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

We decided that the Plan does not have to pay foran x-ray provided on August 11, 2020 by an out of network (OON) provider.You asked the Plan to pay foran x-ray. You say that you would like this claim reprocessed and paid. You say that you thought you were in-network.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 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 foran x-ray provided on August 11, 2020 by an out of network (OON) provide
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe SNF stay provided from July 8, 2020, to July 30, 2020.You asked the Plan to waive the copayment forthe SNF stay. You say that you wanted to leave the facility two days earlier, but the facility insisted you stay. 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 $0 copayment for each day for days 1 to 20 and a $160 copayment each day for days 21 to 62. You have been asked to pay a $320 copayment for the SNF stay. The SNF stay falls within the "Skilled Nursing Facility (SNF) Care"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 forthe SNF stay provided from July 8, 2020, to July 30, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay forthe crown (D2751) provided on August 11, 2020.You asked the Plan to pay forthe dental service. You say that one of your front upper teeth broke off near the gum. You say that the impression was made on August 11, 2020. You say that this was the initial crown. You also say that this temporary crown was placed for now until a permanent one could be made.The Plan denied your request. The Plan says that there is no evidence that the crown placed was the initial crown or a replacement crown. The Plan also says that an x-ray was required but not received.The rules say a plan must disclose to its enrollees in clear, accurate terms the situations in which services are not covered. Your contract with the Plan does not say in clear and accurate terms the situations in which covered dental services would not becovered. We looked at your contract with the Plan. We did not see where the contract says that x-rays are required to determine if a crown would be covered. The Plan contract does not clearly state the situations in which crowns are not covered. This means that the Plan did not follow Medicare rules.Therefore, we decided that the Plan has to pay forthe crown (D2751) provided on August 11, 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/orsend 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe extraction, erupted tooth requiring removal of bone and/or sectioning of tooth (D7210), alveoloplasty in conjunction with extractions (D7310), deep sedation/general anesthesia (D9222, D9223) provided on June 30, 2020 by an out-of-network (OON) provider.You asked the Plan to pre-approvethe extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, alveoloplasty in conjunction with extractions, anddeep sedation/general anesthesia. You say that you were not aware the dentist was OON.The Plan denied your request. The Plan says no benefits are available for procedures performed by OON providers.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. The Plan covers the extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, alveoloplasty inconjunction with extractions, and deep sedation/general anesthesia when the services are provided by an in-network dentist.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 forthese items/services.Therefore, we decided that the Plan does not have to pre-approvethe extraction, erupted tooth requiring removal of bone and/or sectioning of tooth (D7210), alveoloplasty in conjunction with extractions (D7310), deep sedation/general anesthesia (D9222, D9223) provided on June 30, 2020 by an out-of-network (OON) provider.Your complaint about potentially receiving misinformation regarding the network status of the provider you saw is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services provided on September 22, 2020 by an out of network (OON) provider.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without prior authorization.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the 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 forthe laboratory services provided on September 22, 2020 by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay forphysical therapy services (97110, 97140) provided on July 28, 2020.You asked the Plan to pay forphysical therapy services. You say that these codes are supported in the records.The Plan denied your request. The Plan says the billed units are not supported.The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code.We find that 2 units each of CPT codes 97110 and 97140 are not supported in the medical record. Each unit of these codes represents 15 minutes of service. The time spent on these services is not documented in the records; therefore, the billed units cannot be verified. Based on this information, we decided that Medicare rules for coverage of physical therapy services have not been met.Therefore, we decided that the Plan does not have to pay forphysical therapy services (97110, 97140) provided on July 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

e decided that the Plan does not have to pay for physician's services providedon August 25, 2020.You asked the Plan to pay for the physician's services.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 nota 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 physician's services provided on August 25, 2020
Appeal type: SNF
Decision: Favorable

We decided that the Plan does not have to pay for the subsequent nursing facility visits (99308, 1123F, 3288F) provided to the enrollee on May 13, 2020 and May 20, 2020.
You asked the Plan to pay this claim. You say that this service should be paid for by the Plan. The Plan denied your request. The Plan says Medicare billing criteria were not met. We overturned the Plan's denial. The Plan requested a reopen and provided additional information. The Plan says that this claim was denied because the provider was not eligible for payment of this service. The Plan states the NPI Registry shows this provider is listed as a Nurse Practitioner. The Plan states that the provider did not bill with this taxonomy. The Plan provided additional information from the claim that shows the provider has billed with a Registered Nurse taxonomy.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate taxonomy codes and those codes must be Medicare eligible providers. In this case, the billing provider is not eligible for Medicare payment based on the issues with the taxonomy code provided. Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility visits (99308, 1123F, 3288F) provided to the enrollee on May 13, 2020 and May 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital observation or inpatient care (99235) provided.

You asked the Plan to pay for the hospital observation or inpatient care. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says the claim was not submitted timely.

The Plan follows Medicare rules. The rules say that claims for services furnished, must be filed no later than one calendar year after the date of service.

The record shows that a claim for the hospital observation or inpatient care was not filed until August 17, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay for the hospital observation or inpatient care (99235) provided.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ultrasound of pelvis (76856) provided on September 16, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe ultrasound of pelvis. You say that you were not aware you were an OON provider.The Plan denied your request. The Plan says there is no authorization on file for the non-contracted provider service.Medicare rules saythat 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 forthe ultrasound of pelvis (76856) provided on September 16, 2020 by an out of network (OON) provider.
Appeal type: ER
Decision: Favorable

We decided that the Plan does not have to pay for emergency department services provided to the enrollee on May 19, 2020 and billed under claim 820201501010804 for code 99283.
You asked the Plan to pay for this service. You say that these services should be paid by the Plan. The Plan denied your request. The Plan says Medicare billing criteria were not met. We overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan states that this claim denied because the provider billed with a missing diagnosis or condition. The Plan states this claim was billed with diagnosis code T50.905A for "Adverse effect of unspecified drugs, medicaments and biological substances, initial encounter as the primary diagnosis." The Plan states this is a secondary diagnosis code and cannot be billed as the primary or first listed or principal diagnosis for any procedure or service. The ICD-10-CM Poisoning by, adverse effects of and under-dosing of drugs, medicaments and biological substances (T36-T50) guidelines explains: "When coding a poisoning or reaction to the improper use of medication (e.g., overdose, wrong substance given or taken in error, wrong route of administration), first assign the appropriate code from categories T36-T50".
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate diagnosis codes. In this case, this claim was submitted without a valid primary diagnosis code. Medicare billing criteria were not met. Therefore, we decided that the Plan does not have to pay for emergency room services provided to the enrollee on May 19, 2020 and billed under code 99283.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost share for the specialist office visit or the Part B drug provided on August 31, 2020.
You asked the Plan to reduce the cost share for the office visit and the Part B drug. You say that you were told there would be a $125 copayment for this service. You say you would have found a less expensive treatment. 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 $45 copayment for in-network physician specialist services and 20% coinsurance for all other drugs covered under Medicare Part B. You have been asked to pay a $45 copayment for the specialist office visit. You have also been asked to pay $800 which is 20% of the allowed amount for the Part B drug. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The Part B drug falls within the "Medicare Part B prescription drugs" 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 reduce the cost share for the specialist office visit or the Part B drug provided on August 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe preventive procedure (D1999), panoramic x-ray (D0330), and detailed and extensive oral evaluation (D0160) provided on October 27, 2020.You asked the Plan to pay forthe preventive procedure, panoramic x-ray, and detailed and extensive oral evaluation. You say that you were advised by the Plan that as long as you went to a doctor that was approved by your insurance the services would be covered. You also say that this claim was supposed to be paid under medical, and not dental.The Plan denied your request. The Plan says procedures not listed on the patient charge schedule are not covered. The Plan also says that an authorization was not obtained for this specialistvisit.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 panoramic x-ray was done for diagnostic purposes in relation to a potential medical condition. This x-ray is not a preventive x-ray.Therefore, we decided that the Plan does not have to pay forthe preventive procedure (D1999), panoramic x-ray (D0330), and detailed and extensive oral evaluation (D0160) provided on October 27, 2020.
Please Note:The provider stated that they wouldrebill this claim as a medical claim. Please refer to the provider and the Plan for more information about the medical claim processing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean expandable controller (E2377, E2313, E2311) and a power seat elevation system (E2300).You asked the Plan to pre-approvean expandable controller and a power seat elevation system. You say that the enrollee needs these items.The Plan denied your request. The Plan says the enrollee can control the power options through their own switches and the power seat elevator is non-covered.The Plan follows Medicare rules. Medicare rules say that expandable controllers are covered when medically necessary for the functions described above. Power seat elevation features are non-covered because they are not primarily medical in nature.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 an expandable controller and a power seat elevation system. Our reviewer says that the criteria for coverage of the requested items have not been met. Our physician reviewer found the documentation does not show that the patient requires other types of proportional input devices, 3 or more powered seating actuators through the drive control, a separate display, other electronic devices, or an attendant control. The patient's strength and functional ability, indicating independence in feeding, using a urinal independently and needing a power wheelchair for self dressing and meal prep,are sufficient to operate any power options through their own switches.  The power seat elevation system is non-covered.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an expandable controller and a power seat elevation system have not been met.Therefore, we decided that the Plan does not have to pre-approvean expandable controller (E2377, E2313, E2311) and a power seat elevation system (E2300).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex superion procedure (CPT Code(s): 22869 and 22870).

You asked the Plan to pre-approve the services. You say that the services are necessary.The Plan denied your request. The Plan says the services are considered experimental and investigational.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 the services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the spinous process device is experimental. More research is needed to show safety and efficacy.

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 have not been met.Therefore, we decided that the Plan does not have to pre-approve the Vertiflex superion procedure (CPT Code(s): 22869 and 22870)
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on October 15, 2019 by an out of network (OON) provider.
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was obtained. The Plan says that the referring provider is also out-of-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 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 lab work provided on October 15, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay forvitamin D assay testing provided to the enrollee on April 27, 2020.You asked the Planto pay forthe testing. You say that this should be paid for.The Plandenied your request. The Plansaysthe services are not authorized because code 82306 is not a Medicare benefit for the diagnoses listed on the claim and is done for screening purposes.The Plan must follow Medicare rules. Medicare rules say that vitamin D assay testing cannot be done for screening purposes. The testing at issue in this case was done for screening purposes. The enrollee is not indicated for the testing. Based on this information, we decided that Medicare rules for coverage of the testing have not been met.Therefore, we decided that the Plandoes not haveto pay forvitamin D assay testing provided to the enrollee on April 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlab work provided on October 15, 2020, by an out-of-network (OON) provider.You asked the Plan to pay forlab work. You say that you would like this claim reprocessed and paid.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 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 forlab work provided on October 15, 2020, by an out-of-network (OON) provider.