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

We decided that the Plan does not have to pay for out of network physician services provided on February 8,
2021.
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 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 out of network physician services provided on
February 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Coronavirus testing you had on December 18, 2020.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were paid at the Medicare rate.
The Plan must follow Medicare rules. Medicare rules say that for services of a non-contracting, original Medicare, participating provider; there is no balance billing paid by either the plan or the enrollee. We looked at your request, the file and Medicare rules. Based on this information we have determined that Medicare coverage criteria have not been met. Specifically, the record indicates that the Plan has reimbursed you the allowed amount for the testing services. The documentation submitted also indicates that these services were rendered by an out-of-network provider, meaning that balance billing will not be paid by the Plan. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the Coronavirus testing you had on December 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the six localized deliveries of antimicrobial agents (D4381 x6), four adjunctive pre-diagnostic tests (D0431 x4), four gingival irrigations (D4921 x4), and two drugs or medicaments dispensed in the office for home use (D9630 x2) provided on March 9, 2021.
You asked the Plan to pay for the localized deliveries of antimicrobial agents, adjunctive pre-diagnostic tests, gingival irrigations, and drugs or medicaments. You say that you verified that the doctor and office were in-network before you received these services. The Plan denied your request. The Plan says these services are 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 six localized deliveries of antimicrobial agents (D4381 x6), four adjunctive pre-diagnostic tests (D0431 x4), four gingival irrigations (D4921 x4), and two drugs or medicaments dispensed in the office for home use (D9630 x2) provided on March 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone density study provided on February 27, 2021.
You asked the Plan to pay for Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine) (77080). You say that the medical claim was billed correct using the correct patient age. The Plan denied your request. The Plan says the claim was denied because it was reported as a screening study for a male.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal, Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine) (77080), 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 bone density study provided on February 27, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (87541) provided May 4, 2020.
You asked the Plan to pay for the lab services. You say that the lab testing was medically necessary. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that Multiplex PCR respiratory viral panels of 6 or more pathogens are non-covered. We looked at the file and Medicare rules. The record shows the test was for more than 5 pathogens. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (87541) provided May 4, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the SNF services provided from December 7, 2020, to December 31, 2020 by an OON provider.
You asked the Plan to pay for the speech/hearing therapy, therapeutic exercises, neuromuscular reeducation of movement, gait training therapy, therapeutic activities, self-care/home management training, and wheelchair management training. The Plan denied your request. The Plan says a prior authorization was never requested by the OON provider or enrollee 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 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 SNF services provided from December 7, 2020, to December 31, 2020 by an OON provider
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for emergency care and outpatient hospital observation provided from July 18, 2020, to July 20, 2020.
You asked the Plan to waive the copayments for emergency care and outpatient hospital observation. You say that you were discharged but later 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. Your contract with the Plan also clearly says that you must pay a $125
copayment for outpatient hospital observation. The medical records show that you received emergency care on July 18, 2020. Therefore, you are responsible to pay the $90 copayment. The medical records show that you received outpatient hospital observation from July 18, 2020, to July 20, 2020. Therefore, you are responsible to pay the $125 copayment. The total amount you owe is: $215. You have been asked to pay the total copayment amount of $215 for emergency care and outpatient hospital observation. Emergency care falls within the emergency care benefit category. Outpatient hospital observation falls within the outpatient hospital observation 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 copayments for emergency care and outpatient hospital observation provided from July 18, 2020, to July 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a second unit of cytopathology services (88120) provided on
February 4, 2021.
You asked the Plan to pay for cytopathology services. You say that this is not a duplicate charge. The Plan
denied your request. The Plan says this was previously billed and paid.
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 a second unit of CPT code 88120 is not supported in the medical record. The medical record only
supports 1 unit of CPT code 88120, which was previously billed and paid. Based on this information, we
decided that Medicare rules for coverage of cytopathology services have not been met. Therefore, we decided
that the Plan does not have to pay for a second unit of cytopathology services (88120) provided on February 4,
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic manipulative treatment (98940) functional outcomes assessment (G8942, G8539) provided January 14, 2021 to May 12, 2021.

You asked the Plan to pay for the chiropractic services. You say that it is necessary that you see a chiropractor to help with treatment as you are unable to take over the counter and other prescription medications due to reactions and you have been off opioids for 3 years. The Plan denied your request. The Plan says maintenance chiropractic care is not covered under Medicare or the Plan.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic manipulative treatment (98940) functional outcomes assessment (G8942, G8539) provided January 14, 2021 to May 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on January 23, 2021.
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 procedure code 44139 is 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 44139 is Mobilization (take-down) of splenic flexure
performed in conjunction with partial colectomy (List separately in addition to primary procedure).
We find that CPT code 44139 is not supported in the medical record. Specifically, this is an add-on code that
was not billed with a required primary procedure code. 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
pay for the surgical services rendered on January 23, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81206, 81210, 81235, 81275, 81276, 81292, 81295, 81298, 81317, 81401, & 81309) provided February 25, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim is not payable as billed.
The Plan must follow Medicare rules. Medicare rules say that a panel constitutes a single procedural service, so one CPT code must be submitted for the panel. We looked at the file and Medicare rules. Multiple unbundled codes were billed for the testing panel. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81206, 81210, 81235, 81275, 81276, 81292, 81295, 81298, 81317, 81401, & 81309) provided February 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compression device (CPT code E0673) provided to the enrollee on November 13, 2020.
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. The Plan says this is not covered by the health plan or Medicare.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met The pneumatic compression device and/ or supplies is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery, at home, or in any setting. The enrollee used the equipment in the facility during and/or after surgery. Payment for this service would have been included in the facility DRG or PPS prospective payment. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device (CPT code E0673) provided to the enrollee on November 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2750) provided on March 11, 2021.
You asked the Plan to pay for the crown. You say that you needed this service to save your tooth. 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 crown
(D2750) provided on March 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the compression stockings identified with code A6530 that were issued on March 26, 2021.
You asked the Plan to pay for the compression stockings. You say that prior to your purchase you checked with the Plan and was told that compression stockings purchased from an out of network distributor would be eligible for reimbursement for 80% of the purchase price. The Plan denied your request. The Plan says the compression stockings is not covered.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression stockings identified with code A6530 that were issued on March 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit, physical therapy, basic radiological services, and an MRI provided by a participating provider on March 19, 2021, to March 21, 2021.
You asked the Plan to waive the copayment for an emergency room visit, physical therapy, basic radiological services, and an MRI. You say that you do not agree with any of these copayments. The Plan denied your request. The Plan says the correct copayments 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 $90 copayment for emergency care/in-network, a $20 copayment for outpatient rehabilitation services/physical therapy, a $25 copayment for outpatient diagnostic tests/basic radiological services and a $200 copayment for outpatient diagnostic tests/advanced imaging services/outpatient hospital. You have been asked to pay a $90 copayment for an emergency room visit, a $20 copayment for physical therapy, a $5 copayment for basic radiological services, a $200 copayment for an MRI. The total amount you are being asked to pay is $315 ($90 + $20 + $5 + $200 = $315). An emergency room visit falls within the emergency care/in-network benefit category. Physical therapy falls within the outpatient rehabilitation services/physical therapy benefit category. Basic radiological services and an MRI falls within the outpatient diagnostic tests/basic radiological services and outpatient diagnostic tests/advanced imaging services/outpatient hospital 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 an emergency room visit, physical therapy, basic radiological services, and an MRI provided by a participating provider on March 19, 2021, to March 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Shingrix vaccine (CPT code 90750) provided on May 4, 2021.
You asked the Plan to pay for the Shingrix vaccine. You say that you were told that the Shingrix vaccine was covered. The Plan denied your request. The Plan says Shingles/Shingrix is not covered under your Part B (medical benefit) as outlined below in the EOC. The Plan states you can submit for reimbursement for your Shingrix vaccine under Part D.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Shingrix vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the Shingrix vaccine. Therefore, we decided that the Plan does not have to pay for the Shingrix vaccine (CPT code 90750) provided on May 4, 2021.
Benefits for the Shingrix vaccine 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 waive the copayment for a specialist office visit provided by a participating provider on March 12, 2021.
You asked the Plan to waive the copayment for a specialist office visit. You say that you were told that everything was covered. The Plan denied your request. The Plan says the correct copayment has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 copayment for physician/practitioner services/specialist. You have been asked to pay a $45 copayment for a specialist office visit. The correct copayment has been applied to the office visit that was provided. A specialist office visit falls within the physician/practitioner services/specialist 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 a specialist office visit provided by a participating provider on March 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional 15 minutes of moderate sedation provided on September 25, 2020, billed with code 99153.
You asked the Plan to pay for the moderate sedation services as billed. You say that these services should be paid. The Plan denied your request. The Plan says payment was approved for all services except 99153. This code is not payable in the outpatient hospital setting.
The Plan must follow Medicare rules. Medicare rules say that the OPPS recognizes that CPT code 99153 is a practice expense (PE) only code and is not paid to the physician in the facility setting. The Outpatient Prospective Payment System (OPPS) applies to all hospital outpatient departments.
As these services were rendered in the outpatient hospital setting, no payment for code 99153 is allowed to the provider. Therefore, we decided that the Plan does not have to pay for the additional 15 minutes of moderate sedation provided on September 25, 2020, billed with code 99153.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a SNF stay provided from October 12, 2019, to October 30, 2019.

You asked the Plan to waive the copayment for a SNF stay. You say that you 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 $20 copayment for days 1-20 and a $160 copayment for days 21-100 for SNF care.

You had a SNF stay from October 12, 2019, to October 30, 2019. Therefore, you are responsible to pay a $20 copayment for days 1-18 (October 12, 2019, to October 29, 2019). The total amount you owe is: $20 (copayment) x 18 (SNF days) = $360.

You have been asked to pay the total copayment amount of $360 for a SNF stay. A SNF stay falls within the 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 for a SNF stay provided from October 12, 2019, to October 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on February 22, 2021.
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 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 out of network physician services provided to the enrollee on February 22, 2021.