Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided March 25, 2020, to April 1,
2020.
You asked the Plan to pay for acute inpatient hospital care. You say that it was prudent to admit the enrollee for
further evaluation. The Plan denied your request. The Plan says that the enrollee needed to be in a hospital but
could have stayed in an observation type setting.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
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 acute inpatient hospital care. Our reviewer
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician
reviewer found the enrollee had a past medical history of anxiety/depression and hypothyroidism and was
admitted to the hospital for suicide attempt with overdose on March 25, 2020. psychiatry determined the
enrollee is not suicidal and can be followed as outpatient with safety planning. Per nurses' notes, the enrollee
was medically stable for discharge on March 27, 2020, but the enrollee had no plans for discharge and the
enrollee could not be discharged immediately as she needed approval for emergency placement. On March 31,
2020, the enrollee was still awaiting placement and on April 1, 2020, the enrollee discharged with her daughter.
The review indicates that the record showed that at the time of inpatient admission, the admitting physician
reasonably expected that the enrollee necessary hospital care (including earlier emergency department and/or
observation care) would span two midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan
has to pay for the acute inpatient hospital care provided March 25, 2020, to April 1, 2020.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services received from October 14, 2021, to November 3, 2021.

You asked the Plan to pay for the services. You say that the cost of psychotherapy should be covered based on a book you received. The Plan denied your request. The Plan says the services were not authorized by network/primary care providers.

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 psychotherapy services received from October 14, 2021, to November 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network services provided from May 10, 2021, to
August 9, 2021.
You asked the Plan to pay for these services. You say that you were not happy with the care you received and
should not have to pay for these services. The Plan denied your request. The Plan says you did not have prior
authorization for 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 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 out of network
services provided from May 10, 2021, to August 9, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service, basic life support, emergency transport
(A0429, A0425) provided on June 16, 2021.
You asked the Plan to pay for ambulance service, basic life support, emergency transport. The Plan denied your
request. The Plan says the enrollee's claims history indicates they were in an inpatient hospital status on this
date of service. Ambulance services used for the transportation of a hospital inpatient to another facility for
diagnostic tests or special treatment for example is considered part of the inpatient admission, and not
separately payable.
The Plan must follow Medicare rules. Medicare rules say that transportation from one hospital to another is
considered "patient transportation" and is covered as an inpatient hospital service.
We looked at the file and Medicare rules. In this case, the documentation has determined the enrollee was
transported to another facility temporarily for care. This is not separately payable from the inpatient services
according to Medicare rules. Therefore, we decided that the Plan does not have to pay for ambulance service,
basic life support, emergency transport (A0429, A0425) provided on June 16, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the duplex extracranial artery scan rendered on February 8, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim is a duplicate.

The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. 

We looked at the file and Medicare rules. The documentation supports one unit of billed code 93880 (duplex extracranial artery scan), which has been paid by the Plan. Therefore, we decided that the Plan does not have to pay for the duplex extracranial artery scan rendered on February 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided on
September 18, 2021.
You asked the Plan to waive the copayment for the inpatient hospital care. You say that the service should be
covered. The Plan denied your request. The Plan says the cost share 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 a $325
copay each day one through five for inpatient hospital care.
You have been asked to pay a $325 copay each day one through five for the inpatient hospital care. This
service falls within the inpatient hospital care 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 inpatient hospital care provided on September 18, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on May 11, 2021.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed
codes cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate code.
We looked at the file and the rules. The claim billed a place of service code of 11, an office setting. The records
show that the enrollee was at an assisted living facility at the time the specimen was obtained. Based on this
information, we decided that Medicare rules for coverage of the services provided have not been met.
Therefore, we decided that the Plan does not have to pay for the lab services provided on May 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient hospital surgery provided on
September 10, 2021.
You asked the Plan to waive the copayment for the outpatient hospital surgery. You say that you should not be
charged another copayment because you had this procedure done before. The Plan denied your request. The
Plan says the proper copayment was applied 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 $250
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including
but not limited to hospital or other facility charges and physician or surgical charges.
You have been asked to pay a $250 copayment for the outpatient hospital surgery. The outpatient hospital
surgery falls within the Outpatient Surgery and Other Medical 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 an outpatient hospital surgery provided on September 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lift chair purchased on September 3, 2021.
You asked the Plan to pay for a lift chair. You say that the item should be covered. The Plan denied your
request. The Plan says you obtained this item through a provider that is not enrolled in Medicare.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is
not enrolled in the Medicare program.
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare
program. Therefore, we decided that the Plan does not have to pay for a lift chair purchased on September 3,
2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services received on September 23, 2021.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the provider did not bill as required by Medicare coding regulations.

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 76377 is a column II code to column I code 77063. 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 imaging services received on September 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services received from
January 19, 2021, to January 27, 2021.
You asked the Plan to waive the copayment for the services. You say that you do not agree with the
responsibility on this claim. The Plan denied your request. The Plan says the claim was processed
appropriately.
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 $275
copayment per day for day 1-5 for inpatient hospital care.
You have been asked to pay a $275 copayment per day for the first five days of this stay, for a total of $1375.
These services fall within the inpatient hospital care 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 inpatient hospital services received from January 19, 2021, to January 27, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for monitoring services (procedure code 95938, 95940) provided to the enrollee on July 26, 2021.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says payment for this service is including in the payment to the facility.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of the denied codes is: 

CPT 95938: 

Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper and lower limbs 

CPT 95940:

Continuous intraoperative neurophysiology monitoring in the operating room, one on one monitoring requiring personal attendance, each 15 minutes (List separately in addition to code for primary procedure) 

We find that CPT codes 95938 and 95940 are not supported in the medical record. Specifically, these codes cannot be paid separately, and would be included in the payment to the facility, as the services are for the facility. 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 monitoring services (procedure code 95938, 95940) provided to the enrollee on July 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit rendered on August 24, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services were not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of
service (POS) code.
We looked at the file and Medicare rules. The file shows that the claim for these services was billed with POS
code 23 for an emergency room; however, the services were rendered in an urgent care setting and should be
billed with POS code 20. Therefore, we decided that the Plan does not have to pay for the office visit rendered
on August 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for pathology services provided on July 1, 2021.

You asked the Plan to pay for pathology services. You say that according to the correct coding initiative policy manual, Medicare does allow this modifier. The Plan denied your request. The Plan says the denial of payment for these services is correct, because modifier -59 has been billed on every code on this claim which is not valid.

The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service. 

The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural service. Specifically, every code on this claim has been billed with a -59 modifier; however, not all of the codes are separate and distinct procedures. Based on this information, we decided that Medicare rules for coverage of services billed with a -59 modifier have not been met. Therefore, we decided that the Plan does not have to pay for pathology services provided on July 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for imaging services received on September 21, 2021.

You asked the Plan to waive the copayment for the services. You say that this should be paid for. The Plan denied your request. The Plan says cost sharing is a contractual obligation under the plan and cannot be waived.

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 diagnostic radiology services. 

You have been asked to pay $109.04 for the services, as this allowed amount is less than the usual $150 for the services. the services falls within the diagnostic radiology 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 copayment for imaging services received on September 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Monovisc for joint injection (J7327), Aspiration/injection of major joint or joint capsule (20611), provided on August 10, 2021.

You asked the Plan to waive the copayment for the injection services. You say that the service should be covered. The Plan denied your request. The Plan says the cost share 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 a 20% coinsurance for Medicare Part B prescription drugs. 

You have been asked to pay a 20% coinsurance for the injection services. This service 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 Monovisc for joint injection (J7327), Aspiration/injection of major joint or joint capsule (20611), provided on August 10, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for radiology services received on September
23, 2021.
You asked the Plan to waive the copayment for the services. You say that this scan was requested by your
oncologist, and you do not understand why it was denied. The Plan denied your request. The Plan says the cost-
share applied is your responsibility.
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 $375
copayment for computed tomography (CT) scans.
You have been asked to pay a $375 copayment for the services. The services fall within the computed
tomography (CT) scans 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 radiology
services received on September 23, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on October
14, 2021.
You asked the Plan to waive the copayment for the laboratory services. You say that you were told there would
be no copayment. The Plan denied your request. The Plan says prior to the appeal there was no contact with the
enrollee and the Plan. The proper copayment was applied.
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 for In-Network lab services and diagnostic procedures/tests performed in an outpatient hospital
facility.
You have been asked to pay a $30 copayment for laboratory services. The laboratory services falls 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 laboratory services provided on October 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete
series of intraoral x-rays (D0210) provided on September 2, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral x-rays. You
say that the treating provider advised you that they accepted your plan and were in-network. You also say that
you were under the impression that these services would be processed under your in-network benefits. The Plan
denied your request. The Plan says the treating provider is not a participating dental provider under your plan,
and you do not have any OON dental benefits included under your plan. The Plan also says that there is no
record of you contacting the Plan prior to this date of service to verify the participation status of the treating
provider.
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 requested items or services are not
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the
comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) provided on September
2, 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 rendered on March 20, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.
The test at issue in this appeal, cardiology genetic screening, was requested solely for screening purposes.
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not
have to pay for the laboratory services rendered on March 20, 2021.