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

We decided that the Plan does not have to pay for the electrocardiogram provided on August 9, 2020.
You asked the Plan to pay for the electrocardiogram. You say that the Plan should pay this claim. The Plan
denied your request. The Plan says an emergency department visit claim was submitted by the same group.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this
case, we have confirmed that code the electrocardiogram has a bundled relationship with code 99285 and
cannot be paid as billed. Both providers are within the same group and have the same specialty. The review is
already included in the emergency department evaluation and management payment. This code cannot be paid 
as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore,
we decided that the Plan does not have to pay for the electrocardiogram provided on August 9, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August 13, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says prior
authorization was not obtained by the provider or facility.
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
physician's services. 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 13, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (G0453, 95999) provided on May 12, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are bundled.
The Plan must follow Medicare rules. Medicare rules say that all services which are integral to accomplishing a procedure are considered a component part of a comprehensive code. Medicare rules also say that if a provider reports the two codes of an edit pair, the column two code is denied, and the column one code is eligible for payment. 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. Additionally, code G0453 is part of an edit pair with code 95955. Code 95955 is a column one code, and code G0453 is a column two code. Code 95955 has been for the same date of services, which means that Code G0453 is not eligible for payment. 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 (G0453, 95999) provided on May 12, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 10, 2019 by a non-network provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-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 for the medical services provided on September 10, 2019 by a non-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital care provided on August 19, 2019.
You asked the Plan to pay for the hospital care. You say that the filing timeline was extended. The Plan denied
your request. The Plan says the claim was untimely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010,
must be filed no later than one calendar year after the date of service.
The record shows that a claim for the hospital care was not filed until October 3, 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 care provided on August 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on August 5, 2020.You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says this service requires 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 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 subsequent nursing facility care provided on August 5, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on April 10,
2020.
You asked the Plan to pay for the services. You say that this should be paid for. 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 rendering 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 services provided to the enrollee on
April 10, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a diagnostic ultrasound provided on August 14, 2020.You asked the Plan to pay for the diagnostic ultrasound. The Plan denied your request. The Plan says this service requires 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 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 a diagnostic ultrasound provided on August 14, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided from August 25, 2020, to August 28, 2020.
You asked the Plan to waive the copayment for emergency care. You say that you were admitted inpatient and disagree with the charges. 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 a $90 copayment for emergency care. The medical records show that you received emergency care on August 25, 2020, to August 28, 2020. There is no indication that you were admitted inpatient. Therefore, you are responsible to pay the $90 copayment. You have been asked to pay a $90 copayment for emergency care. Emergency care falls within the emergency 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 for emergency care provided from August 25, 2020, to August 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel rendered on August
20, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan
does not have to pay for the cardiovascular risk assessment panel rendered on August 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment foran outpatient hospital visit provided on July 24, 2020.You asked the Plan to reduce the copayment forthe outpatient hospital visit. You say that you went for a nuclear stress test and it was only half-way completed.  The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a planmust 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 $225 copayment for each Medicare-covered in-network outpatient hospital facility visit. You have been asked to pay a $225 copayment for the outpatient hospital visit. The outpatient hospital visit falls within the "Outpatient hospital services" benefit category. The medical record shows the hospital outpatient visit was completed.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 copayment forthe outpatient hospital visit provided on July 24, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for emergency services provided on October 21,
2019.
You asked the Plan to reimburse you for the emergency services. You say that the Plan should reimburse you
for the emergency care. The Plan denied your request. The Plan says they do not cover emergency services
when rendered outside of the United States or its Territories.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at the file and Medicare rules. Emergency services were rendered on a cruise ship outside the U.S
and are not covered outside the U.S. or its territories. Based on this information, we decided that Medicare
rules for coverage of emergency services have not been met. Therefore, we decided that the Plan does not have
to reimburse you for emergency services provided on October 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse more forthe partial upper denture (D5211) provided on October 5, 2020.You asked the Plan to reimburse more forthe dental item. You say that you paid $1,500 out of pocket for the partial denture. You also say that you do not agree with the amount of reimbursement that you received.The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that covered dental services that you receive out of network have a higher cost share amount. The Plan also says that you will be responsible for the copay or coinsurance that may be higher if they visit an out of network provider.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 and the partial denture is listed as covered, dental services that you receive out of network have a higher copay or coinsurance that you are responsible for.Therefore, we decided that the Plan does not have to reimburse more forthe partial upperdenture (D5211) provided on October 5, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 14, 2020 to January 23, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the outpatient mental health services. You say that you would like reconsideration because you have been trying to get your contract updated and would like an exception for continuity of care for this member. The Plan denied your request. The Plan says authorization was not obtained for the out-of-network 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 for the medical services provided on January 14, 2020 to January 23, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the X-ray of chest provided on August 14, 2020, by an out of network (OON) provider.
You asked the Plan to pay for the X-ray of chest. You say that you were not aware you were OON with the Plan. The Plan denied your request. The Plan says prior authorization was not obtained by the provider or facility.
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 X-ray of chest provided on August 14, 2020, 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 cone beam computed tomography (CT) capture (D0367) and surgical placement of implant body (D6010) provided on August 24, 2020.
You asked the Plan to pay for cone beam CT capture and surgical placement of implant body. You say that you were under the impression the Plan would cover the dental services you received. The Plan denied your request. The Plan says the services you received are not covered benefits under your supplemental 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. Therefore, we decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture (D0367) and surgical placement of implant body (D6010) provided on August 24, 2020.
Your complaint about the Plan potentially giving you misinformation regarding coverage 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forincision procedures on the hand and fingers (26020) arthrotomy, with exploration, drainage, or removal of loose or foreign body (26075) provided September 25, 2020.You asked the Plan to waive the copayment forthe surgical procedure. You say that the claim was processed and the correct copayment was applied per the evidence of coverageThe Plan denied your request. The Plan says the claim was 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 $200 for each Medicare covered surgery procedure or service including blood transfusions and invasive procedures such as epidurals and bronchoscopies at an ambulatory surgical center. You have been asked to pay $200 for the surgical procedure. The surgical procedure 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 forincision procedures on the hand and fingers (26020) arthrotomy, with exploration, drainage, or removal of loose or foreign body (26075) provided September 25, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided on July 27, 2020.You asked the Plan to pay forthe ambulance services. You say that you had fallen and the medics helped you get back up.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 July 27, 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 forthe ambulance services provided on July 27, 2020
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from July
19, 2020 to July 30, 2020.
You asked the Plan to pay for the SNF services. You say that you feel that the plan should cover for the SNF
services. The Plan denied your request. The Plan says medical necessity cannot be established for continued
SNF level of coverage.
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 SNF services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing
and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily
basis and does 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 SNF services have not been met. Therefore, we decided that the Plan does
not have to pay for the skilled nursing facility (SNF) services provided from July 19, 2020 to July 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for moderate sedation provided by an out-of-network provider
on February 15, 2018.
You asked the Plan to pay for the moderate sedation. You say that the documents support the level of service
provided. You say that the claim should be reprocessed for payment. The Plan denied your request. The Plan
says services should be received from network providers.
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
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 moderate sedation provided by an out-of-network
provider on February 15, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe moderate sedation services coded 99152 provided on July 24, 2020.You asked the Plan to pay forthe moderate sedation 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.In this case, the CPT Code Manual definition of code 99152 is moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older.We find that CPT code 99152 is not supported in the medical record. Specifically, the documentation submitted did not indicate the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; therefore, the billed service cannot be verified. Based on this information, we decided that Medicare rules for coverage of the moderate sedation services have not been met.Therefore, we decided that the Plan does not have to pay forthe moderate sedation services coded 99152 provided on July 24, 2020.