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

We decided that the Plan does not have to pay for subsequent nursing facility care (99308) provided on March 24, 2020.
You asked the Plan to pay for the subsequent nursing facility care. You say that you would like reconsideration because the services rendered were medically necessary. The Plan denied your request. The Plan says when an enrollee elects hospice, Original Medicare takes effect on that day and all services after that date should be billed to Original Medicare.
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 dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care (99308) provided on March 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 15, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the injections (64635 and 64636). You say that you would like reconsideration because these services did not require prior authorization. The Plan denied your request. The Plan says utilization of network providers is required when possible and available.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on August 15, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded 80307 and G0483 provided on August 21, 2019.
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 codes 80307 and G0483 are not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in an office setting place of service 11; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an outpatient rehabilitation setting place of service 57. 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 drug testing coded 80307 and G0483 provided on August 21, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 87641, 87798, and 87900 provided on September 4, 2019.You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not supported by the documentation.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 codes 87641, 87798, and 87900 are not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met.Therefore, we decided that the Plan does not have to pay for the laboratory services coded 87641, 87798, and 87900 provided on September 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 27, 2020 by an out of network (OON) provider.You asked the Plan to pay for the outpatient visit (99202). You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says utilization of a network provider is required when possible and available.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for the medical services provided on February 27, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-ofnetwork
provider on December 5, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network
deficiency for these 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 has network providers
available who can provide 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 medical services provided to the enrollee by an out-of-network provider
on December 5, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the arthrocentesis provided on February 11, 2020.
You asked the Plan to waive the copayment for the arthrocentesis. You say that you were not informed of any additional fees for this service. You say you have never paid a specialty room fee before. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $300 copayment for surgery services at an in-network outpatient hospital. You have been asked to pay a $175 copayment for the arthrocentesis which is less than the standard copayment amount. The arthrocentesis falls 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 arthrocentesis provided on February 11, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a colonoscopy provided on January 7,
2020.
You asked the Plan to waive the coinsurance for a colonoscopy. You say that you thought that the provider was
in-network. 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 50%
coinsurance for out-of-network colorectal cancer screenings.
You received a colonoscopy on January 7, 2020 from an out-of-network provider. Therefore, you are
responsible to pay your share of the out-of-network charges. The allowed amount is $440.91 and 50% of that is
$220.45.
You have been asked to pay the total coinsurance amount of $220.45 for a colonoscopy. A colonoscopy falls
within the colorectal cancer screening benefit category. This means that you have been asked to pay the correct
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for a
colonoscopy provided on January 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services post-op visit provided to the enrollee on August
15, 2019.
You asked the Plan to pay for the visit. The Plan denied your request. The Plan says payment for this service is
included in payment for the surgery.
The Plan must follow Medicare rules. Medicare rules say that Medicare approved amount for global surgical
procedures includes payment for the above services related to the surgery when furnished by the physician who
performs the surgery.
We looked at the file and Medicare rules. The surgical procedure provided to the enrollee on August 15, 2019,
has a 90-day global surgical period. This means that any post-op visit provided within 90 days of the surgery is
included in the payment for the surgery. Payment for the requested post-op visit is included in the payment for
the surgery performed on the same date. Based on this information, we decided that Medicare rules for
coverage of the visit have not been met. Therefore, we decided that the Plan does not have to pay for the
services post-op visit provided to the enrollee on August 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on April 16,
2020.
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 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. The Plan did not pre-approve the service 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 physician services provided to the enrollee on April 16, 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) provided on March 4, 2020.You asked the Plan to pay for the problem focused limited oral evaluation. You say that you called the Plan prior to having the service rendered, and were told it would be paid for under preventive services.The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan.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 records show that the Plan verified there were no calls regarding the dental services prior to the March 3, 2020 date of service.Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on March 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a preventive medicine reevaluation (99396) provided on February 26, 2020.
You asked the Plan to pay for the preventive medicine reevaluation. You say that you would like reconsideration because this is a new provider to you and do not know why the provider ran tests on you. The Plan denied your request. The Plan says you had a periodic preventive exam which is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the preventive medicine reevaluation have not been met. Specifically, this service is not a Medicare covered benefit. Therefore, we decided that the Plan does not have to pay for a preventive medicine reevaluation (99396) provided on February 26, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Clonidine, Lisinopril, Carvedilol, Cholecalciferol, Insulin Glargine, Hydralazine, Atorvastatin, and aspiring provided from January 10, 2020 to January 12, 2020.You asked the Plan to pay for the self-administered drugs. You say that these drugs were provided to you in the hospital as part of your treatment. You also say that you contacted the Plan on February 21, 2020 and were advised that everything would be covered by the Plan, but later you received a bill for these drugs.The Plan denied your request. The Plan says these are self-administered medications that are not covered under Part B.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pay for the Clonidine, Lisinopril, Carvedilol, Cholecalciferol, Insulin Glargine, Hydralazine, Atorvastatin, and aspiring provided from January 10, 2020 to January 12, 2020.Benefits for the self-administered drugs may be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services provided on December 31, 2019 by an out of network (OON) provider.You asked the Plan to pay for radiology services. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the member's primary care physician did not refer these 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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for radiology services provided on December 31, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the cataract surgeries provided on March
5, 2020 to March 12, 2020.
You asked the Plan to waive the coinsurance for the cataract surgeries. You say that you were told that the
surgeries would be covered. You say you do not think you should have to pay this at all. The Plan denied your
request. The Plan says you have been charged the correct cost sharing 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 20%
coinsurance for surgery services at an in-network outpatient hospital or ambulatory surgical center.
You have been asked to pay $421.48 which is 20% of the allowed amount for the cataract surgery on each date
of service. The allowed amount is $2,107.39. ($2,107.39 x 20% = $421.48). ($421.48 + $421.48 = $842.96).
The cataract surgeries 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 coinsurance for cataract surgeries on March 5, 2020 to March 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on April 14, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the 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 has network providers available who can provide 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 medical services provided to the enrollee by an out-of-network provider on April 14, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for retroperitoneal ultrasound provided to the enrollee on
January 22, 2020.
You asked the Plan to pay for the ultrasound. You say that this should be paid for. The Plan denied your
request. The Plan says Current Procedural Terminology (CPT) code 76775 remains 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 76775 is "ultrasound, retroperitoneal, real time with
image documentation; limited."
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 ultrasound. Our reviewer says that the
medical records do not support the services at issue in this case. Our physician reviewer found a review of the
report of the ultrasound of 1/22/20 finds the contention that the exam was a limited retroperitoneal study is not
supported by the dictated technique or findings. In particular the report describes transthoracic findings
including evaluation of the proximal aorta but there is no discussion of the appearance of the abdominal aorta
and kidneys. There is a statement concerning non diagnostic evaluation of the abdomen but in summary there is
no justification within the report for coding of the exam CPT 76775.
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 ultrasound have not been met. Therefore, we decided that the Plan does not
have to pay for retroperitoneal ultrasound provided to the enrollee on January 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on February 25,
2020.
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 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. The Plan did not pre-approve the service 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 physician services provided to the enrollee on February 25, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that you believe the ambulance services should
be covered. You say that the enrollee fell while in the bath and was unable to get out on his own. The
emergency services were called to help the member out of the shower. You stated that the bill seems too high
for the services provided and the short distance that was travelled by the responders. You say that the services
should be covered by the Plan, and you asked the Plan to reconsider providing payment. The Plan denied your
request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.
The ambulance company did not provide transport services on April 1, 2020. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for the ambulance services.