covered services either.

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. Additionally, the record shows that you signed a financial agreement accepting financial responsibility for services that are not covered. Therefore, we decided that the Plan does not have to pay for the initial 15 minutes of deep sedation (D9222), and additional 15 minutes of deep sedation (D9223), and the therapeutic parenteral drugs (D9612) provided on October 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services you received.

You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says this is not a covered benefit.

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 dental services you received.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) and related services (94060, 94727, 94200, 94729, 94010) provided by an out of network (OON) provider.

You asked the Plan to pay for an OON office visit and related services. You say that the provider believed there was a referral for this patient. The Plan denied your request. The Plan says these services were not authorized.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the office visit (99214) and related services (94060, 94727, 94200, 94729, 94010) provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lumbar-sacral orthosis, sagittal-coronal control (L0650).

You asked the Plan to pay for lumbar-sacral orthosis. You say that the item is medically necessary. The Plan
denied your request. The Plan says the services were not documented in patient's medical records and the
supporting documentation does not match the information sent on the claim.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are 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 lumbar-sacral orthosis. Our reviewer says
that the requested item is not considered medically reasonable and necessary in this case. Our physician
reviewer found the documentation does not support that the lumbar-sacral orthosis was prescribed for one or
more of the covered indications in this case, as there is insufficient documentation of a credible evaluation and
credible physical examination of the back.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of lumbar-sacral orthosis have not been met. Specifically, the member does not
meet the criteria for this item. This means the item is not medically necessary or reasonable. Therefore, we
decided that the Plan does not have to pay for lumbar-sacral orthosis, sagittal-coronal control (L0650).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services (D9120).

You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says this 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. The Plan covers only those dental services for which the codes are
listed in the Evidence of Coverage. Dental code D9120 is not listed, and therefore is not covered. Therefore, we
decided that the Plan does not have to pay for the dental services (D9120).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81225, 81226, 81230, 81231, 81232, 81240,
81241, 81283, 81328, 81335, 81350, 81408, and 81479) provided on July 15, 2020.
You asked the Plan to pay for genetic testing. You say that these tests are supported in the records. The Plan
denied your request. The Plan says these tests were not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. If a laboratory assays two or more genes in a
patient in parallel, then those two or more genes will be considered part of the same panel. A panel constitutes
a single procedural service, so one HCPCS codes must be submitted for the panel.
We find that CPT codes 81225, 81226, 81230, 81231, 81232, 81240, 81241, 81283, 81328, 81335, 81350,
81408, and 81479 are not supported in the medical record. Specifically, the record shows that these tests are
considered part of the same panel and should be reported with a single HCPCS code. Based on this
information, we decided that Medicare rules for coverage of genetic testing have not been met.
Therefore, we decided that the Plan does not have to pay for genetic testing (81225, 81226, 81230, 81231,
81232, 81240, 81241, 81283, 81328, 81335, 81350, 81408, and 81479) provided on July 15, 2020.