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

We decided that the Plan does not have to waive the copayment for the esophagogastrodudenoscopy (EGD) you had at an ambulatory surgery center on April 14, 2021.
You asked the Plan to waive the copayment for the EGD. You say that you were under the impression that your insurance would cover this in full The Plan denied your request. The Plan says this copayment was charged 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 $200 copayment for outpatient surgery at an ambulatory surgery center.
You have been asked to pay a $200 copayment for the EGD. The EGD falls within the outpatient surgery at an ambulatory surgery center 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 esophagogastrodudenoscopy (EGD) you had at an ambulatory surgery center on April 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the abdominal ultrasound provided on May 24, 2021.
You asked the Plan to pay for the ultrasound. You say that the enrollee had multiple exams on this date of
service. The Plan denied your request. The Plan says an appropriate modifier was not billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate code.
We find that CPT code 76705 was billed with code 93976. The code at issue is payable when billed with an
appropriate modifier. The claim does not show that an appropriate modifier was billed. Based on this
information, we decided that Medicare rules for coverage of the ultrasound have not been met. Therefore, we
decided that the Plan does not have to pay for the abdominal ultrasound provided on May 24, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the infectious disease testing (0202U) provided on January 11, 2021.
You asked the Plan to pay for the infectious disease testing. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says predictive screening testing is not a Medicare benefit.
The Plan must follow Medicare rules. Medicare rules say that panels with >5 respiratory pathogens performed in the Part B outpatient setting are considered not medically reasonable and necessary. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the infectious disease testing have not been met. Specifically, CPT code 0202U includes 22 pathogens. This testing is not a Medicare covered benefit. Therefore, we decided that the Plan does not have to pay for the infectious disease testing (0202U) provided on January 11, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cytopathology testing provided on May 19, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the cytopathology testing. You say that the service was referred to you by an authorized provider. The Plan denied your request. The Plan says no prior authorization was obtained.
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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The record shows the referring provider is a non-participating provider with the Plan. Therefore, we decided that the Plan does not have to pay for the cytopathology testing provided on May 19, 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 the office visit provided on March 30, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent.
Therefore, we decided that the Plan does not have to pay for the office visit provided on March 30, 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 out of network physician services provided to the enrollee on November 23, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee 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 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 out of network physician services provided to the enrollee on November 23, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head.
You asked the Plan to pay for the CT scan. You say that the enrollee had multiple exams on this date of service. The Plan denied your request. The Plan says an appropriate modifier was not 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. We find that CPT code 70450 was billed with code 70496. We looked at the file and the rules. Code 70450 is payable when billed with 70496 when an appropriate modifier is used. The claim provided does not show that the service at issue was billed with a suitable modifier. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the head.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve continued inpatient psychiatric hospital care from September 29, 2021, onward.
You asked the Plan to pre-approve continued inpatient psychiatric hospital services. You say that continued inpatient mental health care is medically necessary as you do not have a good support system at home, and you need additional time to stabilize. The Plan denied your request. The Plan says that the limited records provided indicate that you are doing better, are more hopeful and do not have active suicidal ideation. Your medication regimen has been established and you are tolerating it well. Continued psychiatric care at the inpatient level is not medically necessary; you can receive mental health care in an alternate setting.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 continued inpatient psychiatric hospital services. Our reviewer says that the health plan's denial of continued inpatient psychiatric services is inappropriate in this case. Our physician reviewer found that based upon a review of the records provided, it was expected that this enrollee would improve in a reasonable period of time for the dates in question as she did have suicidal, no homicidal ideation noted. She had no auditory or visual hallucinations. It did appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as she did have dangerousness to self but not others. She was compliant with treatment and it did appear that active treatment was taking place beyond the date in question. This reviewer was unable to find an individualized treatment plan; however, it is alluded to in the record. It does appear that the records were supervised and evaluated by a physician. Based upon this review of the provided records, the enrollee does meet the criteria for continued acute inpatient mental health treatment from September 29, 2021, forward as she was shown to be a danger to herself but not others.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued inpatient psychiatric hospital services have been met. Therefore, we decided that the Plan has to pre-approve continued inpatient psychiatric hospital care from September 29, 2021, onward.
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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90837) provided on December 13,
2020, to January 6, 2021.
You asked the Plan to pay for psychotherapy services. You say that at no time was the provider informed of the
requirement that services would only be paid if provided by a licensed psychiatrist. The Plan denied your
request. The Plan says rules for payment have not been met.
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 psychotherapy services (90837)
provided on December 13, 2020, to January 6, 2021.
Your complaint about receiving erroneous or incomplete information from representatives of the Plan 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 subsequent nursing facility care and the advanced care planning provided on May 17, 2021 to June 4, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the subsequent nursing facility care and the advanced care planning. You say that the services were medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the services at issue were urgent or emergent. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care and the advanced care planning provided on May 17, 2021 to June 4, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of residual tooth roots (D7250) provided on May 11, 2021.
You asked the Plan to pay for the removal of residual tooth roots. You say that this service was medically necessary. You pay for the additional dental benefits and feel they should cover this service. The Plan denied your request. The Plan says this service is not covered by your dental 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 removal of residual tooth roots (D7250) provided on May 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the spine x-ray and chest x-ray provided on May 20, 2021.
You asked the Plan to waive the copayment for the spine x-ray and chest x-ray. You say that there is a $0 copayment for a primary care physician. You say that you were told you needed to pay $25 and you should be refunded. The Plan denied your request. The Plan says the copayments 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 $15 copayment for each x-ray service.
You have been asked to pay a $15 copayment for the spine x-ray and chest x-ray. The spine x-ray and chest x-ray 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 copayment for the spine x-ray and chest x-ray provided on May 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically appropriate. The Plan denied your request. The Plan says the enrollee does not meet criteria for LTACH admission.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that the review indicates that there is no documentation provided necessitating admission to an LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.
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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction services represented by code 92015 provided on May 10, 2021.
You asked the Plan to pay for the eye refraction services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says eye refractions are only covered when performed as a routine service under the Plan's supplemental vision benefit. In this case, your claim was billed with a medical diagnosis for bilateral age-related nuclear cataracts (H25.13).
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. We looked at the file, the Plan's contract and Medicare rules. Eye refractions are only covered when performed as a routine service under the Plan's supplemental vision benefit. In this case, your claim was billed with a medical diagnosis for bilateral age-related nuclear cataracts (H25.13). You are responsible for the $70 amount billed for the eye refraction. Therefore, we decided that the Plan does not have to pay for the eye refraction services represented by code 92015 provided on May 10, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Afirma testing services provided on December 16, 2020.
You asked the Plan to pay for the services provided. You say that the test was ordered to determine if the nodule carries a risk of malignancy. The Plan denied your request. The Plan says the screening test was not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that the information submitted must corroborate the documentation in the beneficiary's medical documentation. We looked at the file and the rules. The test at issue was ordered to determine the enrollee's risk factor. There were insufficient medical records to show that the testing was ordered based on the enrollee's history of characteristics that required additional testing. This testing is not covered for screening purposes. 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 Afirma testing services provided on December 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220) and intraoral - periapical each additional radiographic image (D0230) provided April 26, 2021, core buildup, including any pins when required (D2950) provided May 3, 2021, and crown - porcelain/ceramic (D2740) provided May 26, 2021.
You asked the Plan to pay for the intraoral x-rays, crown and core buildup. You say that you feel you were provided misinformation about network coverage and would like a one-time exception regarding the network status of the provider. The Plan denied your request. The Plan says these services are not covered under your benefits.
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 intraoral - periapical first radiographic image (D0220) and intraoral - periapical each additional radiographic image (D0230) provided April 26, 2021, core buildup, including any pins when required (D2950) provided May 3, 2021, and crown - porcelain/ceramic (D2740) provided May 26, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for occupational therapy services provided on April 29, 2021.
You asked the Plan to pay for occupational therapy services. You say that the Plan is required to pay non-contracted providers at the preferred rate if the services are not available from preferred providers. You say that the in-network benefits should be honored, and the claim processed for payment. The Plan denied your request. The Plan says the records do not support the service billed.
The Plan must follow Medicare rules. Medicare rules say that therapy services billed as services incident to a physician/non-physician practitioner's service must meet all incident requirements. Medicare rules also say that the services of an OTA shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of occupational therapy services have not been met. Specifically, the billing provider is a nurse practitioner, and not a licensed therapist. As such, OT services cannot be paid incident to this provider's professional services. Additionally, the record does not include the rendering providers credentials, so we are unable to verify the billed services. Therefore, we decided that the Plan does not have to pay for occupational therapy services provided on April 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on November 6, 2020 by an out-of-network provider.
You asked the Plan to pay for the office visit (99213) and destruction of premalignant lesions (17004). You say that the services were medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained by the provider.
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 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 physician services provided on November 6, 2020 by an out-of-network provider.