Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the outpatient mental health care visits provided on September 10, 2020, to February 24, 2021, by an out-of-network (OON) provider.  

You asked the Plan to pay for the outpatient mental health care visits. You say that the services were medically necessary. 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 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 outpatient mental health care visits provided on September 10, 2020, to February 24, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869).  You asked the Plan to pre-approve the insertion of a Vertiflex device. You say that this is covered by Medicare. The Plan denied your request. The Plan says this is experimental.  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 insertion of a Vertiflex device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show it is safe and effective.  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 insertion of a Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869).
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a sleep study (95811).  

You asked the Plan to pre-approve a sleep study. You say that this study is medically necessary. You presented for previous sleep studies in 2019 and they were difficult to perform because you were experiencing extreme breathing issues while attempting to sleep. You have been using a CPAP device since 2019, but your current CPAP device is malfunctioning, and you want to ascertain whether the CPAP is still appropriate for your sleep condition. The Plan denied your request. The Plan says the clinical documentation submitted does not show the need for a follow up sleep study. There has been no change in your condition. The provided documentation shows that your symptoms have improved, and there is no evidence of change in your underlying sleep pattern.  

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 a sleep study. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case you were noted to have previously undergone sleep testing which led to a diagnosis of sleep apnea. The records which were provided for review did not readily discuss why you had been referred for repeat sleep testing. There was not a significant change noted in your health history that would immediately prompt a need for a repeat diagnostic sleep study, particularly given that the diagnosis is already known. The records otherwise indicated that you were having a positive response to the use of PAP therapy. In this setting it cannot be determined that the requirements of Medicare Criteria for repeat sleep testing have been satisfied based on the information provided.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a sleep study have not been met. Therefore, we decided that the Plan does not have to pre-approve a sleep study (95811).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the physician services provided on August 2, 2021 by an out-of-network (OON) provider.  

You asked the Plan to pay for the physician 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 physician services provided on August 2, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to provide additional payment for the frames (V2020) and lenses, polycarbonate or equal (V2784) provided September 28, 2021.  

You asked the Plan to provide additional payment for the frames and polycarbonate lenses. You say that you were not told that the Plan wasn't going to pay the balance. The Plan denied your request. The Plan says the full $100 vision benefit has been applied to your routine eyewear and no further payment is due.  

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. The Plan covers the frames and polycarbonate lenses up to a $100 annual allowance amount.   

We looked at the file and Medicare rules. In this case the Plan provided documentation showing that the full $100 allowance has been applied to your routine eyewear. You have been asked to pay the remaining cost for the frames and polycarbonate lenses. This means that you have been asked to pay the correct amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to provide additional payment for the frames (V2020) and lenses, polycarbonate or equal (V2784) provided September 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the specialist office visit provided on August 23, 2021.  

You asked the Plan to waive the copayment for the specialist office visit. You say that you should not be responsible for the copayment. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing 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 $30 copayment if services are provided by an in-network specialist.    

You have been asked to pay a $30 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" 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 specialist office visit provided on August 23, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for chemotherapy administration provided on June 1, 2021, and June 28, 2021.  

You asked the Plan to waive the copayment for chemotherapy administration. You say that you are not charged for chemotherapy administration unless you have two visits within a month. The Plan denied your request. The Plan says the copayment applied was correct.    

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 $0 copayment for each chemotherapy or infusion therapy Part B drug. Your contract with the Plan also clearly says that you must pay a $10 copayment for the administration of the chemotherapy drug as well as for infusion therapy.  

You have been asked to pay a $10 copayment for chemotherapy administration. Chemotherapy administration falls within the Medicare Part B Prescription Drugs 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 chemotherapy administration provided on June 1, 2021, and June 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for sacroiliac (SI) radiofrequency ablation (RFA) provided on February 2, 2021.  

You asked the Plan to pay for SI RFA. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this procedure is not covered by Medicare.  

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 SI RFA. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered an experimental/investigational procedure because of the wide variation in efficacy reported in the literature.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SI RFA have not been met. Therefore, we decided that the Plan does not have to pay for sacroiliac (SI) radiofrequency ablation (RFA) provided on February 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the CxBladder testing (0013M) provided on June 11, 2021.  

You asked the Plan to pay for code 0013M. 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 CPT codes 0012M and 0013M for CxBladder are non-covered.  

We looked at the file and Medicare rules. The service at issue is non-covered. Therefore, we decided that the Plan does not have to pay for the CxBladder testing (0013M) provided on June 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient care provided from August 3, 2020, to August 13, 2020, and billed with DRG (diagnosis related group) 871.  You asked the Plan to pay for inpatient care. You say that this was billed correctly. The Plan denied your request. The Plan says the sepsis diagnosis is not supported.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.    In this case, you billed the inpatient services provided with the principal diagnosis code A41.01, sepsis due to Methicillin susceptible Staphylococcus aureus, and DRG 871, septicemia or severe sepsis without mechanical ventilation greater than 96 hours with major complications or comorbidities. 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 inpatient care. Our reviewer says that the billed DRG is not supported. Our physician reviewer found the records indicate that sepsis secondary to Methicillin susceptible Staphylococcus aureus (MSSA) was likely present on admission due to his timeline and resolved by discharge. The rules say that the circumstances of inpatient admission always govern the selection of principal diagnosis, therefore coding this as the principal diagnosis is not appropriate.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient care provided from August 3, 2020, to August 13, 2020, and billed with DRG (diagnosis related group) 871.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), periapical x-ray (D0220), additional periapical x-ray (D0230), and bitewing x-rays (D0274) provided on August 5, 2021.  You asked the Plan to pay for the dental services. You say that prior to your appointment you specifically asked if insurance would cover your appointment. You say that you were told yes. You say that you feel you should not be billed. You also say that you feel you were misled by the insurance. The Plan denied your request. The Plan says there is an annual maximum benefit of $1,000 per plan year. The Plan also says that the 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 and the services are listed as covered, the annual maximum benefit has been exhausted.  Date of Service Plan Paid 1/19/2021 $64 1/21/2021 $60 2/11/2021 $11 3/2/2021 $553 3/22/2021 $16 4/15/2021 $296 8/5/2021 $0 TOTAL: $1,000  Additionally, the Evidence of Coverage clearly states that after the annual maximum is exhausted, any remaining charges are your responsibility. Therefore, we decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), periapical x-ray (D0220), additional periapical x-ray (D0230), and bitewing x-rays (D0274) provided on August 5, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for a chest x-ray billed with code 71045 for date of service August 16, 2021.  

You asked the Plan to pay for code 71045. You say that the enrollee had multiple exams on this date of service. You say that the reports provided support the level of services billed. The Plan denied your request. The Plan says a procedure to procedure edit exists between the code in dispute and code 71046 which was billed for the same date of service.  

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, we have confirmed that code 71045 is a column II code to column I code 71046. 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 a chest x-ray billed with code 71045 for date of service August 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit and urine drug test provided on January 18, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the office visit and urine drug test. You say that the services were medically necessary. 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 services at issue were urgent or emergent. Therefore, we decided that the Plan does not have to pay for the office visit and urine drug test provided on January 18, 2021, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transportation provided on September 9, 2020.

You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when they meet certain origin and destination requirements. A doctor's office is not a covered destination. 

The services you have asked the Plan to pay for are ambulance transport services to a doctor's office. Therefore, we decided that the Plan does not have to pay for the ambulance transportation provided on September 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient hospital services provided on February 4, 2020, through February 21, 2020 and billed with Diagnosis Related Group (DRG) code 853.  You asked the Plan to pay for the inpatient hospital services billed with DRG 853. You say that you would like reconsideration because the record supports the DRG code billed. The Plan denied your request. The Plan says the documentation submitted does not support diagnosis codes A40.8 and R65.21.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.    In this case, you billed the inpatient services provided with diagnosis codes A40.8 and R65.21. 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 inpatient hospital services billed with DRG 853. Our reviewer says that the documentation was inconsistent regarding a diagnosis of sepsis. Even though severe sepsis is documented in the medical record, supporting documentation was not found. Our physician reviewer found there was no clinical or laboratory evidence of sepsis. The review has determined that the documentation did not support the diagnoses of other streptococcal sepsis and severe sepsis with septic shock.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided on February 4, 2020, through February 21, 2020 and billed with Diagnosis Related Group (DRG) code 853.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the infrared therapy (97026) provided on August 3, 2021.  You asked the Plan to pay for the infrared therapy. You say that you would like this claim to be reprocessed for payment. The Plan denied your request. The Plan says this is a non-covered service.    The Plan must follow Medicare rules. Medicare rules say that the use of infrared and/or near-infrared light and/or heat, including monochromatic infrared energy, is non-covered for the treatment, including the symptoms such as pain arising from these conditions, of diabetic and/or non-diabetic peripheral sensory neuropathy, wounds and/or ulcers of the skin and/or subcutaneous tissues.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the infrared therapy have not been met. Therefore, we decided that the Plan does not have to pay for the infrared therapy (97026) provided on August 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the psychotherapy services provided on April 28, 2021.  You asked the Plan to pay for the psychotherapy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the case file is missing required documentation.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We looked at the file and Medicare rules. Review of the file shows that evaluation and management by psychologists is covered when the provider attempts to consult the attending or primary care physician about the services furnished and document the consent or declination date to consultations, and the date of consultations in the enrollee's medical record. In addition, there is no referring physician listed on the claim. Based on this information, we decided that Medicare rules for coverage of the psychotherapy services have not been met. Therefore, we decided that the Plan does not have to pay for the psychotherapy services provided on April 28, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hospital services provided on June 3, 2021, through June 6, 2021.  You asked the Plan to pay for the hospital services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says an Explanation of Payment from the primary payer has not been received in order to coordinate benefits as a secondary payer.  The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.  The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the hospital services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the hospital services provided on June 3, 2021, through June 6, 2021.