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

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied
your request. The Plan says this 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 the admission. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found you have stabilized medically, and are
ready for discharge from the hospital. You do not require skilled nursing and/or skilled therapy services on a
daily basis. You are medically stable, and can receive further rehabilitation services at a lower level of care.
Although further rehab services would be appropriate to improve function, as a practical matter, the
intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. You do not
have any parenteral medication, complex wound care, or nutrition given via a feeding tube. Your physical
function is at or near the baseline and you can receive services at a lower level of care. Admission to a SNF for
inpatient skilled rehab services is not medically necessary.
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 admission have not been met. Therefore, we decided that the Plan does not
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a specialist office visit (99203) provided on March 5, 2021,
by an out-of-network (OON) provider.
You asked the Plan to pay for a specialist office visit. You say that prior to your appointment you called the
clinic to verify if they were a provider of the Plan and they stated that they were indeed a provider of the Plan.
You also say that on October 25, 2021, you received an explanation of benefits for this visit stating the claim
has been denied. The Plan denied your request. The Plan says you must receive your care from a network
provider and that the only exceptions are emergencies, urgently needed services when the network is not
available, and cases in which the Plan authorizes the use of out-of-network providers. The Plan also says that
they have no record of a phone call from you prior to the service.
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 a specialist office visit (99203) provided on March 5, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary or rest home visit (99336) provided on March
12, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for a domiciliary or rest home visit. You say that authorization was not obtained
prior to seeing this patient since it is the nursing facility's responsibility to get authorizations for their patients.
You also say that it was medically necessary for the patient to receive the treatment by this provider, and we
did not know that the facility failed to get preauthorization for this patient, so we treated this patient anyway.
The Plan denied your request. The Plan says this provider is out-of-network with the Plan and authorization
was not obtained prior to the 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 a domiciliary or rest home visit (99336) provided
on March 12, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a manual wheelchair (K0003) provided on July 26, 2021.
You asked the Plan to pay for a manual wheelchair. You say that the item at issue was a medical necessity for you. The Plan denied your request. The Plan says rules for payment have not been met because the supplier of the item at issue is not enrolled in the Medicare program.
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 manual wheelchair (K0003) provided on July 26, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on November 3, 2021.
You asked the Plan to pay for ambulance response and treatment, no transport. You say that the ambulance services should be covered since the ambulance was close by and did not have to travel far and did not transport you. The Plan denied your request. The Plan says per Medicare guidelines and members 2021 Evidence of Coverage ambulance services are not covered if there is no transport.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on November 3, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on November 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered by the out-of-network (OON) provider on August 14, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue.
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered by the out-of-network (OON) provider on August 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the treatment of speech, language, voice, communication, and/or auditory processing disorder services provided on June 3, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for these OON services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the rendered services are not a covered benefit.
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 treatment of speech, language, voice,
communication, and/or auditory processing disorder services provided on June 3, 2021, by an out-of-network
(OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit coded 99285 provided on
October 15, 2020.
You asked the Plan to pay for the emergency department visit. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the services are not payable 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, the CPT Code Manual definition of code 99285 is emergency department visit for the evaluation
and management of a patient, which requires these 3 key components within the constraints imposed by the
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive
examination; and Medical decision making of high complexity. Counseling and/or coordination of care with
other physicians, other qualified health care professionals, or agencies are provided consistent with the nature
of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high
severity and pose an immediate significant threat to life or physiologic function.
We find that CPT code 99285 is not supported in the medical record. Specifically, this code was billed with a
date of service of October 15, 2020; however, the documentation shows that these services were really
provided October 14, 2020. This means this claim was billed with an incorrect date of service. Based on this
information, we decided that Medicare rules for coverage of the emergency department visit have not been met.
Therefore, we decided that the Plan does not have to pay for the emergency department visit coded 99285
provided on October 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Zoster (Shingles) vaccine received on September 3, 2021.
You asked the Plan to pay for the Shingles vaccine. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Shingles vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the Shingles vaccine. Therefore, we decided that the Plan does not have to pay for the Zoster (Shingles) vaccine received on September 3, 2021.
Benefits for the Shingles vaccine 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 80157, 80159, 80162, 80173,
80177, and 80201 provided on March 15, 2021.
You asked the Plan to pay for the laboratory services. 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 supported by the documentation.
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 codes 80157, 80159, 80162, 80173, 80177, and 80201 are not supported in the medical
record. Specifically, the documentation supports that the laboratory services were performed with blood
sampling. Blood specimen collection is by venipuncture, however, the lab requisition states a urine specimen
was collected; therefore, the billed services cannot be verified. Based on this information, we decided that
Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan
does not have to pay for the laboratory services coded 80157, 80159, 80162, 80173, 80177, and 80201
provided on March 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the intravenous (IV) tubing extension set (S1015) provided
on August 25, 2021.
You asked the Plan to pay for the IV tubing extension set. You say that you would like this claim reprocessed.
The Plan denied your request. The Plan says Medicare does not provide payment for this 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 looked at the file and Medicare rules. In this case, Medicare uses another code for reporting these services
and no payment is made. Based on this information, we decided that Medicare rules for coverage of the IV
tubing extension set have not been met. Therefore, we decided that the Plan does not have to pay for the
intravenous (IV) tubing extension set (S1015) provided on August 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Obinutuzumab injections (J9301 x 3)
and the chemotherapy administration (96413, 96415) provided from August 24, 2021, through August 31,
2021.
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to
the services provided.
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 of Medicare Part B drugs.
You have been asked to pay $2,123.84 (Plan's allowed amount of $10,619.18 x 20%) for the Medicare Part B
drugs provided. 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 the Obinutuzumab injections (J9301 x 3)
and the chemotherapy administration (96413, 96415) provided from August 24, 2021, through August 31,
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS)
therapy and prolotherapy rendered on March 4, 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 a covered benefit.
The Plan must follow Medicare rules. The rules say that TENS therapy for chronic low back pain (CLBP) is
covered when the beneficiary is enrolled in an approved clinical study meeting specific requirements.
We looked at the file and Medicare rules. The file shows that the enrollee did not receive TENS therapy for
CLBP related to an approved clinical study. The prolotherapy is not a covered benefit. Therefore, we decided
that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) therapy and
prolotherapy rendered on March 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible and copayment for skin growth removal
performed on September 8, 2021.
You asked the Plan to waive the deductible and copayment for the growth removal. You say that you do not
understand why you the provider is charging a deductible and copayment when that did not apply to your
colonoscopy. The Plan denied your request. The Plan says the correct amount was applied to your deductible
and the correct cost sharing amount was charged.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that there is a $750 deductible which applies to certain items and services.
Your contract with the Plan also clearly says that you must pay a $350 copayment for surgery or other services
provided at an outpatient hospital.
The item or service you asked the Plan to waive the deductible for falls within the Outpatient Surgery and
Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750
deductible which applies to certain items and services. This cost sharing is a contractual obligation that was
met during the growth removal procedure visit. Therefore, you have been asked to pay the remaining $573.62
toward the deductible for the growth removal. You have also been asked to pay $286.81, which is less than the
$350 copayment for the skin repair performed with the growth removal. The growth removal and skin repair
fall within the Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and
Ambulatory Surgical Centers benefit category. Please note that your previous colonoscopy procedure was a
screening, and therefore was not subject to a copayment or deductible per your Plan benefits. 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 deductible and copayment for skin growth removal performed on September 8,
2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound services of head and neck (93880) provided on July 13, 2021.
You asked the Plan to pay for the ultrasound services. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says this claim has not been billed with an appropriate modifier as required by Medicare rules.
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 76536 is a column II code to column I code 93880. 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 ultrasound services of head and neck (93880) provided on July 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you an additional amount for hearing aids provided on
September 9, 2021.
You asked the Plan to reimburse you an additional amount for the hearing aids. The Plan denied your request.
The Plan says benefit provides $1,000 towards the purchase of hearing aids. Your reimbursement request was
approved and a check in the amount of $1,000 was sent to you on October 12, 2021.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case.
We looked at the file and the Plan's rules. The file shows that the Plan reimbursed you the maximum benefit
allowance of $1,000 and you are responsible for the difference. Therefore, we decided that the Plan does not
have to reimburse you an additional amount for hearing aids provided on September 9, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0483) provided on April 15, 2021.
You asked the Plan to pay for drug testing. You say that this is supported in the records. The Plan denied your
request. The Plan says this was not billed correctly.
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 April 15, 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
October 7, 2021.
You asked the Plan to pay for the comprehensive oral evaluation. You say that you found a new provider
because the dentist you saw previously did not meet your expectations. You also say that you would like this
service to be covered. The Plan denied your request. The Plan says you have exhausted your benefit coverage
for this service.
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, comprehensive oral exam (D0150) is
limited to once per three years. The record shows that you received a comprehensive oral evaluation (D0150)
on April 6, 2021 and your comprehensive oral evaluation (D0150) benefit has been exhausted. Therefore, we
decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on October
7, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on December 16, 2020.
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. In this case, the claim entered a place of service as 81, an independent laboratory. The records do not indicate the specimen at issue was obtained at the independent laboratory. 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 December 16, 2020.