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

We decided that the Plan does not have to pay for SNF services provided from July 6, 2021, through
August 4, 2021.
You asked the Plan to pay for SNF services. The Plan denied your request. The Plan says the SNF services were 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 pay for SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that at the time of discharge from the hospital the enrollee had stabilized medically. The enrollee did not require any skilled nursing or rehabilitation services on a daily basis at an inpatient level of care. He was not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or self-care tasks. The enrollee did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, the enrollee did not require any skilled services on an inpatient basis, at a SNF level of care at the time of discharge from the hospital. The enrollee did not have any parental medications, or complex wound care. He was medically stable without any acute exacerbations of chronic medical problems. His physical function was at or near his baseline and he could have received further services at a lower level of care. Admission to the nursing facility at a skilled level of care for inpatient skilled services was 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pay for SNF services provided from July 6, 2021, through August 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on June 7, 2021.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says these services are not payable.

The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for the lab services provided on June 7, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Skilled Nursing Facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that you would like reconsideration because the requested SNF services are medically necessary. The Plan denied your request. The Plan says the member does not meet Medicare criteria for coverage.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the member does not have any parental medication; complex wound care or nutrition given via a feeding tube. She is medically stable without any acute exacerbations of chronic medical problems. Her physical function is at or near her baseline and she 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Skilled Nursing Facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2740) provided on August 12, 2021.
You asked the Plan to pay for the crown. You say that the booklet that was sent to your house does not clearly
explain what is covered and what is not covered. The Plan denied your request. The Plan says this service is not
a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the crown
(D2740) provided on August 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain rendered on July 30, 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 separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 70450 (CT head/brain) and 70496 (computed tomography angiography of the head). Code 70450 is a column II code with a modifier indicator of 1 when billed with column I code 70496. Code 70450 was not billed with an appropriate modifier to allow for separate payment.
Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain rendered on July 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for wound care services provided from March
26, 2021, to August 26, 2021.
You asked the Plan to waive the copayments for the wound care services. You say that the issues with your
foot were never resolved and you were not informed of any copayments. 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 $225
copayment for each outpatient surgical procedure visit at an outpatient hospital facility.
The file shows you had a total of 19 wound care visits. Therefore, you have been asked to pay a $225
copayment for 18 of the visits, and $128.51 for the visit on July 8, 2021, for the wound care services. The total
for all 19 visits is $4178.51. The wound care services fall within the Outpatient Surgery 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 copayments for wound care services provided from March 26, 2021, to
August 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the anatomical crown exposure (D4231) provided on
September 10, 2021.
You asked the Plan to pay for the anatomical crown exposure. You say that this treatment was not performed to
improve the look of the tooth but was performed to treat a problem to treat a problem and stabilize the tooth.
You also say that in order to reinforce the tooth and protect the root a filing of the space was done. The Plan
denied your request. The Plan says this service is excluded from normal coverage.
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
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
anatomical crown exposure (D4231) provided on September 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99152) provided on February 1, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service
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 CPT code.
In this case, the CPT Code Manual definition of code 99152 is "Moderate sedation services provided by the
same physician or other qualified health care professional performing the diagnostic or therapeutic service that
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age
5 years or older".
We asked our coder 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 services. Our reviewer says that the use of code 99152 is
not supported by the records provided. Our reviewer found that the procedure report documents "Versed 1 mg,
Fentanyl 50 mcg. Moderate sedation was provided under my supervision for 17 minutes". The presence of a
independent trained observer is not documented in the report, and therefore this procedure cannot be verified.
We looked at this coder's review, the file, and Medicare rules. 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 the services (99152) provided on February 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the audiometry and spirometry tests provided on July 16, 2021.
You asked the Plan to waive the copayments for the audiometry and spirometry tests. You say that you would like the Plan to cover this bill. The Plan denied your request. The Plan says you have been asked to pay 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 up to a $50 copayment for each Medicare-covered outpatient diagnostic procedure and test in an office setting.
You have been asked to pay up to a $20 copayment for the audiometry and a $34.92 copayment for the spirometry test which is less than the standard copayment amount. The audiometry and spirometry tests fall 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 copayments for the audiometry and spirometry tests provided on July 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and to pay more for the first intraoral periapical x-ray (D0220) provided on September 15, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the problem focused limited oral evaluation or pay more for the first intraoral periapical x-ray. You say that you tried finding an in-network provider but none of them were taking new patients, or you were told you would have to wait months before they could get you in. You also say that you would like help covering this bill because you cannot afford to pay it right now. The Plan denied your request. The Plan says the problem focused limited oral evaluation is not a covered expense under your dental plan. The Plan also says that these services were performed by an OON provider, and you are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for the services.
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, problem focused limited oral evaluation (D0140) is not among those covered under this benefit. You are also responsible for the difference between the billed amount and allowed amount for covered dental services that are received OON. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and to pay more for the first intraoral periapical x-ray (D0220) provided on September 15, 2021 by an out-of-network (OON) provider
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments for laboratory testing (80048, 82043, 83036)
rendered from September 28, 2021, to September 29, 2021.
You asked the Plan to reduce the copayments for laboratory testing. You say that the person who took your
blood on September 28, 2021, called you because she made a mistake and needed to take more. You also say
that you are now being charged two copayments for her mistake and you do not think you should be
responsible for someone else's mistake. The Plan denied your request. The Plan says you were 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 $10
copayment for diagnostic procedures and tests (per day, per facility).
You have been asked to pay a $10 copayment for laboratory testing on September 28, 2021. You have also
been asked to pay a $9 copayment, which is less than the $10 copayment for laboratory testing on September
29, 2021. Laboratory testing falls within the diagnostic procedures and tests (per day, per facility) benefit
category. The record shows you had blood taken for laboratory testing on two separate days. 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 reduce the copayments for laboratory testing (80048, 82043, 83036) rendered from September
28, 2021, to September 29, 2021.
Your complaint about potentially being charged for the mistake of the provider 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for skilled nursing facility services rendered
from May 11, 2021, to June 8, 2021.
You asked the Plan to waive the copayment for skilled nursing facility services. You say that there is no way
you would have stayed the extra week if you had known that you would have to pay the $1,472 charges. The
Plan denied your request. The Plan says you were 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 $184
copayment per day for days 21 through 100 for skilled nursing facility (SNF) care.
You have been asked to pay a total of $1,472 in copayments for 8 days of skilled nursing facility services ($184
copayment x 8 days = $1,472). The record shows that the final week of the skill nursing facility was covered,
however, there still remains a cost sharing that you are responsible for. 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 skilled nursing facility services rendered from May 11, 2021, to June 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on February 11, 2021.
You asked the Plan to pay for the 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 services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on February 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99215) rendered by the out-of-network
(OON) provider on August 25, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan
does not have to pay for the office visit (99215) rendered by the out-of-network (OON) provider on August 25,
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for radiation therapy services (77401, 77280) provided April 26, 2021.
You asked the Plan to pay for the radiation therapy services. You say that the services were medically necessary. The Plan denied your request. The Plan says not enough records were provided to show that this service was medically necessary.
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 radiation therapy services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case.
Our physician reviewer found insufficient clinical documentation was provided to support the billed services. 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 radiation therapy services have not been met. Therefore, we decided that the Plan does not have to pay for radiation therapy services (77401, 77280) provided April 26, 2021
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the SNF stay provided from August 8, 2021, to September 4, 2021.
You asked the Plan to waive the copayment for the SNF stay. You say that you should not be responsible for the copayment. The Plan denied your request. The Plan says you have been asked to pay 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 $0 copayment per day, per admission for days 1 to 20 and a $184 copayment per day, per admission for days 21 to 100.
You have been asked to pay a $1,288 copayment for the SNF stay. The SNF stay falls within the "Skilled nursing facility (SNF) care" benefit category. See chart below.
Dates of Service
Service
SNF Days
Copayment
Day Count
Member Liability
August 8, 2021, to August 27, 2021
SNF care
1-20
$0
20
$0
August 28, 2021, to August 31, 2021
SNF care
21-24
$184
4
$736
September 1, 2021, to September 4, 2021
SNF care
25-28
$184
3
$552
Total
$1,288
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 SNF stay provided from August 8, 2021, to September 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the Wallet Benefit for naturopathic services provided on October 14, 2021.
You asked the Plan to reimburse you for the Wallet Benefit for naturopathic services. The Plan denied your request. The Plan says the Wallet Benefit allowance limit was reached and we cannot process additional reimbursement.
The Plan contract offers a supplemental Wallet Benefit. This benefit is covered with a $400 annual allowance to reimburse you for the cost of covered services.
We looked at the file and the Plan's rules. The file shows that the Wallet Benefit allowance has been exhausted, and you will be responsible for the entire cost of the services. Therefore, we decided that the Plan does not have to reimburse you for the Wallet Benefit for naturopathic services provided on October 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye exam (92004) provided on April 9, 2019.
You asked the Plan to pay for the eye exam. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says it is not appropriate to report unspecified, or left and right diagnosis codes when a more specific code is available.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT code 92004 is not supported in the medical record. Specifically, the diagnosis codes on the claim were not billed to the highest level of specificity. Based on this information, we decided that Medicare
rules for coverage of the eye exam have not been met. Therefore, we decided that the Plan does not have to pay
for the eye exam (92004) provided on April 9, 2019.