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

We decided that the Plan does not have to pay fordrug testing (G0483) provided on May 12, 2020.You asked the Plan to pay fordrug testing. You say that this is supported in the records.The Plan denied your request. The Plan says this was billed with an incorrect place of service.The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).We looked at the file and Medicare rules. Although this service was billed with POS 81 for an independent laboratory, the record shows that the specimen was not taken in a laboratory. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met.Therefore, we decided that the Plan does not have to pay fordrug testing (G0483) provided on May 12, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit and surgery services provided on September 22, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe office visit and surgery services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services rendered are not a covered benefit.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe office visit and surgery services provided on September 22, 2020 by an out of network (OON) provider
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF 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 the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per weekof rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care.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-approveacute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe extraction provided on August 27, 2020.You asked the Plan to pay forthe extraction. You say that you contacted the Plan and were advised that tooth extractions were covered. You also say thatyou are on a fixed income.The Plan denied your request. The Plan says the treating provider opted out of Medicare effective January 12, 2016,to January 12, 2022. The Plan also says that charges incurred by Medicare Opt-Out providers will not be reimbursed by the Plan.The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. The record shows that you contacted the Plan the day after receiving this service, and no calls were made prior to the date of service.Therefore, we decided that the Plan does not have to pay forthe extraction provided on August 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services provided on October 2, 2020 by an out of network (OON) provider.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without prior authorization.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only incases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe laboratory services provided on October 2, 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 hearing aids rendered on November 25, 2019.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 are not covered from an out-of-network provider.Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only from a network provider. We looked at the file and the Plan's rules. Thefile shows that you received hearing aids from an out-of-network 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 hearing aids rendered on November 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay fordeep sedation (D9222, D9223), dental medication (D9630), and an unspecified preventative procedure (D1999) provided on August 18, 2020.You asked the Plan to pay fordeep sedation, dental medication, and an unspecified preventative procedure. You say that these services should be covered because your dentist is in-network.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 fordeep sedation (D9222, D9223), dental medication (D9630), and an unspecified preventative procedure (D1999) provided on August 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forophthalmology services provided on July 30, 2020.You asked the Plan to waive the copayment forophthalmology services. You say that you disagree with the charges because this was your yearly eye exam and you should not owe a copayment.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 $45 copayment for each specialist visit. You received ophthalmology services on July 30, 2020. Ophthalmology services are considered specialist services. Therefore, you are responsible to pay the $45 copayment. You have been asked to pay a $45 copayment for ophthalmology services. Ophthalmology services fall within the physician/practitioner services, including doctor's office visits 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 forophthalmology services provided on July 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), bitewing x-rays (D0274), and the filling (D2335) provided on March 23, 2020.
You asked the Plan to pay for the dental services. You say that you were advised by a plan representative that there were no in network dentists in your area. You say that your dentist that you had used for several years is out of network but you still use him. You also say that since the plan advertises dental coverage, the services should be covered. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says dental services that you receive out of network are not covered. The Plan says there are in network dentist available. The Plan also says that you did not contact them prior to the appointment to verify benefits and provider eligibility.
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 when you receive them out of network. Therefore, we decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), bitewing x-rays (D0274), and the filling (D2335) provided on March 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99239) provided April 13, 2020.

You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.

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 99239 is Hospital discharge day management; more than 30 minutes.

We find that CPT code 99239 is not supported in the medical record. Specifically, the documentation does not detail how much time was spent on this service. Based on this information, we decided that Medicare rules for coverage of the physician services have not been met. Therefore, we decided that the Plan does not have to pay for physician services (99239) provided April 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on July 12, 2019.You asked the Plan to pay forthe services provided. You say that the physician provided services to the enrollee in good faith.The Plan denied your request. The Plan says the claim was received past the allowed timeframe.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 valid claim for the services was not filed until September 1, 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 forthe medical services provided on July 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe massage therapy services rendered on September 3, 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 the services are not covered.The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist.Therefore, we decided that the Plan does not have to pay forthe massage therapy services rendered on September 3, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided by an out of network (OON) provider.

You asked the Plan to pay for skilled nursing services. You say that you would like this claim reprocessed and paid.The Plan denied your request. The Plan says in all long-term care scenarios, the out-of-network provider is responsible for securing prior authorization. The Plan says that prior authorization was not obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for skilled nursing services provided by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on April 3, 2019.You asked the Plan to pay forthe services provided. You say that the physician provided medically necessary services in good faith.The Plan denied your request. The Plan says the claim was received past the allowed timeframe.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 avalidclaim for the services was not filed until September 8, 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 forthe medical services provided on April 3, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services rendered on April 27, 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 80053 and 85025 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 80053 is comprehensive metabolic panel. The definition of code 85025 is blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated differential WBC count.We find that CPT codes 80053 and 85025 are not supported in the medical record. Specifically, there are no laboratory results for the date of service at issue. 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 laboratory services rendered on April 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services rendered on January 13, 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 88305 and 88313 are not covered.The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes. We looked at the file and Medicare rules. Billed procedure codes 88305 and 88313 have a status indicator of I and are not valid for Medicare purposes. These codes were billed with place of service code 22 for an outpatient hospital and therefore paid under outpatient hospital billing and subject to the status indicators. 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 laboratory services rendered on January 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal exam rendered on September 30, 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.
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 periodontal exam rendered on September 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe knee orthosis provided on August 31, 2020.You asked the Plan to pay forthe knee orthosis. You say that the medical records demonstrate medical necessity.The Plan denied your request. The Plan says the billed supply code cannot be verified.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid physician order, or proof of delivery for the supplies provided in this case.The record shows that the Plan made several attempts to obtain the necessary documentation without success.Therefore, we decided that the Plan does not have to pay forthe knee orthosis provided on August 31, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance transportation services provided on September 13 2020.You asked the Plan to pay forthe transportation services. The Plan denied your request. The Plan says the services are not separately 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.We find that the transportation services are covered by the prospective payment rate or reimbursed as reasonable costs under Part A to hospitals excluded from PPS. Based on this information, we decided that Medicare rules for coverage have not been met.Therefore, we decided that the Plan does not have to pay forthe ambulance transportation services provided on September 13 2020
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay formyocardial imaging (78431) provided on July 31, 2020.You asked the Plan to pay formyocardial imaging. You say that this service was performed.The Plan denied your request. The Plan says a second unit is not supported by the records.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 78431 is not supported in the medical record. The medical record only supports one unit of CPT code 78431, which was previously billed and paid. Based on this information, we decided that Medicare rules for coverage of myocardial imaging have not been met.Therefore, we decided that the Plan does not have to pay formyocardial imaging (78431) provided on July 31, 2020
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an ultrasound (76641) provided on June 23, 2020.
You asked the Plan to waive the deductible for an ultrasound. You say that this should be considered part of the screening mammogram. The Plan denied your request. The Plan says this processed 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 there is a $250 deductible for outpatient hospital services. The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient hospital services. Although this ultrasound was provided during the same visit as your screening mammogram, it is a separate service and is subject to cost sharing. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $250 deductible for outpatient hospital services. This cost sharing is a contractual obligation that had not been met at the time an ultrasound was received on June 23, 2020. Therefore, we decided that the Plan does not have to waive the deductible for an ultrasound (76641) provided on June 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 21, 2020.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 physician's services. We found no exception that would requirethe Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on September 21, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay formental health services (90792) provided July 8, 2019.You asked the Plan to pay forthe mental health services. You say that the services were medically necessary.The Plan denied your request. The Plan says the claim was not filed timely.The Plan follows Medicare rules. The rules say that claims for services furnished on orafter 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 mental health services was not filed until September 1, 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 formental health services (90792) provided July 8, 2019.