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

We decided that the Plan does not have to pay for the medical services provided on September 30, 2020, by a provider who has opted out of Medicare.
You asked the Plan to pay for the medical services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says you are a provider who has opted out of Medicare and no payment can be made.
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 medical services provided on September 30, 2020, by a provider who has opted out of Medicare.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted procedure, larynx services coded 31599 provided 
on April 19, 2020. 
 
You asked the Plan to pay for the unlisted procedure, larynx services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
The Plan must follow Medicare rules. 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 31599 is unlisted procedure, larynx. 
 
We find that CPT code 31599 is not supported in the medical record. Specifically, the documentation supports 
that a more appropriate code for the procedure performed would be billed instead. Based on this information, 
we decided that Medicare rules for coverage of the unlisted procedure, larynx services have not been met. 
Therefore, we decided that the Plan does not have to pay for the unlisted procedure, larynx services coded 
31599 provided on April 19, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the wrist x-ray rendered on March 2, 2020. 
 
You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. 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 $75 
copayment for in-network Medicare-covered x-rays.  
 
Review of the file shows that you received a wrist x-ray on March 2, 2020. You have been asked to pay a $75 
copayment for these services. These services fall within the in-network Medicare-covered x-rays benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for the wrist x-ray rendered on March 2, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forurgent care services provided on August 26, 2020.You asked the Plan to waive the copayment forurgent care services. You say that you were told you would not be charged since they could not help you.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 $65 copayment for Urgently Needed Services. You have been asked to pay a $65 copayment for urgent care services. Urgent care services fallwithin the Urgently Needed 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 forurgent care services provided on August 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal scaling and root planing of four or more teeth 
per quadrant and three periodontal scalings and root planings of one to three teeth per quadrant provided on 
September 22, 2020, and September 29, 2020. 
 
You asked the Plan to pay for the scalings and planings. You say that the provider told you that your insurance 
plan would cover some of the costs. 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 for the 
periodontal scaling and root planing of four or more teeth per quadrant and three periodontal scalings and root 
planings of one to three teeth per quadrant provided on September 22, 2020, and September 29, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CTAs of the chest, abdomen and pelvis (71275 and 
74174) provided on July 24, 2020. 
 
 
You asked the Plan to pay for the CTAs. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the member was registered inpatient on the billed date 
of service. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician/practitioner/supplier furnishing 
services to a patient who is a registered inpatient, shall, at a minimum, report the inpatient hospital POS code 
21 irrespective of the setting where the patient actually receives the face-to-face encounter. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the CTAs have not been met. Specifically, the record indicates that the member was registered 
inpatient on the billed date of service. It is not appropriate to bill an outpatient place of service code when the 
member is registered inpatient. Therefore, we decided that the Plan does not have to pay for the CTAs of the 
chest, abdomen and pelvis (71275 and 74174) provided on July 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forcontinuous intraoperative neurophysiology monitoring (G0453) urodynamic procedures on the bladder (51785) needle electromyography (95861) evoked potentials and reflex testing procedures (95938) provided May 13, 2020.You asked the Plan to pay forneuromonitoring services. You say that you are submitting medical records for review to support the billing of procedures as medically necessary.The Plandenied your request. The Plan says the diagnosis code reported does not 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 fileand Medicare rules. Based on this information, we decided that Medicare rules for coverage of neuromonitoring services have not been met.Therefore, we decided that the Plan does not have to pay forcontinuous intraoperative neurophysiology monitoring(G0453) urodynamic procedures on the bladder (51785) needle electromyography (95861) evoked potentials and reflex testing procedures (95938) provided May 13, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on October 8, 2020. 
 
You asked the Plan to pay for the dental service. You say that you should not have to pay for this service. You 
also say that you were not told that they would be doing more than 1 x-ray that day. The Plan denied your 
request. The Plan says 1 full mouth or panoramic x-ray is covered per calendar year. 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 1 full mouth or 
panoramic x-ray per calendar year has been exceeded. The record shows that the Plan paid for the full mouth x-
ray that you received on this date of service, thus exhausting the benefit. Therefore, we decided that the Plan 
does not have to pay for the panoramic x-ray (D0330) provided on October 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for transthoracic echocardiography (93306) provided October 21, 2020. You asked the Plan to waive the copayment for the radiology services. You say that $40 copay should have been paid by the plan. You received a letter that all copays would be covered by the plan until the end of the year, due to COVID. The Plan denied your request. The Plan says the claim was processed and the correct copayment was applied per the Evidence of Coverage. 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 $40 copayment specialist's office. You have been asked to pay $40 copayment for the radiology services. The radiology services fall 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 transthoracic echocardiography (93306) provided October 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services coded 99152 provided on 
June 26, 2020. 
 
You asked the Plan to pay for the moderate sedation 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 a duplicate service. 
 
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 99152 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial fifteen minutes of intraservice time, patient 
age five years or older. 
 
We find that CPT code 99152 is not supported in the medical record. Specifically, this is an exact duplicate 
service to a claim billed by the same exact provider on the same date of service. This service is not separately 
payable. Based on this information, we decided that Medicare rules for coverage of the moderate sedation 
services have not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation 
services coded 99152 provided on June 26, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on July 1, 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 procedure code 52224 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 52224 is cystourethroscopy, with fulguration (including 
cryosurgery or laser surgery) or treatment of MINOR (less than 0.5 cm) lesion(s) with or without biopsy. 
 
We find that CPT code 52224 is not supported in the medical record. Specifically, there is no indication of a 
cystourethroscopy with fulguration or treatment of minor lesions with biopsy. There is a more appropriate code 
for the documented services. 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 for the surgical services 
rendered on July 1, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
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 complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
humeral fracture after a fall on November 6, 2020. You were transferred to skilled nursing facility on 
November 16, 2020, then to home on December 9, 2020. You have received home health physical therapy and 
has ongoing weakness and difficulty with ambulation. Medical conditions are stable. There are no medical 
needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical record documents a need for physical and occupational 
therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable 
expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this 
information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we 
decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting 
from July 15, 2020, to July 17, 2020. 
 
You asked the Plan to pay for the self-administered drugs. You say that you feel you are not responsible for the 
medications on this bill. The Plan denied your request. The Plan says the medications that you received 
considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D 
prescription drug plan. The Plan also says the medications you received are not covered under Medicare Part B. 
 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided in an outpatient setting from July 15, 2020, to July 17, 2020.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) and endodontic therapy (D3310) provided.

You asked the Plan to pay for the core buildup and endodontic therapy. The Plan denied your request. The Plan says these services are not covered benefits under your dental plan.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) and endodontic therapy (D3310) provided.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that the enrollee currently meets IRF admission criteria.The Plan denied your request. The Plan says criteria for admission to the Acute Inpatient Rehabilitation setting have 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 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. Our reviewer found that 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 documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. Our physician reviewer also found that 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-approveacute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 17, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that authorization should not be needed. The Plan 
denied your request. The Plan says the services were not urgent, emergent, or 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 file shows that the enrollee was seen for a new patient visit. The provider in this case is not a network 
provider with the Plan. The Plan has network providers available who could have provided 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 for the medical services 
provided on August 17, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion therapy services coded S9328 provided 
from May 28, 2020, to August 13, 2020. 
 
You asked the Plan to pay for the home infusion therapy services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code S9328 is home infusion therapy, implanted pump pain 
management infusion; administrative services, professional pharmacy services, care coordination, and all 
necessary supplies and equipment (drugs and nursing visits coded separately), per diem. 
 
We find that CPT code S9328 is not supported in the medical record. Specifically, this code has a status code 
of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code 
for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for 
coverage of the home infusion therapy services have not been met. Therefore, we decided that the Plan does 
not have to pay for the home infusion therapy services coded S9328 provided from May 28, 2020, to August 
13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on October 5, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that in most 
cases, care you receive from an out-of-network provider (a provider who is not part of our plan?s network) will 
not be covered. If you need medical care that Medicare requires our Plan to cover and the providers in our 
network cannot provide this care, you can get this care from an out-of-network provider. You, or your PCP, 
must obtain authorization from the Plan prior to seeking care. In this situation, you will pay the same as you 
would pay if you got the care from a network 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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on October 5, 2020.