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

We decided that the Plan does not have to pay for the CT scan, head or brain; without contrast material (CPT
code 70450) provided to the enrollee on September 28, 2021.
You asked the Plan to pay for the CT scan. You say that the claim should be paid. The Plan denied your
request. The Plan says the service is 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 70450
is a column II code to column I code 70496. 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 CT scan, head or brain; without contrast material (CPT code
70450) provided to the enrollee on September 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on June
7, 2021.

You asked the Plan to pay for the comprehensive oral evaluation. You say that the dental office was not honest
with the enrollee. You also say these services should be covered. The Plan denied your request. The Plan says 1
comprehensive oral evaluation is covered every 3 plan years. The Plan also says the frequency limit 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 and the service is listed as covered, the
frequency limit has been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation
that you received on April 13, 2020. Therefore, we decided that the Plan does not have to pay for the
comprehensive oral evaluation (D0150) provided on June 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the arthrocentesis procedure you had at an
outpatient hospital facility on November 18, 2021.
You asked the Plan to waive the copayment for the arthrocentesis procedure. You say that you were not told
this procedure wasn't covered. The Plan denied your request. The Plan says this procedure was covered. The
Plan says that you are being charged for the correct cost sharing for this 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). Your contract with the Plan clearly says that you must pay a $300
copayment for outpatient surgery at a hospital.
You have been asked to pay a $300 copayment for the arthrocentesis procedure. The arthrocentesis procedure
falls within the outpatient surgery at a 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 arthrocentesis procedure you had at an outpatient hospital facility on November 18, 2021.
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pre-approve continued home health skilled care visits.
You asked the Plan to pre-approve home health services. You say that you are appealing with supporting
records. The Plan denied your request. The Plan says that the denial of authorization for home health care is
correct.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
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 home health services. Our reviewer
says that the enrollee meets the Medicare criteria for home health care. Our physician reviewer found it is
unclear how the Plan came to its decision to deny authorization as no home visit records have been submitted
for review. As such, the documentation does not support the Plan's denial.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of home health services have been met. Therefore, we decided that the Plan has to
pre-approve continued home health skilled care visits.
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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care (99223) provided on April 14, 2021.
You asked the Plan to pay for the evaluation and management service. You say that the provider saw the
enrollee prior to the time that they enrolled in hospice. The Plan denied your request. The Plan says the
enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits
starting on the date of election until the last day of the month in which hospice is revoked.
The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services
and to know proper billing procedures for a Medicare Advantage member on hospice.
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 the initial hospital care (99223) provided on April 14, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services you received on
September 9, 2021.
You asked the Plan to waive the copayment for the ambulance services. You say that you should not have to
pay this copayment because the facility you originally went to did not have a cardiac catheterization lab. You
had to go to a facility that had this capability. 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 $250
copayment for ambulance services.
You have been asked to pay a $250 copayment for the ambulance services. This copayment applies regardless
of the reason for the transport. 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 ambulance services you
received on September 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on April 6, 2021, by an OON
provider.

You asked the Plan to pay for an office visit. You say that services were provided to the enrollee out of medical
necessity. The Plan denied your request. The Plan says the provider is an out-of-network provide with no pre-authorization.
There was no referral from an in-network provider and the services provided were not urgent or
emergent.

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 an office visit provided on April 6, 2021, by an
OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a cystourethroscopy with stone removal
performed on September 8, 2021.
You asked the Plan to waive the copayment for the cystourethroscopy. You say that you feel that this procedure
was post-operative and you should not have a copayment. The Plan denied your request. The Plan says you
have been charged 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 $300
copayment for outpatient surgery services.
You have been asked to pay a $300 copayment for the cystourethroscopy. The cystourethroscopy falls within
the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical
Centers 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 cystourethroscopy with
stone removal performed on September 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1851) provided August 20, 2021.
You asked the Plan to pay for the orthosis. You say that see attached documentation in order to reprocess this
claim according to the enrollee's out of network PPO coverage. The Plan denied your request. The Plan says
the available medical records do not support necessity of the medical equipment as defined by Medicare
criteria.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for the orthosis. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found based on the medical records provided there is no documentation that the enrollee meets LCD
criteria for the knee orthoses (L1851) provided on August 20, 2021. Records do not document recent injury to
or a surgical procedure on the knees or objective description of joint laxity on examination of the knees.
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 orthosis have not been met. Therefore, we decided that the Plan does not
have to pay for knee orthosis (L1851) provided August 20, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional home health skilled care visits.

You asked the Plan to pre-approve home health care. You say that these services are considered medically necessary based on the results of the physical therapy re-evaluation. The Plan denied your request. The Plan says the denial of authorization for additional home health care is correct.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 

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 home health care. Our reviewer says that the enrollee does not meet the Medicare criteria for additional home health care visits. Our physician reviewer found the enrollee does not have documented, ongoing home health skilled therapy needs. The enrollee is functioning at a level appropriate for a lower level of care such as outpatient care or a home exercise program. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health care have not been met. Therefore, we decided that the Plan does not have to pre-approve additional home health skilled care visits.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services provided on September 7, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the laboratory services. You say that the services provided to the enrollee were medically necessary and was ordered by the enrollee's physician. The Plan denied your request. The Plan says the referring provider and the provider of services are both out-of-network providers with no prior authorization. The services provided were not urgent or emergent.  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 laboratory services provided on September 7, 2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for individual psychotherapy services (90832) provided on September 30, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the psychotherapy services. You say that you are appealing the claim along with supporting documents. Kindly process towards payment. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of 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 individual psychotherapy services (90832) provided on September 30, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services (CPT code 88305, 88312, 88313) provided to the enrollee on September 30, 2021.  You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records.  The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. CPT code(s): 88305, 88312, and 88313, remain not supported. The place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an Ambulatory Surgical Center setting POS 24. It is noted multiple attempts were made to obtain additional information from the provider. Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code 88305, 88312, 88313) provided to the enrollee on September 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis - adult (D1110) provided July 12, 2021, by
an out-of-network (OON) provider.
You asked the Plan to pay for the dental cleaning. You say that you would like this service covered. The Plan
denied your request. The Plan says this service is not covered when provided OON.
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 states that you are
responsible for 100% of the cost of dental cleanings when provided OON.
We looked at the file and Medicare rules. 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. Based on this information, we decided that the Plan's rules for coverage of
the dental cleaning have not been met. Therefore, we decided that the Plan does not have to pay for the
prophylaxis - adult (D1110) provided July 12, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit you had with a gynecologist
on September 21, 2021.
You asked the Plan to waive the copayment for the gynecology visit. You say that under your plan, there is no
cost sharing for pap tests or pelvic exams. The Plan denied your request. The Plan says you were charged this
copayment correctly. The Plan says that you were not charged cost sharing for the Pap test and pelvic exam
you had on the same date. The Plan says that you were charged this copayment due to other services you
received.
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 $40
copayment for visits with a specialist.
You have been asked to pay a $40 copayment for the gynecology visit. We agree that there is no copayment for
pap tests and pelvic exams. However, the medical records from this date of service show that in addition to
these screening services, you were evaluated for postmenopausal atrophic vaginitis as well as an elevated blood
pressure reading. These services are beyond the scope of a pap smear and pelvic exam, so the specialist
copayment can apply. 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 office visit you had with a
gynecologist on September 21, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on March 5, 2021, by an out-of-
network (OON) provider.
You asked the Plan to pay for an office visit. You say that the billing by the provider was wrong. The Plan
denied your request. The Plan says the provider is an out-of-network provider and there was no pre-approval or
referral to go to a non-participating provider. Also, services provided were not urgent or emergent, so payment
is denied.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for an office visit provided on March 5, 2021, by an
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Accu-Chek Guide Test Strips.
You asked the Plan to pre-approve the Accu-Chek Guide Test Strips. You say that these specific test strips are
medically necessary. The Plan denied your request. The Plan says the Plan's preferred brand is sufficient.
The Plan follows Medicare rules. Medicare rules say that there are specific coverage criteria that must be met
regarding a Plan's preferred durable medical equipment.
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 Accu-Chek Guide Test Strips. Our
reviewer says that the requested brand of test strips is not medically necessary over the Plan's preferred brand.
Our physician reviewer found the review indicates that the member has not failed all the preferred products.
Member has no limitation of use to the preferred products. The review has determined that it is not medically
necessary for the enrollee to use the Accu-Chek test strips over the Plan's preferred brand.
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 Accu-Chek Guide Test Strips have not been met. Therefore, we decided that
the Plan does not have to pre-approve the Accu-Chek Guide Test Strips.