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

We decided that the Plan does not have to pay for the self-administered drugs you received while in the
hospital on May 17, 2021.
You asked the Plan to pay for the self-administered drugs. You say that you would like this claim paid for by
the Plan. The Plan denied your request. The Plan says these drugs are not covered under the Plan's medical
benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs you
received while in the hospital on May 17, 2021.
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the therapeutic radiology simulation-aided
field setting; intermediate (77285), radiation treatment delivery, superficial and/or ortho voltage, per day
(77401), radiation treatment management, 5 treatments (77427), basic radiation dosimetry calculation, central
axis depth dose calculation (77300), therapeutic radiology simulation-aided field setting; complex (77290) and
office or other outpatient visit for the evaluation and management of an established patient (99212, 99214)
provided February 24, 2021, to April 26, 2021.
You asked the Plan to waive the cost sharing for the radiation therapy services and office visits. You say that
you don't believe you are responsible for any charges above your benefit guideline. The Plan denied your
request. The Plan says the cost-sharing was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% of
the total cost for each Medicare-covered therapeutic radiology service and a $25 copayment for each Medicarecovered
specialist visit.
You have been asked to pay 20% coinsurance for each of the radiation therapy services and a $25 copayment
for each of the office visits. The radiation therapy services fall within the Outpatient diagnostic tests and
therapeutic services and supplies benefit category and the office visits fall 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 cost sharing
for the therapeutic radiology simulation-aided field setting; intermediate (77285), radiation treatment delivery,
superficial and/or ortho voltage, per day (77401), radiation treatment management, 5 treatments (77427), basic
radiation dosimetry calculation, central axis depth dose calculation (77300), therapeutic radiology simulationaided
field setting; complex (77290) and office or other outpatient visit for the evaluation and management of
an established patient (99212, 99214) provided February 24, 2021, to April 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for additional supplies, materials, and clinical staff time over and
above those usually included in an office visit or other non-facility service(s), when performed during a Public
Health Emergency, as defined by law, due to respiratory-transmitted infectious disease (CPT code 99072)
provided to the enrollee on October 29, 2020.
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request.
The Plan says the service is not covered as billed by the provider.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. Review of the records indicated that procedure
99072 has a status indicator of 'B' on the CMS Physician Relative Value File, is always bundled into payment
for other services not specified and no separate payment is made per Medicare. Based on the claim submitted,
Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for
additional supplies, materials, and clinical staff time over and above those usually included in an office visit or
other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to
respiratory-transmitted infectious disease (CPT code 99072) provided to the enrollee on October 29, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the nuclear stress test you had at an outpatient hospital facility on July 7, 2021.
You asked the Plan to waive the copayment for the nuclear stress test. You say that you believe this copayment is too high. The Plan denied your request. The Plan says you were charged this copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 copayment for nuclear medicine at an outpatient hospital.
You have been asked to pay a $325 copayment for the nuclear stress test. The nuclear stress test falls within the nuclear medicine at an outpatient hospital 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 nuclear stress test you had at an outpatient hospital facility on July 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for white colored filling- tooth number(s) and/or area: 5 (CPT code D2393) and other preventative service (CPT code D1999) provided from March 24, 2021, through March 25, 2021, by an opted out Medicare provider.
You asked the Plan to pay for the dental services. You say that you were unaware the provider was out-of-network because the dental office told you that are in-network. The Plan denied your request. The Plan says the services are not covered by a provider that has opted out of Medicare.
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. This provider has opted out of Medicare. The rules say that to receive payment for covered Medicare items or services from either Medicare (in the case of an assigned claim) or a Medicare beneficiary (in the case of an unassigned claim), a provider or supplier must be enrolled in the Medicare program. Even if the provider was a Medicare provider your Plan requires you to see an in-network provider. Therefore, we decided that the Plan does not have to pay for white colored filling- tooth number(s) and/or area: 5 (CPT code D2393) and other preventative service (CPT code D1999) provided from March 24, 2021, through March 25, 2021, by an opted out Medicare provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the unspecified maxillofacial prosthesis (D5999) provided on
March 11, 2021.
You asked the Plan to pay for the unspecified prosthesis. You say that this device is for your sleep apnea and
you do not understand why the Plan will not pay for it. The Plan denied your request. The Plan says they have
made multiple outreach attempts to the provider but have been unable to verify that the prosthesis at issue is
being provided for medical purposes. There is insufficient information for review.
Medicare generally does not cover dental services. The Plan follows the same rule. The rules also say that it is
the responsibility of the provider, supplier or beneficiary, as appropriate, to furnish to the intermediary or
carrier sufficient information to determine whether payment is due and the amount of payment.
There is insufficient information to support that the provided prosthesis is medical in nature and was medically
necessary and reasonable. The Plan has made outreach attempts to the provider but was unable to obtain
medical records to support this service. Therefore, we decided that the Plan does not have to pay for the
unspecified maxillofacial prosthesis (D5999) provided on March 11, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for SNF care provided from March 13, 2021, through April 14, 2021.
You asked the Plan to waive the copayment for SNF care. You say that you were never made aware of overstaying or cost. The Plan denied your request. The Plan says the copayment should be $650 (13 SNF days x $50 copayment); however, you met your maximum out-of-pocket of $799 with this $599 copayment.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that you received SNF care from March 13, 2021, through April 14, 2021. Your 2021 EOC states that enrollees must pay a $0 copayment per day, for days 1-20 and a $50 copayment per day for days 21-100 for SNF care. The copayment should be $650 (13 SNF days x $50 copayment); however, you met your maximum out-of-pocket of $799 with this $599 copayment. 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 SNF care provided from March 13, 2021, through April 14, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay more for the ambulance services provided from January 28,
2021, to April 26, 2021.
You asked the Plan to pay more for the ambulance services. You say that these claims were billed correctly, so
you expect additional payment. The Plan denied your request. The Plan says it originally denied these claims in
error. The Plan has now reprocessed and paid each date of service, minus the enrollee's copayments. The Plan
says that for dates of service April 8, 2021, and April 26, 2021, the allowed amounts for these ambulance
services ($196.35 and $93.65) are less than the enrollee's copayment obligation. As a result, the Plan has not
made payment for those dates of service.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees
must pay a $290 copayment per day for ambulance services.
The enrollee has been asked to pay a $290 copayment per day for the ambulance services. This means that the
enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a
contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan
does not have to pay more for the ambulance services provided from January 28, 2021, to April 26, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive exam (CPT code D0150) provided on June 3, 2021.
You asked the Plan to pay for the dental services. You say that you did see a dentist in 2021 because you did not like the way they treated you. The Plan denied your request. The Plan says you exhausted your 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. Review of the file shows that you exhausted your benefit because you had D0150 done on February 10, 2021. Your 2021 EOC states, D0150- one (1) procedure every three (3) plan years. Therefore, we decided that the Plan does not have to pay for the comprehensive exam (CPT code D0150) provided on June 3, 2021
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy evaluation coded 97162 and the therapeutic activities coded 97530 provided on April 26, 2021.
You asked the Plan to pay for the physical therapy evaluation coded 97162 and the therapeutic activities. 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. We find that CPT code 97162 and 97530 is not supported in the medical record. Specifically, the documentation does not support Physical therapy evaluation: moderate complexity, requiring these components: A history of present problem with 1-2 personal factors and/or comorbidities that impact the plan of care; An examination of body systems using standardized tests and measures in addressing a total of 3 or
more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; An evolving clinical presentation with changing characteristics; and Clinical decision making of moderate complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 30 minutes are spent face-to-face with the enrollee and/or family; therefore, code 97162 cannot be verified. Review of the file shows that code 97530 was already billed and paid; therefore, this code is a duplicate and cannot be paid. Based on this information, we decided that Medicare rules for coverage of the physical therapy evaluation coded 97162 and the therapeutic activities have not been met. Therefore, we decided that the Plan does not have to pay for the physical therapy evaluation coded 97162 and the therapeutic activities coded 97530 provided on April 26, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient behavioral health services provided on May 24, 2021.
You asked the Plan to waive the copayment for outpatient behavioral health services. You say that the testing was incomplete and not performed under false pretenses by the doctor. The Plan denied your request. The Plan says the claim was processed accordingly with your 2021 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the medical records show that you received outpatient behavioral health services on Mary 24, 2021. You were asked to pay a $40 copayment for the services. Your 2021 EOC states that enrollees must pay a $40 copayment for each Medicare-covered individual session.
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 outpatient behavioral health services provided on May 24,
2021
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF care.
You asked the Plan to pre-approve SNF care. You say that the facility told you that you are not getting any services because your benefit ran out. You state it is not fair that you need rehabilitation and care, and you are not receiving any of that when you need it. The Plan denied your request. The Plan says you exhausted your 100 SNF days benefit.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that you received 100 days of SNF care during the benefit period from March 1, 2021, through October 7, 2021. The Plan has covered 100 days of SNF care.
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. You will be eligible for a new benefit period when you have not been receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the Plan does not have to pre-approve continuation of SNF care.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for bone replacement graft - retained natural tooth - first site in
quadrant (CPT code D4263), biologic materials to aid in soft and osseous tissue regeneration (CPT code
D4265), biologic materials to aid in soft and osseous tissue regeneration (CPT code D4267) and excision of
benign tumor-lesion (CPT code D7431) provided on March 16, 2021.
You asked the Plan to pay for the dental services. You say that the services should be considered under your
medical benefits. The Plan denied your request. The Plan says the services are not covered.
Medicare generally does not cover dental services. The Plan follows the same rule.
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid
for by Medicare. Therefore, we decided that the Plan does not have to pay for bone replacement graft - retained
natural tooth - first site in quadrant (CPT code D4263), biologic materials to aid in soft and osseous tissue
regeneration (CPT code D4265), biologic materials to aid in soft and osseous tissue regeneration (CPT code
D4267) and excision of benign tumor-lesion (CPT code D7431) provided on March 16, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the enrollee is not able to walk and does not
have anyone to care for him. The Plan denied your request. The Plan says the guidelines for coverage have not
been met. The Plan says that the enrollee's needs can be met at a lower level of care.
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 services. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral
medications and had stable vital signs. The enrollee received therapy and was at a maximal to total assist for
bed mobility and activities of daily living. The enrollee was able to follow simple commands. There are no
identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee
does not meet the severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 services have not been met. Therefore, we decided that the Plan does
not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to pay for the emergency department (ED) evaluation and management services (99284-25) and the strapping of the left knee (29530-LT).
You asked the Plan to pay for the ED visit and left knee strapping. You say that this should be paid. The Plan denied your request. The Plan says that procedure code 29530 must be reported with 1 unit of service and modifier 50 (bilateral modifier), on one claim line.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has not submitted an applicable denial rationale in this case. In regard to code 29530, the Plan indicates that this must be reported with a bilateral modifier. As this procedure was not done bilaterally, which is clearly documented in the record, the use of this modifier would be inappropriate. Instead, modifier LT was used, which is correct to reflect the rendered services. Regarding code 99284, the Plan failed to provide any reason to support this denial. The claim appears to be denied for a similar reason as code 29530, stating that more than one unit was billed; however, the claim shows one ED visit was billed, and the records support that an ED visit was provided. Without any valid reason to deny payment being cited, we find the Plan's decision is not supported. Therefore, we decided that the Plan has to pay for the emergency department (ED) evaluation and management services (99284-25) and the strapping of the left knee (29530-LT).
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.