Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of intraoral x-rays provided on February 12, 2021.
You asked the Plan to pay for the complete series of intraoral x-rays. You say that you were told this would be a free dental checkup and were not aware you would be billed. The Plan denied your request. The Plan says this service is not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the complete series of intraoral x-rays provided on February 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on February 10, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for lab tests. You say that this testing fully satisfies medical necessity guidelines. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this provider is out-of-network with the Plan and authorization was not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on February 10, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic parenteral drugs provided on January 15, 2021.
You asked the Plan to pay for the therapeutic parenteral drugs. You say that you would like this service to be covered. The Plan denied your request. The Plan says this service is not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the therapeutic parenteral drugs provided on January 15, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the tissue exam services provided on December 16, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the OON services. You say that you cannot afford to let the claims go unpaid. The Plan denied your request. The Plan says the services 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 pathology 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 tissue exam services provided on December 16, 2020 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 the psychotherapy services (90837) provided on September 16, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the psychotherapy services. You say that the service was provided with no adequate time frame to obtain authorization for the service. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 psychotherapy services (90837) provided on September 16, 2020 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 the hospital discharge day management, more than 30 minutes (99239) provided June 20, 2020.
You asked the Plan to pay for the hospital discharge day management, more than 30 minutes. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the medical records do not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99239 is hospital discharge day management, more than 30 minutes. We asked our coder 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 hospital discharge day management, more than 30 minutes. Our reviewer says that the coverage criteria for the code as billed have not been met. Our reviewer found the medical records provided do not include sufficient documentation of 31 minutes or more to validate that hospital discharge day management, more than 30 minutes was performed on June 20,2020. Therefore, this service cannot be verified. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the hospital discharge day management, more than 30 minutes have not been met. Therefore, we decided that the Plan does not have to pay for the hospital discharge day management, more than 30 minutes (99239) provided June 20, 2020.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve carpal tunnel release.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
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 pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee enrollee has a year and half history of bilateral hand pain, numbness, and tingling. She has positive Tinel and Phalen bilaterally. EMG/NCV indicates right carpal tunnel syndrome. There is no evidence of left carpal tunnel syndrome. There is no record of an adequate trial of non-surgical management on the left. The enrollee has decided to proceed with the left release first. The records do not support that the procedure is reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. 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 pre-approve carpal tunnel release.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment with no transport
provided on May 31, 2020.
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you did
not ask for the paramedic's assistance. You also say that you told the paramedics you did not want to be
transported to the hospital. The Plan denied your request. The Plan says this expense is not covered by the Plan.
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 May 31, 2020. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
The record shows that you signed a form acknowledging that you refused to be transported. Therefore, we
decided that the Plan does not have to pay for the ambulance response and treatment with no transport provided
on May 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for diagnostic imaging and the deductible and coinsurance for an injection provided by a participating provider on February 3, 2021
You asked the Plan to waive the deductible for diagnostic imaging and the deductible and coinsurance for an injection. You say that you do not agree with these charges. The Plan denied your request. The Plan says the correct charges have 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 $300 deductible and a 20% coinsurance for Medicare Part B prescription drugs/in-network. You have been asked to pay a $300 deductible and a 20% coinsurance of the allowed amount for an injection.
CPT Code
Allowed Amount
Deductible
Coinsurance
Total Amount
92134
$41.41
$41.41
---
$41.41
67028
$114.66
$114.66
---
$114.66
J2778
$1,621.35
$143.93
$295.48 (20%)
$439.41
Total Amount Being Asked to Pay: $41.41 + $114.66 + $439.41 = $595.48
An Injection falls within the Medicare Part B prescription drugs/in-network 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 deductible for diagnostic imaging and the deductible and coinsurance for an injection provided by a participating provider on February 3, 202
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram (ECG) interpretation and report (93010) provided on January 23, 2021.
You asked the Plan to pay for the ECG services. You say that this was billed correctly and should be paid. The Plan denied your request. The Plan says since 93010 was billed without a modifier, no payment can be made.
The Plan must follow Medicare rules. Medicare rules say that for NCCI edit pairs, only the Column 1 code is payable unless the Column 2 code has a clinically appropriate modifier. In this case, the denied code is a Column 2 code in relation to code 12001, defined as simple repair of superficial wounds, 2.5 cm or less. Since no modifier was used on the Column 2 code, no payment can be made. Therefore, we decided that the Plan does not have to pay for the electrocardiogram (ECG) interpretation and report (93010) provided on January 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the telephone evaluation provided on January 4, 2021, by an OON provider.
You asked the Plan to pay for the services provided. You say that this plan is the primary payor. The Plan denied your request. The Plan says prior authorization was not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The 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 telephone evaluation provided on January 4, 2021, by an OON provider
Appeal type: Lab
Decision: Partially Favorable

We decided that the Plan has to pay for CPT 88361. We decided that the Plan does not have to pay for CPT
88305.
You asked the Plan to pay for the services. The Plan says that the services are not covered.
We decided that the Plan has to pay for CPT 88361.
The Plan follows Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or
service, then that item or service will be covered when it is medically necessary.
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. Our reviewer says that the
services (88361) are medically reasonable and necessary in this case. Our physician reviewer found that the
enrollee underwent an upper endoscopy and had a WATS diagnostic platform. The requested testing at issue in
this case is medically reasonable and necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of CPT 88361 have been met. Therefore, we decided that the Plan has to pay for
CPT 88361.
We also decided that the Plan does not have to pay for CPT 88305.
The Plan follows 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 88305 is not supported in the medical record. Specifically, the records show that CPT
88305 was paid by the Plan on a separate claim as a professional component. In this case, CPT 88305 was
billed as a global code, which is not separately payable as a global service when the professional component
has been billed and paid. Based on this information, we decided that Medicare rules for coverage of CPT 88305
have not been met. Therefore, we decided that the Plan does not have to pay for CPT 88305.
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: 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 you are not able to get around on your own. You state you cannot go from chair to bed or walk to the bathroom. You state you are not able to do every day basic tasks and are a fall risk. The Plan denied your request. The Plan says the stay is not medically necessary. The Plan states you can receive the care you need in another setting, such as home, a long-term care facility, or other outpatient setting.
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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the individual psychotherapy services (90832) provided on October 14, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the individual psychotherapy services. You say that the service was provided with no adequate time frame to obtain authorization for the service. The enclosed medical records clearly reflect the medical necessity for the services rendered. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 individual psychotherapy services (90832) provided on October 14, 2020 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 services (90837) provided on September 24, 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 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 psychotherapy services (90837) provided on September 24, 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 rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF 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 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 complexity of the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and
an intensive rehabilitation therapy program.
The enrollee will 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. There is not a
reasonable expectation that this enrollee 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the lab services provided on February 25, 2021.
You asked the Plan to waive the copay for the lab services. You say that you should not have to pay for a service you did not have. The Plan denied your request. The Plan says the claim processed 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 $20 copay for lab tests. You have been asked to pay a $20 copay for lab tests for the lab services. The lab services fall within the outpatient diagnostic tests 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 lab services provided on February 25, 2021.