Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The submitted records document a need for physical and occupational therapy services but do not document a need or tolerance for an intensive rehabilitation program. Services could be provided in a lower level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive orthodontic treatment of the adolescent
dentition provided on February 21, 2019.
You asked the Plan to pay for the comprehensive orthodontic treatment of the adolescent dentition. You say
that in order for the doctor to treat the periodontal disease, you had to have your teeth straightened out first.
The Plan denied your request. The Plan says this service is not a covered 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
comprehensive orthodontic treatment of the adolescent dentition provided on February 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home INR monitoring materials (HCPCS G0249) provided to the enrollee from January 26, 2020 to February 11, 2020.
You asked the Plan to pay for the materials. You say that this should be paid for. The Plan denied your request. The Plan says HCPCS G0249 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 G0249 is "Provision of test materials and equipment for home INR monitoring of patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria; includes: provision of materials for use in the home and reporting of test results to physician; testing not occurring more frequently than once a week; testing materials, billing units of service include 4 tests." We find that HCPCS code G0249 is not supported in the medical record. Specifically, these services were billed for 20 and 17 billing days, which is less than the required 25 billing days. Based on this information, we decided that Medicare rules for coverage of the materials have not been met. Therefore, we decided that the Plan does not have to pay for home INR monitoring materials (HCPCS G0249) provided to the enrollee from January 26, 2020 to February 11, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on December 5, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. 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 physician's services provided on December 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on March 2, 2020 by a non-Medicare provider.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says the provider does not accept Medicare and you were made aware that they did not accept Medicare prior to any services being rendered.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
Review of the file show that you received dental services on March 2, 2020 from a provider that has opted out of Medicare. The Medicare rules say Medicare Advantage Plans may not make payment directly or indirectly for Medicare covered services furnished to a Medicare beneficiary by a physician or practitioner who has opted out of Medicare except in cases involving emergency or urgent care services furnished to a beneficiary who has not previously entered into a private contract with the physician or practitioner. 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 dental services provided on March 2, 2020 by a non-Medicare provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for transportation of an x-ray (R0070) provided on February 21, 2020.
You asked the Plan to pay for the transportation of an x-ray. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code R0070 has a Professional Component (PC)/Technical Component (TC) indicator of 3 per the 2020 National Physician Fee Schedule Relative Value File January Release.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code R0070 is not supported in the record. Specifically, the record indicates that this service was billed with Place of Service (POS) code 31. POS 31 is defined as an SNF for a Part A resident. According to Medicare rules, if the member is in a Part A SNF stay, the transportation and set up costs are subject to consolidated billing and not separately billable. Based on this information, we decided that Medicare rules for coverage of the transportation of an x-ray have not been met. Therefore, we decided that the Plan does not have to pay for transportation of an x-ray (R0070) provided on February 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive oral evaluation - new or established patient (D0150), bitewings - four radiographic images (D0274), intraoral - periapical first radiographic image (D0220), and intraoral - periapical each additional radiographic image (D0230) provided on March 10, 2020.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says the services are not a covered benefit under the plan.
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 services are not listed in your EOC as a covered benefit; therefore, the services are not covered. Therefore, we decided that the Plan does not have to pay for comprehensive oral evaluation - new or established patient (D0150), bitewings - four radiographic images (D0274), intraoral - periapical first radiographic image (D0220), and intraoral - periapical each additional radiographic image (D0230) provided on March 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visits provided from September 10, 2019 to
September 30, 2019.
You asked the Plan to pay for the office visits. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the services are billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that the office visits are not supported in the medical record. Specifically, code 99211 has a status code
of "B". The edit 62 is used when a code is not recognized by the Outpatient Prospective Payment System
(OPPS) and an alternate code for the same service may be available. A claim processed with an edit 62 has a
disposition of return claim to provider. The claim is not eligible for payment based on billing guidelines. Based
on this information, we decided that Medicare rules for coverage of the office visits have not been met.
Therefore, we decided that the Plan does not have to pay for the office visits provided from September 10,
2019 to September 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided from February 19, 2020 to March 11, 2020.
You asked the Plan to pay for the chiropractic services. The Plan denied your request. The Plan says that in most cases, the care you receive from an out-of-network provider will not be covered.
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 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 chiropractic services provided from February 19, 2020 to March 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services provided to the enrollee on January 6, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not covered.
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 services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the chiropractic services provided to the enrollee on January 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on September 10, 2019.
You asked the Plan to pay for drug tests. You say that you have submitted a valid physician laboratory
requisition form. The Plan denied your request. The Plan says the denial of payment for these services is
correct, because the documentation submitted does not include a valid physician order, lab requisition, or
medical records stating exactly which tests were to be performed.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific
lab services is required for covered lab services.
We looked at the file and Medicare rules. The documentation submitted does not include a physician order or
clear intent to order the specific lab services billed on this claim. Based on this information, we decided that
Medicare rules for coverage of drug tests have not been met. Therefore, we decided that the Plan does not have
to pay for drug testing provided on September 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on February 27, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests 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 lab services at issue in this appeal were requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on February 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0483 provided on November 26, 2019.
You asked the Plan to pay for the drug testing. 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 G0483 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed. We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation does not support that 22 or more drug classes were tested. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0483 provided on November 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the office visit provided on January 21, 2020.
You asked the Plan to waive the deductible for the office visit. You submitted your bill for review. The Plan denied your request. The Plan says the deductible applied correctly.
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 your deductible is $198, which applies to all items and services except those specifically excluded by the Plan's contract. This is the amount you have to pay out-of-pocket before we will pay its share for your covered Medicare Part A and B services. Office visits are not excluded from the deductible. The item or service you asked the Plan to waive the deductible for falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $198 deductible applies to office visits. This cost sharing is a contractual obligation that had not been met at the time the office visit was received on January 21, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the office visit provided on January 21, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services coded S9328 provided from August 20, 2019 to October 22, 2019.
You asked the Plan to pay for the home infusion therapy 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 payable.
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 S9328 is home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem. We find that CPT code S9328 is not supported in the medical record. Specifically, code S9328 has a status code of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy services coded S9328 provided from August 20, 2019 to October 22, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from December 3, 2019 to January 17, 2020.
You asked the Plan to pay for home health services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the wrong type of claim form was submitted. the out of network home health agency claim is submitted on a handwritten CMS 1500 claim form, which is the incorrect type of claim form. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from December 3, 2019 to January 17, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided to the enrollee from December 11, 2019 to December 23, 2019.
You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says that the member required no nursing services which would be considered skilled services by Medicare.
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 that the enrollee's condition did not meet Medicare criteria for SNF services.
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 to the enrollee from December 11, 2019 to December 23, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laryngeal injection provided on January 31, 2020.
You asked the Plan to waive the copayment for the laryngeal injection. You say that you have been charged similarly for your quarterly visits and your appeals were approved in 2019. You say you would like this appeal approved. 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 $300 copayment for all other outpatient services including observation and outpatient surgical services not provided in an in-network Ambulatory Surgical Center. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $300 copayment for the laryngeal injection.
You have been asked to pay a $242.72 copayment for the laryngeal injection. The laryngeal injection 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 for the laryngeal injection provided on January 31, 2020.
Our decision is only about the 2020 services. If you have any questions about prior years billing, please contact the plan directly.