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

We decided that the Plan does not have to pay forlab tests provided on December 9, 2020 by an out of network (OON) provider.You asked the Plan to pay forlab tests. You say that you would like this claim reprocessed and paid.The Plan denied your request. The Plan says the referring provider is not in-network with this specific plan.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 forlab tests provided on December 9, 2020 by an out of network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fornursing facility care provided by an out-of-network provider on December 18, 2020.You asked the Plan to pay fornursing facility care. You say that the services were performed in an inpatient facility,so the doctoris not aware when authorization is obtained. You say that it is not acceptable to refuse payment because the facility did not obtained authorization.The Plan denied your request. The Plan says prior authorization was required but 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 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 haveto pay fornursing facility care provided by an out-of-network provider on December 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in other settings, for example: a skilled nursing facility.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for surgical repair of a hip fracture after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for ambulance services provided on December 27, 2020.

You asked the Plan to waive the co-payment for ambulance services. You say that you were admitted to the hospital so the co-payment should be waived. 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 co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 co-payment for ambulance services.

You have been asked to pay a $350 co-payment for ambulance services. Ambulance services fall within the ambulance services 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 co-payment for ambulance services provided on December 27, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided on November 3, 2020.

You asked the Plan to pay for the physical therapy. 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 physical therapy. 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 physical therapy provided on November 3, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound rendered on December 24, 2020.
You asked the Plan to waive the copayment for these services. You say that you were told that the services would be covered at no cost. The Plan denied your request. The Plan says the copayment 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 a $100 copayment for ultrasounds.
Review of the file shows that you received a diagnostic breast ultrasound on December 24, 2020. Per the contract with the Plan, there is a $100 copayment for ultrasounds. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. However, the Medicare allowed amount for these services was $93.54. Given that the allowed amount was less than the $100 copayment, you have been asked to pay $93.54 for these services.
Therefore, we decided that the Plan does not have to waive the copayment for the ultrasound rendered on December 24, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) provided November 19, 2020.
You asked the Plan to pay for the ambulance response and treatment, no transport. You say that you received a bill from the ambulance provider for $136. The claim was denied by the plan and you would like to appeal. The Plan denied your request. The Plan says this service is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on November 19, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) provided November 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora bath or shower chair (E0240), a bathtub wall railing (E0241), a crutch substitute (E0118), and a waterproof cast cover (A9270) purchased from an internet retailer on November 10, 2020.You asked the Plan to pay fora bath or shower chair, a bathtub wall railing, a crutch substitute, and a waterproof cast cover. You say that the requested items are medically necessary for you.The Plan denied your request. The Plan says rules for payment have not been met.The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program.Therefore, we decided that the Plan does not have to pay fora bath or shower chair (E0240), a bathtub wall railing (E0241), a crutch substitute (E0118), and a waterproof cast cover (A9270) purchased from an internet retailer on November 10, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an abutment supported porcelain fused to metal crown (D6059) and a custom fabricated abutment (D6057) provided on July 20, 2020.

You asked the Plan to pay for an abutment supported porcelain fused to metal crown and a custom fabricated abutment. You say that you thought these services would be covered. The Plan denied your request. The Plan says the services at issue are 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 an abutment supported porcelain fused to metal crown (D6059) and a custom fabricated abutment (D6057) provided on July 20, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on July 9, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on July 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe outpatient surgery provided on August 12, 2020.You asked the Plan to waive the copayment forthe outpatient surgery. You say that you do not have a copayment.The Plan denied your request. The Plan says you were charged this copayment 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 a $200 copayment for Outpatient Surgery as amember of the plans. You have been asked to pay a $200 copayment forthe outpatient surgery. The outpatient surgery falls within the Outpatient Surgery for members of the plans 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 forthe outpatient surgery provided on August 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing facility care provided by an out-of-network provider on October 14, 2020.
You asked the Plan to pay for nursing facility care. You say that the treatment received was medically necessary and the claim should be processed for payment. The Plan denied your request. The Plan says services were not ordered by an in-network provider and 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 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 nursing facility care provided by an out-of-network provider on October 14, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for thesupply allowance for therapeutic continuous glucose monitor (CGM) (K0553) provided November 2, 2020.You asked the Plan to pay for thesupply allowance for therapeutic CGM. You say that you have attached documents for review in regards to the denial.The Plan denied your request. ThePlan says the enrollee does not meet the criteria as the records provided documents blood sugar check and insulin dosage 2 times daily.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of supply allowance for therapeutic CGM have not been met.Therefore, we decided that the Plan does not have to pay for thesupply allowance for therapeutic continuous glucose monitor (CGM) (K0553) provided November 2, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on November 4, 2020.
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the charges because you were diagnosed with COVID-19. 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 $275 copayment for ambulance services. You received ambulance services on November 4, 2020. Ambulance services are not part of the COVD-19 waiver. Therefore, you are responsible to pay the $275 copayment. You have been asked to pay a $275 copayment for ambulance services. Ambulance services fall within the ambulance services 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 ambulance services provided on November 4, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided on June 23, 2020.
You asked the Plan to waive the copayment for a CT scan. You say that you were told that you would only owe a $40 copayment and were not told you would owe a higher amount. 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 $110 copayment for each radiological diagnostic service, including CT scans. You have been asked to pay the allowed amount of $87.58, which is less than the $110 copayment for a CT scan. A CT scan falls within the outpatient diagnostic tests and therapeutic services and supplies 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 CT scan provided on June 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services provided on September 14, 2020.You asked the Plan to pay forthe laboratory services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed.We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed prior to services taking place.Therefore, we decided that the Plan does not have to pay forthe laboratory services provided on September 14, 2020
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 August 20, 2020.
You asked the Plan to pay for home health services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the claims were not initially billed under a UB-04 in order to establish the required HHA reports on the 0023 revenuecode line the date of the first covered visit provided during the initial episode.
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, this claim was not submitted on an appropriate form. Home Health services must be reported on an institutional claim form. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from August 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the periodic oral evaluation (D0120), prophylaxis (D1110), and the re-cement of a crown (D2920) provided on November 23, 2020.
You asked the Plan to pay more for the dental services. You say that these services should be covered. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that dental services are paid based on the Maximum Allowable Charge (MAC). The Plan also says that out of network providers may bill you for the difference between what the Plan pays and what the provider charges.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage and the services are listed as covered, dental services that you receive out of network may have a higher cost share amount. The Evidence of Coverage clearly states that you may still be billed by an out of network provider for any amount greater than the MAC payment made by the plan to the provider.
CPT Code
Billed Amount
Allowed Amount
Plan Paid
Billed - Allowed
Your Responsibility
D0120
$40
$19
$19
$21
$21
D1110
$73
$40
$40
$33
$33
D2950
$86
$40
$40
$46
$46
TOTAL:
$99
$100
This is a contractual obligation that you agreed to when you signed up for the Plan. The record shows that the Plan paid for the service at the allowed amount. Therefore, we decided that the Plan does not have to pay more for the periodic oral evaluation (D0120), prophylaxis (D1110), and the re-cement of a crown (D2920) provided on November 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (HCPCS G0481) provided to the enrollee on July 16, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Healthcare Common Procedure Coding System (HCPCS) code G0481 (1 Unit) remains not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. We find that HCPCS code G0481 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing services (HCPCS G0481) provided to the enrollee on July 16, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the knee (73721).
You asked the Plan to pre-approve the MRI. You say that the MRI is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. 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 MRI. Our reviewer says that the MRI is not medically necessary. Our physician reviewer found the medical record does not indicate that physical therapy or conservative treatments have been tried and failed. 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the knee (73721).