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

We decided that the Plan has to pay for the professional services for the administration of subcutaneous
immunotherapy or other subcutaneous infusion drug or biological (G0069) provided on June 1, 2021.

You asked the Plan to pay for the professional services for the administration of subcutaneous immunotherapy
or other subcutaneous infusion drug or biological. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says that there is insufficient documentation to
support the number of units 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 G0069 is professional services for the administration of subcutaneous immunotherapy or other
subcutaneous infusion drug or biological for each infusion drug administration calendar day in the individual's
home, each 15 minutes.

We find that CPT code G0069 is supported in the record. Specifically, the documentation submitted supports
the number of units billed. Based on this information, we decided that Medicare rules for coverage of the
professional services for the administration of subcutaneous immunotherapy or other subcutaneous infusion
drug or biological have been met. Therefore, we decided that the Plan has to pay for the professional services
for the administration of subcutaneous immunotherapy or other subcutaneous infusion drug or biological (G0069) provided on June 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory service (81479) rendered by the out-of-
network (OON) provider on March 19, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network
provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the service 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 this service. Therefore, we decided that the Plan
does not have to pay for the laboratory service (81479) rendered by the out-of-network (OON) provider on
March 19, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 81225, 81226, 81230, 81231, 81240, 81241, 81291, and 81328 provided on June 16, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are 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. We find that CPT codes 81225, 81226, 81230, 81231, 81240, 81241, 81291, and 81328 are not supported in the medical record. Specifically, if a laboratory assays two or more genes in an enrollee in parallel, then those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one code must be submitted for the panel. Review of the file does not support that only one code was submitted for these services. 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 for the laboratory services coded 81225, 81226, 81230, 81231, 81240, 81241, 81291, and 81328 provided on June 16, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the SNF admission. You say that you believe that you require this care. The Plan denied your request. The Plan says there is no need for daily skilled services.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is a female suffering from failure to thrive. From a nursing perspective, the beneficiary received oral medications. The beneficiary had stable vital signs. Regarding rehabilitation services, the beneficiary received physical therapy. The beneficiary was at a maximal to moderate assist level with bed mobility and transfers. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. This beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory service (81546) rendered by the out-of-
network (OON) provider on June 12, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network
provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the service 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 this service. Therefore, we decided that the Plan
does not have to pay for the laboratory service (81546) rendered by the out-of-network (OON) provider on
June 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services received on November 25, 2020.
You asked the Plan to pay for the dental services. You say that you feel that this request for reimbursement should be honored as this service was a continuation of the procedure for 2019 and no other professional would step in to continue the procedure started by another provider. 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 dental services received on November 25, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergency transportation, wheelchair van provided from April 29, 2021, through May 13, 2021.
You asked the Plan to pay for non-emergency transportation, wheelchair van. You say that the enrollee was in a rehabilitation center and would not have been able to get to doctor's appointments related to the condition otherwise. The Plan denied your request. The Plan says wheelchair van (chair car) transportation is not covered by Medicare even if provided by an ambulance company.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport services.
The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided that the Plan does not have to pay for non-emergency transportation, wheelchair van provided from
April 29, 2021, through May 13, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the crutch substitute (E0118) provided on June 14, 2021.
You asked the Plan to pay for the crutch substitute (E0118). You say that you would like the Plan to reconsider
their denial of payment. The Plan denied your request. The Plan says the provider is not enrolled in the
Medicare program.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is
not enrolled in the Medicare program.
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare
program. Therefore, we decided that the Plan does not have to pay for the crutch substitute (E0118) provided
on June 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services (D2740 and D2950) provided on
July 6, 2021.
You asked the Plan to pay for dental codes D2740 and D2950. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says dental codes D2740 and D2950 are not covered under the Plan's supplemental dental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, dental codes D2740 and D2950 are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental services (D2740 and D2950) provided on July 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services (99291) provided on January 28,
2021.
You asked the Plan to pay for code 99291. You say that you would like the Plan to reconsider their denial of
payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that 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 medical record. Specifically, there were no medical
records provided for the January 28, 2021 date of service to verify if the services were billed correctly. Based
on this information, we decided that Medicare rules for coverage of code 99291 have not been met. Therefore,
we decided that the Plan does not have to pay for the critical care services (99291) provided on January 28,
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (procedure code 99291) provided to the
enrollee on February 18, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says Current Procedural Terminology (CPT) code 99291 remains not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate 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 medical record. Specifically, there was no documentation
showing the time spent providing the critical care services. This documentation is necessary as CPT 99291 is a
time-based code. Based on this information, we decided that Medicare rules for coverage of the services have
not been met. Therefore, we decided that the Plan does not have to pay for critical care services (procedure
code 99291) provided to the enrollee on February 18, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from January 18, 2021 to February 11, 2021.
You asked the Plan to pay for home health services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the claim was billed with an incorrect Q code for the services rendered. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from January 18, 2021 to February 11, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics (L3000) provided on May 11, 2021.
You asked the Plan to pay for foot orthotics. You say that the items at issue are a medical necessity for the
enrollee. The Plan denied your request. The Plan says these items are not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace.
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pay for foot orthotics
(L3000) provided on May 11, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on May 17, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says due to the enrollee's hospice election at the time of service, this claim must be submitted
to Original Medicare first for review.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for physician services provided to the enrollee on May 17, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on July 14, 2021.
You asked the Plan to pay for ambulance response and treatment, no transport. The Plan denied your request. The Plan says ambulance services are covered when actual transportation occurs.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.
The ambulance company did not provide transport services on July 14, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on July 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for venipuncture (36415) and prothrombin time (85610)
provided on July 21, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for venipuncture and prothrombin time. You say that the copayment was paid at the
time of service. You also say the member is asking the Plan to reprocess the claim and find her not responsible
as this is a necessity to maintain her life. The Plan denied your request. The Plan says they denied for out of
network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan 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 venipuncture (36415) and prothrombin time
(85610) provided on July 21, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to provide reimbursement for two of the dental extractions provided. We decided
that the Plan does not have to provide reimbursement for the limited oral exam, the remaining extractions,
removal of the torus, and sedation services.
You asked the Plan to provide reimbursement for two of the dental extractions provided. You say that the cost
for this care is too much for you to pay and you were not able to be seen in time by other network providers.
The Plan says that this provider has opted out of the Medicare program and cannot be paid for these services.
We decided that the Plan has to provide reimbursement for two of the dental extractions provided.
The Plan follows Medicare rules. Medicare rules say that the services provided by network providers are
deemed approved by the Plan unless they are explicitly excluded from coverage.
In this case, although this provider has opted out of Medicare, the Plan has indicated in multiple places in the
file that he is participating with your Plan. As such, up to the two dental extractions are considered approved
since they are covered services in your contract. Therefore, we decided that the Plan has to provide
reimbursement for two of the dental extractions provided.
We also decided that the Plan does not have to provide reimbursement for the limited oral exam, the
remaining extractions, removal of the torus, and sedation services.
The Plan follows Medicare rules. Medicare rules say that dental services are generally not covered. Services
provided by network providers can only be considered approved when not explicitly excluded from coverage.
More than two extractions, limited oral exams, moderate sedation, and torus removal are not listed as covered
by your dental benefit. As such, these are correctly denied by the Plan. Therefore, we decided that the Plan
does not have to provide reimbursement for the limited oral exam, the remaining extractions, removal of the
torus, and sedation services.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory work provided on July 23, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the laboratory work. You say that the service was medically necessary and was ordered by a network physician. The Plan denied your request. The Plan says no prior authorization was 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. The records provided for review do not show that the service at issue were urgent or emergent. Therefore, we decided that the Plan does not have to pay for laboratory work provided on July 23, 2021, by an out-of-network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214) provided on November 18, 2019.
You asked the Plan to pay for an office visit. You say that this was originally filed timely. The Plan denied
your request. The Plan says this was filed more than a year after the date of service.
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 an office visit was not filed until August 13, 2021. 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 for an office visit (99214) provided on November 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services (D4355) provided on July 29, 2021.
You asked the Plan to pay for dental code D4355. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says dental code D4355 is not covered under the
Plan's supplemental dental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, dental code D4355 is not among those
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental services
(D4355) provided on July 29, 2021.
Your complaint about the Plan is not a valid appeal for medical coverage. This part of your complaint is a
grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types
of complaints.