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

We decided that the Plan does not have to pay for a pelvic x-ray (72170) provided on July 4, 2020.
You asked the Plan to pay for a pelvic x-ray. You say that this procedure was performed. The Plan denied your request. The Plan says this procedure cannot be paid without an appropriate modifier.
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, we have confirmed that code 72170 has a Column One/Column Two relationship with code 73502, which was billed by the same provider for the same date of service and cannot be paid as billed.
This code cannot be paid as a separate line item without an appropriate modifier. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for a pelvic x-ray (72170) provided on July 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 3, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the medical services. You say that these services were medically necessary. The Plan denied your request. The Plan says unauthorized, non-plan care is not 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 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 the medical services provided on July 3, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on May 13, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.
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 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 May 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the denture adjustments for teeth # 7 and 23 provided on May 15, 2020.
You asked the Plan to reimburse you for the dental services. You say that this was your first attempt at using your card. You say that you should be reimbursed for the services. The Plan denied your request. The Plan says denture adjustments are not listed as covered services.
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 reimburse you for the denture adjustments for teeth # 7 and 23 provided on May 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 10, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the podiatry services. You say that the patient gave you incorrect insurance information, so you were unable to get authorization. The Plan denied your request. The Plan says unauthorized, non-plan care is not 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. You 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. It is the provider's obligation to confirm a patient's insurance coverage prior to rendering services. 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 October 10, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental extractions x11 (D7140) immediate upper denture (D5130) and immediate lower denture (D5140).
You asked the Plan to pre-approve the dental services. You say that you were told that your dental extractions and services would be covered. You had made an appointment and had the 12 teeth extracted because of being in pain. The Plan denied your request. The Plan says the frequency limitation for the extractions has been exceeded and dentures are not covered under the plan benefits.
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 records show that the plan had already approved for 3 dental extractions of teeth 4, 5 and 19, therefore the benefit limit has been exceeded. 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 pre-approve dental extractions x11 (D7140) immediate upper denture (D5130) and immediate lower denture (D5140).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that you have been suffering from COVID19 and you have been put on a ventilator, intubated on December 20, 2020 and you are stabilized and ready for transfer to a long term acute care to get around the clock care to make sure you are stable and to continue ventilator weaning. The Plan denied your request. The Plan says you are receiving appropriate in-patient acute care and you do not require transfer to LTACH.
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 that long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include oxygen supplementation, PEEP support, nebulizer treatments, surveillance laboratory studies, fluid balance, and therapy services. The documentation does not support that you require services at the LTACH that are not available at the acute care hospital where you 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 your diagnosis and condition 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 of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services coded 87799, 87798, 87482, and 87150 provided on August 14, 2020.You asked the Plan to pay forthe laboratory 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.We find that CPT codes 87799, 87798, 87482, and 87150 are not supported in themedical record. Specifically, the documentation did not show why these services were ordered. In addition, the standard of care for urinalysis is with urine culture and sensitivity. Therefore, this testing is considered unproven and the documentation doesnot support medical necessity. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met.Therefore, we decided that the Plan does not have to pay forthe laboratory services coded 87799, 87798, 87482, and 87150 provided on August 14, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the behavioral health services received by an opt out provider.

You asked the Plan to pay for the behavioral health services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services received are not a covered benefit when provided by an opt out provider.

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.Therefore, we decided that the Plan does not have to pay for the behavioral health services received by an opt out provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ultrasound services coded 76937 provided on December 11, 2019.You asked the Plan to pay forthe ultrasound services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services bare not payable as 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 76937 is Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle entry, with permanent recording and reporting (List separately in addition to code for primary procedure).We find that CPT code 76937 is not supported in the medical record. Specifically, this code is an add-on code. This code was not billed with an appropriate primary procedure code. Based on this information, we decided that Medicare rules for coverage of the ultrasound services have not been met.Therefore, we decided that the Plan does not have to pay forthe ultrasound services coded 76937 provided on December 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids provided on March 5, 2020.
You asked the Plan to pay for the hearing aids. The Plan denied your request. The Plan says hearing aids ordered through providers other than the Plan provider are not covered.
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. We looked at the file and the Plan's rules. The file shows that the hearing aids were provided by a provider that is not a Plan hearing aid provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids provided on March 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 14, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the medical services. You say that authorization for these anesthesia services should be included in the authorization for the procedure itself. The Plan denied your request. The Plan says unauthorized, non-plan care is not 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 provider in this case is not a network provider with the Plan. It is the provider's obligation to confirm patient insurance prior to rendering care. 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 14, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for prostate specific antigen (PSA) testing (G0103) provided.

You asked the Plan to pay for PSA testing. You say that this was medically necessary.The Plan denied your request. The Plan says this was not billed correctly.

The Plan must follow Medicare rules. Medicare rules say that Prostate Specific Antigen (PSA) blood tests must be billed using either screening ("V") code V76.44 (Special Screening for Malignant Neoplasms, Prostate if ICD-9-CM is applicable) or if ICD-10-CM is applicable, diagnosis code Z12.5 (Encounter for screening for malignant neoplasm of prostate)

.We looked at the file and Medicare rules. Neither of the above diagnosis codes were billed on the claim for this test. Based on this information, we decided that Medicare rules for coverage of PSA testing have not been met.Therefore, we decided that the Plan does not have to pay for prostate specific antigen (PSA) testing (G0103) provided.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided on July 23, 2020 by an out of network (OON) provider.
You asked the Plan to pay for lab services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says 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 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 lab services provided on July 23, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglassesprovided on June 15, 2020.You asked the Plan to pay for the eyeglasses. The Plan denied your request. The Plan says provider is out of network provider and the Plan's optical provider is not delegated for out of network providers.Medicare generally does not cover routineeyewear services. However, the Plan offers a routineeyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers theseservices when provided by a network optical provider.We looked at thefile and the Plan's rules. The requested provider in this case is not a networkopticalprovider with thePlan. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglasses providedon June 15, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay fora chest x-ray (71045) provided on September 13, 2020You asked the Plan to pay fora chest x-ray. You say that the enrollee had multiple exams on this date of service.The Plan denied your request. The Plan says this is not payable without an appropriate modifier.The Plan must follow Medicare rules. Medicare rules say that providers must reportservices correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 71045 has a Column One/Column Two relationship with code 74022, which was billed by the same provider for the same date of service,and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met.Therefore, we decided that the Plan does not have to pay fora chest x-ray (71045) provided on September 13, 2020
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve Magnetic Resonance Imaging (MRI) scan. You asked the Plan to pre-approve an MRI scan. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested services are not medically necessary. 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 an MRI scan. Our reviewer says that the documentation does support that the requested MRI is medically reasonable and necessary. Our physician reviewer found the enrollee has failed conservative treatment for 3 months for hip pain. The documentation supports persistent hip pain and has failed conservative therapy. Therefore, the enrollee meets criteria for the requested MRI. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI scan have been met. Therefore, we decided that the Plan has to pre-approve Magnetic Resonance Imaging (MRI) scan.
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 out of network (OON) providers.You asked the Plan to pay forthe medical services. You say that these providers rendered medically necessary services in good faith.The Plan denied your request. The Plan says unauthorized, non-plan care is not 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 providers in this case are not network provider with the Plan. The Plan has 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 noexception 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 out of network (OON) providers.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental cleaning (D1110), bitewing X-ray (D0274) and periodic oral evaluation (D0120) provided on July 29, 2020, by an out-of-network (OON) provider.
You asked the Plan to pay for the dental cleaning, bitewing X-ray, and periodic oral evaluation. You say that you would like this cost share reprocessed and approved. The Plan denied your request. The Plan says the cost share applied correctly and no reimbursement is due.
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. You have been asked to pay a total cost share of $203 for the dental services. The Plan calculated the coinsurance of 50% of the allowed amount for the services provided ($94 allowed x 50% = $47 coinsurance). However, when services are received from an OON provider, the provider is allowed to bill you the difference between the average negotiated in-network fee schedule and the dentists' charged fees. 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 pay for the dental cleaning (D1110), bitewing X-ray (D0274) and periodic oral evaluation (D0120) provided on July 29, 2020, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe MRI provided on July 2, 2020.You asked the Plan to waive the copayment forthe MRI. The Plan denied your request.The Plan says the copayment 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 $160 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a in-network physician's office or at a free-standing facility. You have been asked to pay a $160 copayment for the MRI. The MRI falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The Plan says that you have already made a payment of $72.10 leaving a balance of $87.90 ($160 -$72.10 = $87.90). 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 MRI provided on July 2, 2020.