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

We decided that the Plan does not have to pay for the laboratory services provided on April 7, 2021.
You asked the Plan to pay for the laboratory services. 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 as billed.
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately
payable.
Labs should bill the facility directly for lab services as they are considered part of the composite rate. No other
payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for the
laboratory services provided on April 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the Laminotomy (63042) provided on July 14, 2021.
You asked the Plan to pay for code 63042. 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 as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 63042
is a column II code to column I code 22633. This claim has not been billed with an appropriate modifier to
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we
decided that the Plan does not have to pay for the Laminotomy (63042) provided on July 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a CT scan and does not have to waive the coinsurance for medical supplies provided on July 15, 2021.  You asked the Plan to waive the copayment for a CT scan and to waive the coinsurance for medical supplies. You say that you were not informed that you would owe anything for the service. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $150 copayment for CT scans and 20% coinsurance for medical supplies.  You received a CT scan on July 15, 2021. Therefore, you are responsible to pay the $150 copayment.  You received medical supplies on July 15, 2021. Therefore, you are responsible to pay your share of the cost-sharing charges. The total allowed amount is $16 and 20% of that is $3.20.  The total amount you owe is: $158.20.   You have been asked to pay the total amount of $158.20 for a CT scan and medical supplies. A CT scan and medical supplies 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 a CT scan and does not have to waive the coinsurance for medical supplies provided on July 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on September 20, 2021.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that the only reason you went to this appointment was to have your tooth extracted. The Plan denied your request. The Plan says your benefits for this service have been satisfied and the frequency limitation 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, periodic oral exam and emergency diagnostic exam share a frequency limitation of two procedure codes per calendar year. The record shows that you received periodic oral evaluations (D0120) on March 2, 2021, and September 7, 2021 and your periodic oral exam and emergency diagnostic exam benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on September 20, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiac rehabilitation provided on August 2, 2021, to August
30, 2021, by an OON provider.
You asked the Plan to pay for cardiac rehabilitation. You say that these services were medically necessary. The
Plan denied your request. The Plan says prior authorization was not obtained for these services. The Plan says
that there are in-network providers available who could have provided these 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 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 cardiac rehabilitation provided on August 2, 2021,
to August 30, 2021, by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has had a prolonged hospital course and remains with evidence of infection while awaiting dialysis access placement. The record indicates that the enrollee requires ongoing acute care services, and these have not been denied. The enrollee does not require services that he is not currently receiving but that would be available at the LTACH facility.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a walker (E0144) provided on September 16, 2021, by an out-of-network provider.
You asked the Plan to pay for a walker. You say that you needed the item at issue on a faster timeframe than the Plan could get it for you and you got it much cheaper than the Plan would have spent. The Plan denied your request. The Plan says rules for payment for out-of-network services have not been met.
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 a walker (E0144) provided on September 16, 2021, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on
September 9, 2021.
You asked the Plan to pay for the comprehensive oral evaluation. You say that you would like this service to be
covered. The Plan denied your request. The Plan says your benefits for this service have been satisfied and the
frequency limitation has been exceeded. The Plan also says that you did not contact the Plan prior to this date
of service to verify benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, comprehensive oral evaluation
(D0150) is limited to one procedure code every three years. The record shows that you received a
comprehensive oral evaluation (D0150) on January 16, 2020 and your comprehensive oral evaluation (D0150)
benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive
oral evaluation (D0150) provided on September 9, 2021.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve an unattended sleep study (95806).
You asked the Plan to pre-approve the sleep study. You say that the enrollee has not undergone polysomnography (PSG) since 1999, and the enrollee needs new PSG results to obtain new CPAP supplies. The enrollee did not meet diagnostic criteria for obstructive sleep apnea (OSA) at that time, The Plan denied your request. The Plan says that the records show that the enrollee has had this same test or one like it before. The results of the test were not submitted. The prior test may have shown the doctor what they needed to see in order to treat the enrollee's condition, but repeat testing is not supported without results of prior tests that show a clear reason for it.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the sleep study. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee in this case is suspected of having OSA. While the member had PSG over 20 years ago, they were not diagnosed with OSA at that time. Rather, the diagnosis they were given was upper airway resistance syndrome (UARS), because their apnea hypopnea index (AHI) was less than 5 at the time. As the member did not meet diagnostic criteria for OSA at that time, the results of prior testing would not qualify them for a CPAP unit. Given that OSA is again/still suspected, and there are not prior test results available that could support the provision of therapy, it would be reasonable and necessary to repeat sleep testing. The enrollee otherwise has symptomatology that would be consistent with the indications for which the requested service is covered. 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 sleep study have been met. Therefore, we decided that the Plan has to pre-approve an unattended sleep study (95806).
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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the two crowns (D2740 x2), two prefabricated posts and cores in addition to crowns (D2954 x2), or pay more for the endodontic therapy (D3330) provided from September 11, 2021, to September 25, 2021.  You asked the Plan to pay for the crowns, prefabricated posts and cores, and to pay more for the endodontic therapy. You say that you are aware that you have a $1,000 dental allowance but feel the Plan should make an exception to cover the denied services due to not having been able to go to the dentist during the year of 2020. The Plan denied your request. The Plan says your annual maximum benefit has been exhausted.  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 Plan offers a $1,000 annual dental benefit maximum, less the cost-sharing you pay. The contract says that after your annual maximum benefit maximum has been met, you are responsible for the full charges of any additional dental services. The record shows that you met the annual maximum benefit on September 11, 2021 and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the two crowns (D2740 x2), two prefabricated posts and cores in addition to crowns (D2954 x2), or pay more for the endodontic therapy (D3330) provided from September 11, 2021, to September 25, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for hip replacement surgery (27130) and a physical therapy visit (97161) provided on June 14, 2021, and June 16, 2021.
You asked the Plan to waive the cost-sharing for the hip replacement surgery and physical therapy visit. You say that the services should be covered at an inpatient rate. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.
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 20% coinsurance for Outpatient hospital services and a $40 copayment for Outpatient rehabilitation services.
You have been asked to pay a 20% coinsurance for hip replacement surgery (the total allowed amount is $11,664.54 x 20% = $2,332.9) and a $40 copayment for a physical therapy visit. The record indicates that these services were performed in an outpatient setting. Hip replacement surgeries fall within the Outpatient hospital services benefit category and physical therapy services fall within the Outpatient rehabilitation 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 cost-sharing for hip replacement surgery (27130) and a physical therapy visit (97161) provided on June 14, 2021, and June 16, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on August 28, 2021.  You asked the Plan to pay for the ambulance response and treatment with no transport. You say that by the time the paramedics responded and performed an electrocardiogram, your heart had returned to your regular abnormal-normal and pain and difficulty breathing had resided. You also say that transport at that time was unnecessary. The Plan denied your request. The Plan says this service ambulance service without transport is not a Medicare covered benefit.  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 August 28, 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 the ambulance response and treatment with no transport (A0998) provided on August 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on September 4, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the laboratory services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.  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 laboratory services provided on September 4, 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 the office visit provided on August 20, 2021 by an out-of-
network (OON) provider.
You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the services provided are not a covered benefit.
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 office visit provided on August 20, 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 the office visit services provided on June 9, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the office visit services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.  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 office visit services provided on June 9, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a hospital outpatient clinic visit with laboratory services (G0463, 36415, 80053, 82607, 82728, 82746, 83540, 84443, 84466, 85025, 90686) provided on October 7, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for a hospital outpatient clinic visit with laboratory services. You say that this provider regularly complies with all administrative requirements for payments. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not referred by a network provider. The Plan also says that they have also determined that these services are not urgent or emergent, nor were they approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan 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 a hospital outpatient clinic visit with laboratory services (G0463, 36415, 80053, 82607, 82728, 82746, 83540, 84443, 84466, 85025, 90686) provided on October 7, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an orthosis (L1851, L2397) provided to the enrollee on 
September 13, 2021.

You asked the Plan to pay for the services. You say that the enrollee had an in-person visit within six months of 
signed standard written order (SWO), and the primary care physician (PCP) prescribed knee braces. The Plan 
denied your request. The Plan says the information does not document any physician evaluation or physical 
signs or symptoms of pain, instability, or other findings supportive of the need for a 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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the case file does not contain documentation of recent injury or surgery to the knee, or knee instability 
documented on exam. The case file contains signed orders for ordered deluxe knee orthoses for the right and 
left knees, as well as a lumbar orthosis. However it is documented that the physician denied ordering the brace, 
in a phone call.

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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for an orthosis (L1851, L2397) provided to the enrollee on September 13, 2021.