Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forcustodial care (S9122) provided on June 10, 2020 through July 14, 2020.You asked the Plan to pay forcustodial care. You say that the member requires daily care as member can do very little for himself.The Plan denied your request. The Plan says Medicare doesn't cover custodial care delivered by non-skilled health care worker or caregivers such so activities of daily living (like bathing, dressing, cooking, laundry, shopping, etc.)The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. The file shows that skilled nursing or therapy services were not provided during the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay forcustodial care (S9122) provided on June 10, 2020 through July 14, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay forthe chest x-ray (71045) provided on July 28, 2020.You asked the Plan to pay forthe chest x-ray. You say that you would like reconsideration because the claim was billed with the correct place of service.The Plan denied your request. The Plan says the diagnosis code does not support an emergency medical condition.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT code 71045 is not supported in the record. Specifically, this claim was billed with an emergency department place of service code. The diagnosis code billed, Z00.00 indicates an encounter for general adult medical examination without complaint, suspected or reported diagnosis. The records show that the member was symptomatic and the diagnosis code does not support an emergency medical condition. Based on this information, we decided that Medicare rules for coverage of the chest x-ray have not been met.Therefore, we decided that the Plan does not have to pay forthe chest x-ray (71045) provided on July 28,2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic exercises (97710) and manual therapy (97140) and chiropractic manipulative treatment (98940) provided September 8, 2020 to September 28, 2020.
You asked the Plan to pay for the chiropractic services. You say that from your understanding you were covered and was under the impression your doctor did send a request for you to have this service. You would not have gone if this was an issue. The Plan denied your request. The Plan says enrollee's must receive their services from an in-network provider. Non-emergent services with non-contracted providers require prior authorization before services being rendered. Therapeutic exercises and manual therapy are not covered under the plan benefits.
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 service at issue is not manual manipulation of the spine. 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. Therefore, we decided that the Plan does not have to pay for therapeutic exercises (97710) and manual therapy (97140) and chiropractic manipulative treatment (98940) provided September 8, 2020 to September 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forcritical care services (99291) provided on April 3, 2020, through April 4, 2020.You asked the Plan to pay forthe critical care services. You say that you would like reconsideration based on the records submitted.The Plandenied your request. The Plan says the documentation does not support the service 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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in the record. Specifically,the documentation does not indicate the amount of time spent rendering critical care services. Based on this information, we decided that Medicare rules for coverage of the critical care services have not been met.Therefore, we decided that the Plan does not have to pay forcritical care services (99291) provided on April 3, 2020, through April 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe wound care services (11043, 11042, 11045, 11044) services provided on May 5, 2020 to May 26, 2020 by an out of network (OON) provider.You asked the Plan to pay forOON wound care services. You say that these were medically necessary services provided by the on-call specialist.The Plan denied your request. The Plan says these services were not authorized.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe wound care services (11043, 11042, 11045, 11044) services provided on May 5, 2020 to May 26, 2020 by an out of network (OON) provider
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on June 16, 2020.
You asked the Plan to waive the copayment for the ER visit. You say that your PCP was unable to see you that
day and they directed you to the ER. You said that if your PCP had been able to see you, your copayment
would have been zero. 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 $90
copayment for emergency room services. You have been asked to pay a $90 copayment for the ER visit. This copayment applies regardless of the reason for the visit to the ER. 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 emergency room (ER) visit you had on June 16, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe surgical services rendered on May 6, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plandenied your request. The Plan says procedure code 37233 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 37233 is revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with atherectomy, includes angioplasty within the same vessel, when performed (List separately in addition to code for primary procedure).We find that CPT code 37233 is not supported in the medical record. Specifically, there is no documentation of an open or percutaneous endovascular revascularization. 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 surgical services rendered on May 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on July 16, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not authorized.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on July 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2 additional extractions (D7140) provided on August 10,
2020.
You asked the Plan to pay for the 2 additional extractions. You say that you had a terrible toothache and your
bottom front teeth were loose and sensitive. You say that the dentist advised that the teeth must come out. You
say that you are still socially active and need the front teeth in order to eat good food. You say that you feel this
is a health and medical problem, and not a dental problem. You also say that the cost of these services has been
a financial hardship. The Plan denied your request. The Plan says 2 extractions per calendar year are covered.
The Plan also says that the frequency limit has been exceeded.
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 frequency limit of 2 extractions per
calendar year has been exceeded. The record shows that the Plan already paid for 2 extractions that you
received on the date of service in this case, thus exhausting the benefit. Therefore, we decided that the Plan
does not have to pay for the 2 additional extractions (D7140) provided on August 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the DME provided on March 31,2020.You asked the Plan to pay for the DME. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.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 itemsat issue. We found no exception that would require the Planto pay for these items.Therefore, we decided that the Plan does not have to pay for the DMEprovided on March 31, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection services provided on April 23, 2020.
You asked the Plan to pay for the injection services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says no documentation was submitted to support medical necessity.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Review of the file shows that no medical records were submitted to support that these services rendered were medically necessary. Based on this information, we decided that Medicare rules for coverage of the injection services have not been met. Therefore, we decided that the Plan does not have to pay for the injection services provided on April 23, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe two breast ultrasounds you had on June 16, 2020.You asked the Plan to waive the copayments forthe breast ultrasounds. You saythat it is unfair that you were charged two separate copayments when both breasts were tested in the same visit.The Plan denied your request. The Plan says you were charged these copayments correctly.  These two ultrasounds were performed and billed separately, so two separate copayments apply. However, since the allowed amount for each ultrasound ($73.63) is less than your copayment obligation, you are only being charged the allowed amount (for a total of $147.26.)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. You have been asked to pay a $110 copayment for the breast ultrasounds. The breast ultrasounds fall within the radiological diagnostic service 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 copayments forthe two breast ultrasounds you had on June 16, 2020
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the CT angiography provided on June 29, 2020.
You asked the Plan to waive the deductible for the CT angiography. You say that you were informed that you needed surgery when the scan was read but you didn't need surgery. You say that the bill should go away. 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 $750. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost of your covered services. The item or service you asked the Plan to waive the deductible for falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $750 deductible applies advanced imaging services. This cost sharing is a contractual obligation that had not been met at the time the CT angiography was received on June 29, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the CT angiography provided on June 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forlumbar-sacral orthosis (L0648) provided on June 4, 2020.You asked the Plan to pay forthe lumbar-sacral orthosis. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the documentation does not include a delivery confirmation to show that the member received the billed supply.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 proof of delivery for the supplies provided in this case. Specifically, the record does not include any documentation showing that the member received the lumbar-sacral orthosis. 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 forlumbar-sacral orthosis (L0648) provided on June 4, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan you had on July 14, 2020.
You asked the Plan to waive the copayment for the CT scan. You say that you were never advised there would be a charge for this test. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for this service ($106.69) is less than your copayment, you are responsible for this full 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 CT scans. You have been asked to pay a $300 copayment for the CT scan. 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 computed tomography (CT) scan you had on July 14, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay foremergency department visit (99283) radiologic examination, abdomen (74018) provided May 31, 2020.You asked the Plan to pay forthe emergency services. You say that you currently are not a participating provider with Medicare and is asking for processing of the emergency visit claim as primary and also process the claim as in-network.The Plan denied your request. The Plan says this provider is ineligible and not Medicare certified.The Plan must follow Medicare rules. Medicare rules say that the plan will generally cover your medical care as long as the care you receive is considered medically necessary and you receive your care from a provider who is eligible to provide services under Original Medicare. As a member of the PPO plan you can receive your care from either a network provider or an out-of-network provider.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the emergency services have not been met.Therefore, we decided that the Plan does not have to pay foremergency department visit (99283) radiologic examination, abdomen (74018) provided May 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam (D0120) and prophylaxis (D1110) provided.

You asked the Plan to pay for the dental services. You say that you do not understand why you are receiving a denial letter 7 months after you received the services. The Plan denied your request. The Plan says routine dental services are not covered. The Plan also says that you may use the benefit bank card to pay for the routine dental services that are not covered.

Medicare generally does not cover dental services. The Plan follows the same rule.

The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. The record shows that as there was a balance of $311 available on your Benefit Bank card that you may use towards the services in this case. Therefore, we decided that the Plan does not have to pay for the oral exam (D0120) and prophylaxis (D1110) provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the electroencephalogram (95882) and somatosensory testing (95927 and 95938) provided on November 11, 2019.
You asked the Plan to pay for the electroencephalogram and somatosensory testing. You say that you would like reconsideration because the facility did not render these services The Plan denied your request. The Plan says the place of service code billed is not appropriate and payment for these services is included in the payment to the facility.
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the electroencephalogram and somatosensory testing have not been met. Specifically, the record indicates that the member was inpatient on the billed date of service. The place of service code billed does not reflect the member's inpatient status. Additionally, payment for these services is included in the payment to the facility and is the responsibility of the facility to any vendor. Therefore, we decided that the Plan does not have to pay for the electroencephalogram (95882) and somatosensory testing (95927 and 95938) provided on November 11, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pathology services provided on July 14, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the pathology 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 OON provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the pathology 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 forthe medical services provided to the enrollee by an out-of-network provider on March 4, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services are available in-network.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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on March 4, 2020.