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

We decided that the Plan does not have to pay for the first intraoral periapical x-ray and each additional
intraoral periapical x-ray provided on August 18, 2020.
You asked the Plan to pay for the intraoral periapical x-rays. You say that in the past intraoral periapical x-rays
have been covered under your plan. You also say that you and your provider were not aware of the change in
your plan. 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 first
intraoral periapical x-ray and each additional intraoral periapical x-ray provided on August 18, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient hospital services rendered on July 13, 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 claim was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that outpatient hospital services must be billed with TOB code 13x. We looked at the file and Medicare rules. The file shows that the claim was not billed with the required 13x TOB 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 outpatient hospital services rendered on July 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on June 25, 2020 by a non-participating 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 a non-participating provider without prior authorization.Medicare rules say that plans can requireenrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe medical services provided on June 25, 2020 by a non-participating provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services rendered from June 28, 2020, to June 30, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure codes 52356, 74485, and 99218 are 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 52356 is cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy including insertion of indwelling ureteral stent (e.g., Gibbons or double-J type). The definition of code 74485 is dilation of ureter(s) or urethra, radiological supervision and interpretation.We find that CPT codes 52356, 74485, and 99218 are not supported in the medical record. Specifically, there is noprocedure report indicating a cystourethroscopy was performed to support code 52356.There is no documentation of radiological supervision for dilation of ureters or urethra to support code 74485.The rules say that Medicare may not pay for an evaluation and management service billed with the CPT modifier "-57" if it was provided on the day of or the day before a procedure with a zeroor ten-day global surgical period. The provider billed code 99218 with the -57 modifier. This modifier is not appropriate for this code, as the documentation does not support that the enrollee was admitted as observation status. There is no separate payment for this 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 forthe services rendered from June 28, 2020, to June 30, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe arthrocentesis provided on July 21, 2020.You asked the Plan to waive the copayment forthe arthrocentesis. You say that that this procedure should not have been done in a treatment room. You say this should be an office visit. 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 $200 copayment for Medicare-covered outpatient surgeryin an ambulatory surgical center or hospital outpatient facility. You have been asked to pay a $200 copayment for the arthrocentesis. The arthrocentesis falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows you were billed by an outpatient hospital.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 arthrocentesis provided on July 21, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible forthe laser eye surgery provided on September 1, 2020.You asked the Plan to waive the deductible forthe laser eye surgery. You say that you believe post-cataract surgery should be paid for with cataract surgery. You say thiswas a follow-up laser surgery. 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. Your contract with the Plan says that there is a $750 deductible that applies towards laser eye surgery. The laser eye surgery you asked the Plan to waive the deductible for falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. Please note, there is no provision inthe contract which indicates the deductible would be waived if performed as a follow-upsurgical procedure.The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible that applies towards the laser eye surgery. This cost sharing is a contractual obligation that had not been met at the time the laser eye surgery was received on September 1, 2020. Therefore, we decided that the Plan does not have to waive the deductible forthe laser eye surgery provided on September 1, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on June 1, 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 procedure codes 93312 and 93320 are not supported.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 93312 and 00562. Code 93312 is a column II code with a modifier indicator of 1 when billed with column I code 00562. Code 93312 was not billed with an appropriate modifier to allow for separate payment. Given that the primary procedure code 93312 is not separately payable, add-on code 93320 is also not payable. Therefore, we decided that the Plan does not have to pay for the testing services rendered on June 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 30, 2020, by a nonparticipating 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-participating 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 has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the medical services provided on July 30, 2020, by
a non-participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 28, 2019, by an out-of-network provider.
You asked the Plan to pay for the medical services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says no authorization was obtained and the services rendered were not urgent or emergent services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on February 28, 2019, by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLTACH services.You asked the Plan to pre-approvethe LTACH services. You say that the stay is medically necessary.The Plan denied your request. The Plan says thestay is not medically necessary.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided indicating that admission to a LTACH is medically necessary. The review indicates that the enrollee still requires acute hospital level of care services and isreceiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where they are currently receiving care. There are no services available at the LTACH thatthe enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.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 LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approveLTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed.
You asked the Plan to pre-approve the bed. You say that this is medically necessary. The Plan denied your
request. The Plan says there is no documentation of a need for frequent and immediate changes in body
position.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered
medically necessary when the patient:
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or
2. Requires attachments which can only be attached to a hospital bed; AND
3. Requires frequent changes in body position and/or has an immediate need for a change in body position.
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 bed. Our reviewer says that the
requested bed is not medically reasonable or necessary. Our physician reviewer found the documentation does
not support a need for an immediate or frequent change in body position or special attachments that cannot be
fixed on an ordinary bed. The request for a semi-electric hospital bed is not 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 the bed have not been met. Therefore, we decided that the Plan does not have to
pre-approve a semi-electric hospital bed.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lab services provided on August 18, 2020, by an out-of-network (OON) provider.You asked the Plan to pay forthe OON services. You say that the ordering physician deemed the services to be medically necessary.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 ordering and servicing provider in this case arenot a network providerswith the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the 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 forthe lab services provided on August 18, 2020, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe dental services rendered on July 29, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says services from an out-of-network provider 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. The Plan covers supplemental dental benefits from a participating provider only. We looked at the file and the Plan's rules. The services at issue were performed by a non-participating provider. Based on this information, we decided that the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay forthe dental services rendered on July 29, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the extra heavy duty wheelchair rendered
on July 8, 2020.
You asked the Plan to waive the coinsurance for these services. You say that you shouldn't be liable. The Plan
denied your request. The Plan says the coinsurance was applied 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 20% of
the plan-allowed amount for in-network Medicare-covered durable medical equipment.
Review of the file shows that you received an extra heavy duty wheelchair on July 8, 2020. You have been
asked to pay 20% of the plan-allowed amount for these services. These services fall within the in-network
Medicare-covered durable medical equipment benefit category. This means that you have been asked to pay the
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance
for the extra heavy duty wheelchair rendered on July 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea continuous glucose monitor (A9276).You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not a covered benefit.The Plan must follow Medicare rules. The rules say that a continuous glucose monitor coded with A9276 is not a covered benefit.Your request is coded with HCPCS A9276. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea continuous glucose monitor (A9276).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 25, 2020 by an out
of network (OON) provider.
You asked the Plan to pay for the OON services. You say that the service was rendered due to an emergency
case. The Plan denied your request. The Plan says there are in-network providers who could have provided the
services 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 file shows that the enrollee was seen for chronic lumbar back pain. The provider in this case is not a
network provider with the Plan. The Plan has network providers available who can provide the services at issue
in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the
Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services
provided on August 25, 2020 by an out of network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe physician services rendered on September 15, 2020.You asked the Plan to payforthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 99358 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 99358 is prolonged evaluation and management service before and/or after direct patient care; first hour.We find that CPT code 99358 is not supported in the medical record. Specifically, the records show that 65 minutes of direct patient care were spent on the enrollee and there is a more appropriate code for these services. 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 forthe physician services rendered on September 15, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLTACH services.You asked the Plan to pre-approvethe LTACH services. You say that the stay is medically necessary.The Plandenied your request. The Plan says the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where they are currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage ofthe LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approveLTACH services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 10, 2020 by an
out of network (OON) 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 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 has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the medical services provided on September 10,
2020 by an out of network (OON) provider.