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

 
We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of 
head or brain (70450) provided on September 4, 2020. 
 
You asked the Plan to waive the copayment for the CT scan of head or brain. You say that you would like this 
copayment waived. The Plan denied your request. The Plan says the copayment has processed correctly in this 
case. 
 
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 $195 
copayment for advanced imaging services.  
 
You have been asked to pay a total cost share of $102.38 for the CT scan of head or brain which is less than the 
required $195 copayment. The service provided falls within the advanced imaging 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 the computed tomography (CT) scan of head or brain 
(70450) provided on September 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit, the application of a modality to 1 or more 
areas, the self-care/home management training, and the therapeutic procedure services received by a 
chiropractor on September 15, 2020. 
 
You asked the Plan to pay for the office visit, the application of a modality to 1 or more areas, the self-
care/home management training, and the therapeutic procedure services received by a chiropractor . You say 
that you feel these services should be paid in full as you feel you were misled into thinking the services were 
covered. The Plan denied your request. The Plan says the services received are not a covered benefit. 
 
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. Therefore, we decided that 
the Plan does not have to pay for the office visit, the application of a modality to 1 or more areas, the self-
care/home management training, and the therapeutic procedure services received by a chiropractor on 
September 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on August 21, 2020 by an 
out of network provider. 
 
You asked the Plan to pay for the physician services. You say that you had authorization so the Plan should pay 
this claim. The Plan denied your request. The Plan says you did not have authorization for the out of network 
services. 
 
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 services at issue in this appeal. The Plan did not pre-approve the service 
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 physician services provided on August 21, 2020 by an out of network 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on July 23, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for office services. You say that you were under the assumption that the doctor had 
obtained authorization. The Plan denied your request. The Plan says the denial of payment for these services is 
correct, because this provider is out-of-network with the Plan 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 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 23, 2020 by 
an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lumbar-sacral orthosis (L0650) provided August 3, 2020.You asked the Plan to pay forthe orthosis. You say that attached please find a copy of all records to support medical necessity for a mobility back brace.The Plandenied your request. The Plan says under Medicare guidelines, the request is not medically necessary because the records do not support the need or justification for the brace.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 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 pay for the orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the reviewed documentation indicates that the enrollee was solicited by a DME company to have a back brace delivered.The record sent by your provider indicates that you were seen on July 21, 2020,for various complaints. At this appointment the enrollee stated that she had back pain and the provider increased the Gabapentin dose and referred her to pain management. Therewas no mention of needing a back brace or the intent to order one. There is an order for a back brace signed on July 28, 2020. There is no commensurate note in the medical record on or around that date as to why the brace was being ordered. The review hasdetermined that the medical records provided did not meet the requirements listed in the LCD for Medicare coverage.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverageof the orthosis have not been met.Therefore, we decided that the Plan does not have to pay forthe lumbar-sacral orthosis (L0650) provided August 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forintraoral x-rays (D0220, D0230) provided July 20, 2020.You asked the Plan to pay forthe intraoral x-rays. You say that the services should be covered.The Plan denied your request. The Plan says intraoral x-rays are not a covered benefit 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 forintraoral x-rays (D0220, D0230) provided July 20, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided from August 28, 2020, to September 30, 2020, by an out-of-network (OON) provider.You asked the Plan to pay foroutpatient rehabilitation services. You say that you were unaware that the enrollee had a plan that you were not in-network with.The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan 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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe medical services provided from August 28, 2020, to September 30, 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 on February 26, 2020 by an out of network (OON) provider.You asked the Plan to pay foreye examination. You say that you were unaware of the enrollee's insurance prior to service; therefore, you did not have time to obtain authorization.The Plan denied your request. The Plan says the denial of payment for this service is correct.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe medical services provided on February 26, 2020 byan out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe outpatient office visit (99214) provided on January 16, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe office visit. You say that please process the denied claim for payment as the provider is in network with the plan.The Plandenied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.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 areaurgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe outpatient office visit (99214) provided on January 16, 2020 by an out of network(OON) provider
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay foremergency department visit (99282) provided June 9, 2020.You asked the Plan to pay forthe emergency visit. You say that you are requesting reprocessing of the claim with the attached medical records for reimbursement.The Plan denied your request. The Plan says the claim is missing CMS certification/letter.The Plan must follow Medicare rules. Medicare does not certify freestanding emergency rooms or recognize them as departments since they cannot demonstrate compliance with hospital Conditions of Participation (COP). Therefore, independent freestanding emergency rooms cannot accept Medicare or receive Medicare reimbursement.We looked at the file and Medicare rules. This facility is a non-Medicare approved/certified freestanding emergency facility. Freestanding emergency rooms are not hospitals and have no affiliation with a hospital and are unable to obtain Medicare approval/certification. Medicare does not certify freestanding emergency rooms or recognize them as departments since they cannot demonstrate compliance with hospital Conditions of Participation(COP). Therefore, independent freestanding emergency rooms cannot accept Medicare or receive Medicare reimbursement. Additionally, Medicare guidance allowing payment on emergency hospital claims for non-Medicare certified hospitals does not apply to non-Medicare freestanding emergency facilities. Based on this information, we decided that Medicare rules for coverage of the emergency visit have not been met.Therefore, we decided that the Plan does not have to pay foremergency department visit (99282) provided June 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the unspecified oral surgery procedure (D7999) provided on November 12, 2020.
You asked the Plan to pay for the unspecified oral surgery procedure. You say that you were given this provider's information by the Plan. You say that you paid $264 out of pocket for the services. You say that the provider is requested an additional $130. You also say that the services should be covered. The Plan denied your request. The Plan says the unspecified oral surgery procedure is not listed as a covered service.
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 unspecified oral surgery procedure is not among those covered under this benefit. Although the Plan incorrectly referred you to an out of network provider, this service would not be covered even if the provider was in network. Therefore, we decided that the Plan does not have to pay for the unspecified oral surgery procedure (D7999) provided on November 12, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe emergency room visit (99282) basic metabolic panel (80048) blood count (85027) provided September 8, 2020.You asked the Plan to waive the copayment forthe emergency room visit. You say that you was recommended to go to the emergency room and you waited 4 hours only to be told your potassium level was normal. You should not be responsible to pay this copay since the lab made the error.The Plan denied your request. The Plan says this claim was processed and the correct copayment was applied.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 $75 copayment for emergency room visits.You have been asked to pay $75 copayment for the emergency room visit. The emergency room visit falls within the Emergency care 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 emergency room visit (99282) basic metabolic panel (80048) blood count (85027) provided September 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe root canal (D3330) and the unspecified adjunctive procedure (D9999) provided on July 6, 2020.You asked the Plan to reimburse you forthe dental service. You say that your policy states that the plan will provide some coverage for root canals. You also say that you paid out of pocket for these services.The Plan denied your request. The Plan says root canal is not listed as a covered service. The Plan also says that the unspecified adjunctive procedure is not listed as a covered service.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 forthe root canal (D3330) and the unspecified adjunctive procedure (D9999) provided on July 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an out of network (OON) provider.

You asked the Plan to pay for practitioner visit. You say that your provider depends upon the facility to verify eligibility and obtain the proper authorization.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and the referring facility is also out-of-network with the 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 for the medical services provided by an out of network (OON) provider
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe urinalysis services coded 81003 provided on July 23, 2020.You asked the Plan to pay forthe urinalysis 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 81003 is urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, without microscopy.We find that CPT code 81003 is not supported in the medical record. Specifically, payment isnot allowed for this service. All charges, except for therapies, telehealth originating site facility fee, PPV, influenza virus vaccine, hepatitis B vaccine and hospital-based ambulance services are combined and should be reported under the appropriate revenue code as per CMS guidelines. Based on this information, we decided that Medicare rules for coverage of the urinalysis services have not been met.Therefore, we decided that the Plan does not have to pay forthe urinalysis services coded 81003 provided on July 23, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvemagnetic resonance cholangiopancreatography (MRCP) for the enrollee.You asked the Planto pre-approvethe imaging. You say that this is medically necessary.The Plandenied your request. The Plansaysthere is no supporting documentation to justify this request.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 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 imaging. Our reviewer says that the requested imaging is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee's clinical scenario does not meet the criteria for MRCP. The enrollee's LFTs were elevated on only one lab check andnormalized to the baseline on follow-up lab check several weeks later. In addition, ultrasound as described showed no abnormalities to warrant MRCP imaging as requested.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicarerules for coverage of the imaging have not been met.Therefore, we decided that the Plandoes not haveto pre-approvemagnetic resonance cholangiopancreatography (MRCP) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ultrasound study of arteries and arterial grafts of both legs (93925) provided on November 28, 2019, by an out-of-network (OON) provider.You asked the Plan to pay forthe ultrasound study of arteries and arterial grafts of both legs. You say that the services provided were medically necessary.The Plan denied your request. The Plan says prior authorization was not obtained by the facility or the provider; therefore, payment has been correctly denied.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe ultrasound study of arteries and arterial grafts of both legs (93925) provided on November 28, 2019, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forintraoperative neuromonitoring (G0453) nerve conduction and electromyography (95870) special EEG tests (95955) short-latency somatosensory evoked potential study (95938) provided March 17, 2019You asked the Plan to pay forthe neuromonitoring services. You say that the plan's decision to deny your claim for past timely filing is not justified. Your records indicate that the claim was filed timely.The Plan denied your request. The Plan says the time limit for filing has expired.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.The record shows that a claim for the neuromonitoring services was not filed until July30, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay forintraoperative neuromonitoring (G0453) nerve conduction and electromyography (95870) special EEG tests (95955) short-latency somatosensory evoked potential study (95938) provided March 17, 2019