Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for sedation services (99153) provided on December 11, 2020.

You asked the Plan to pay for sedation services. You say that this service was performed. The Plan denied your request. The Plan says this service cannot be paid as billed.

The Plan must follow Medicare rules. Medicare rules say that services with status indicator N are paid under the Outpatient Prospective Payment System (OPPS), but their payment is packaged into payment for a separately paid service.

We looked at the file and Medicare rules. The code at issue, 99153, has an OPPS status indicator of N, meaning payment for this service is packaged into payment for a separately paid service. Based on this information, we decided that Medicare rules for coverage of sedation services have not been met. Therefore, we decided that the Plan does not have to pay for sedation services (99153) provided on December 11, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from
February 11, 2021, to February 15, 2021, and from March 11, 2021, to March 12, 2021.

You asked the Plan to pay for the SNF care. The Plan denied your request. The Plan says skilled care was no
longer required.

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 pay for the SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found that there were no identifiable skilled nursing
service needs. There were no identifiable skilled therapy service needs. The enrollee did not require skilled
nursing or therapy services on a daily basis. The enrollee did not meet severity of illness or intensity of service
criteria for an inpatient basis in a skilled nursing facility 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 care have not been met. Therefore, we decided that the Plan does not
have to pay for the skilled nursing facility (SNF) services provided from February 11, 2021, to February 15,
2021, and from March 11, 2021, to March 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on June 9, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for skilled nursing services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that the referring provider is also out-of-network.

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 skilled nursing services provided on June 9, 2020 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0483) provided on February 16, 2021.

You asked the Plan to pay for drug testing. You say that this is supported by the records. The Plan denied your request. The Plan says this was billed with an incorrect place of service.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).

We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (G0483) provided on February 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an x-ray provided by a participating provider on May 19, 2021.

You asked the Plan to waive the copayment for an x-ray. You say that you do not agree with this copayment. The Plan denied your request. The Plan says the correct copayment has been 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 $35 copayment for outpatient diagnostic tests/in-network/x-rays. 

You have been asked to pay a $35 copayment for an x-ray. An x-ray was provided; therefore, the correct copayment has been applied. An x-ray falls within the outpatient diagnostic tests/in-network/x-rays 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 x-ray provided by a participating provider on May 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pontics - porcelain/ceramic (D6245) and retainer crowns - porcelain/ceramic (D6740) provided September 29, 2020.

You asked the Plan to pay for the pontics and retainer crowns. You say that your services were pre-approved and you did not know you would be charged. The Plan denied your request. The Plan says at the time the services were approved, you had not yet met your annual maximum. At the time the services were rendered you had exceeded your dental maximum.

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 pontics and retainer crowns up to the annual dental maximum of $2,500. 

We looked at the file and Medicare rules. The Plan provided documentation showing that your annual dental
maximum had been exhausted prior to receiving the services at issue. Based on this information, we decided that the Plan's rules for coverage of the pontics and retainer crowns have not been met. Therefore, we decided that the Plan does not have to pay for the pontics - porcelain/ceramic (D6245) and retainer crowns - porcelain/ceramic (D6740) provided September 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the unspecified preventative procedure (D1999), intraoral Xrays
(D0210), and comprehensive oral evaluation (D0150) provided February 10, 2021.
You asked the Plan to pay for the unspecified preventative procedure, intraoral X-rays, and comprehensive oral
evaluation. You say that you received incorrect information regarding your supplemental dental coverage. The
Plan denied your request. The Plan says they do not provide coverage for dental services obtained by a provider
not in network.
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 dental
services when the services are obtained from a provider in-network with the Plan.
We looked at the file and Medicare rules. In this case, the provider is not contracted with the Plan. Based on
this information, we decided that the Plan's rules for coverage of the unspecified preventative procedure,
intraoral X-rays, and comprehensive oral evaluation have not been met Therefore, we decided that the Plan
does not have to pay for the unspecified preventative procedure (D1999), intraoral X-rays (D0210), and
comprehensive oral evaluation (D0150) provided February 10, 2021.
Your complaint about potentially receiving misinformation regarding your supplemental dental coverage is not
a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the
Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services rendered on March 31, 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 procedure code 99053 is not separately payable.
The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is always bundled into payment for other services not specified. We looked at the file and Medicare rules. Billed procedure code 99053 (service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service) has a status indicator of B and no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for the medical services rendered on March 31, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the cone beam CT capture and interpretation (D0364) and pulp vitality tests (D0460) provided on November 25, 2020.

You asked the Plan to pay for the cone beam CT capture and interpretation and pulp vitality tests. You say that without these procedures the doctor could not have found out that you had an infection. You also say that you believe these services should be covered. The Plan denied your request. The Plan says that these services are not covered under your benefit plan.

The Plan must follow Medicare rules. 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. 

We found that these services are both diagnostic services. The 2021 EOC lists diagnostic services as a covered benefit. The EOC does not clearly state that only certain diagnostic services are covered, nor does the EOC say you should look elsewhere to see what services are covered. You reasonably believed these services would be covered because the contract lists diagnostic services as a covered benefit. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the cone beam CT capture and interpretation and pulp vitality tests have been met. Therefore, we decided that the Plan has to pay for the cone beam CT capture and interpretation (D0364) and pulp vitality tests (D0460) provided on November 25, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room (ER) services rendered on November
12, 2020.
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 procedure code 99285 is not supported.
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 code 99285 is Level 5 emergency department visit for
evaluation and management of patient with problem immediately threatening life, including comprehensive
history and physical examination, and medical decision-making of high complexity.
We find that CPT code 99285 is not supported in the medical record. Specifically, the records do not support
the Level 5 level of emergency care. Based on this information, we decided that Medicare rules for coverage of
these services have not been met. Therefore, we decided that the Plan does not have to pay for the emergency
room (ER) services rendered on November 12, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuropsychological testing rendered on November 2,
2020.
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 must follow Medicare rules. Medicare rules say that claims submitted where the unit of service
exceeds the MUE value cannot be paid when the MAI value is 2.
In this case, the MUE for CPT code 96136 is 1. The MAI value for this code is 2. You billed 2 units of this
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of these
services have not been met. Therefore, we decided that the Plan does not have to pay for the
neuropsychological testing rendered on November 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on August 31, 2020 by a non-participating provider.
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 rendered by a non-participating provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on August 31, 2020 by a non-participating provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on April 9, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were
billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.
We looked at the file and Medicare rules. The documentation shows that the services in question were billed
with POS code 81. However, the records indicate that the specimen was collected in an office setting, which
would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based
on this information, we decided that Medicare rules for coverage of the lab services have not been met.
Therefore, we decided that the Plan does not have to pay for the lab services provided on April 9, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a prolonged office visit (99417) provided on May 11, 2021.
You asked the Plan to pay for a prolonged office visit. You say that this was billed correctly. The Plan denied
your request. The Plan says this was not billed with a valid code.
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 99417 is not supported in the medical record. Specifically, this code has a status
indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this
information, we decided that Medicare rules for coverage of a prolonged office visit have not been met.
Therefore, we decided that the Plan does not have to pay for a prolonged office visit (99417) provided on May
11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for wound care provided on April 28, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for wound care. You say that these services were medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained for these services.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.

Therefore, we decided that the Plan does not have to pay for wound care provided on April 28, 2021 by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a participating provider on March 29, 2021.
You asked the Plan to waive the copayment for a specialist office visit. You say that this should be covered because this is all part of the surgery you had. The Plan denied your request. The Plan says the correct copayment has been 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 $45 copayment for physician/practitioner services/in-network/specialist. You have been asked to pay a $45 copayment for a specialist office visit. Since a specialist office visit was provided, the correct copayment has been applied. A specialist office visit falls within the
physician/practitioner services/in-network/specialist 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 specialist office visit provided by a participating provider on March 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME and related supplies provided from March 30, 2021, to April 4, 2021.
You asked the Plan to waive the coinsurance for DME and related supplies. You say that the equipment did not help you and you are allergic to the mask provided. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for DME and related supplies. You received DME and related supplies on March 30, 2021. The total allowed amount is $32.18 and 20% of that is $6.43.
You received DME and related supplies on April 4, 2021. The total allowed amount is $85.09 and 20% of that is $17.01. The total amount you owe is: $23.44. You have been asked to pay the total coinsurance amount of $23.44 for DME and related supplies. DME and related supplies fall within the DME and related 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 coinsurance for DME and related supplies provided from March 30, 2021, to April 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital care (99233) provided January 23, 2021.

You asked the Plan to pay for the hospital care. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed CPT code.

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 code 99233 is Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of high complexity. 

We find that CPT code 99233 is not supported in the medical record. Specifically, the provided records do not sufficiently show that the services were of a high complexity.

Based on this information, we decided that Medicare rules for coverage of the hospital care have not been met. Therefore, we decided that the Plan does not have to pay for hospital care (99233) provided January 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for extracapsular cataract removal provided on April 12, 2021.
You asked the Plan to waive the copayment for extracapsular cataract removal. You say that you disagree with the charges because you were not charged in the past. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.
You received extracapsular cataract removal at an ambulatory surgical center on April 12, 2021. Extracapsular cataract removal is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $300 copayment. You have been asked to pay a $300 copayment for extracapsular cataract removal. Extracapsular cataract removal 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 extracapsular cataract removal provided on April 12, 2021.