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

We decided that the Plan does not have to pay for an office visit (99204) provided on August 19, 2021, by an
out-of-network (OON) provider.
You asked the Plan to pay for an office visit. You say that these services were needed. The Plan denied your
request. The Plan says the rendering provider is a non-participating provider, and the Plan did not authorize any
services for this 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 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 an office visit (99204) provided on August 19,
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 comprehensive oral evaluation (D0150), periapical x-rays
(D0220, D0230 x 5), bitewing x-rays (D0274), prophylaxis (D1110), fluoride (D1208), and fillings (D2331,
D2392) provided on October 16, 2021.
You asked the Plan to pay for the dental services. You say that you feel the pre-approval of these codes was
sufficient to get the claims paid even though you have reached you annual maximum benefit of $1,000. The
Plan denied your request. The Plan says there is an annual maximum benefit of $1,000 for covered dental
services. The Plan also says that the annual maximum benefit has been exhausted.
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 annual maximum benefit has been
exhausted.
Date of Service Plan Paid
1/8/2021 $22
2/22/2021 $80.40
3/18/2021 $87
4/6/2021 $548.20
5/10/2021 $262.40
TOTAL: $1,000
Additionally, the Evidence of Coverage says that after the annual maximum is exhausted, any remaining
charges are your responsibility. Therefore, we decided that the Plan does not have to pay for the comprehensive
oral evaluation (D0150), periapical x-rays (D0220, D0230 x 5), bitewing x-rays (D0274), prophylaxis (D1110),
fluoride (D1208), and fillings (D2331, D2392) provided on October 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an office visit (99213) provided on June 7, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for an office visit. You say that this is supported in the records. The Plan denied your request. The Plan says this was not authorized.  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 prov
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from December 11, 2019, to December 19, 2019.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the DRG was adjusted and recouped in this case.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.    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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found the review has determined that the items and services denied with denial code G were denied for unbundling. These items were determined inclusive to either room and board or the procedure charge. There were no physician orders and no documentation of service received to support the charge. The DRG adjustment was appropriate in this case.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from December 11, 2019, to December 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) (K0554) and supplies (K0553), provided on May 27, 2021.  You asked the Plan to pay for the CGM and supplies. You say that the items are medically necessary. The Plan denied your request. The Plan says documentation submitted did not sufficiently support the billed supply code; nor did documentation indicate the provider discussed the need for the billed supply code.  The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.   The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. The records submitted do not show medical necessity for these items nor do they show the treating physician ordered them or discussed them with the member. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor (CGM) (K0554) and supplies (K0553), provided on May 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Tdap vaccine provided to the enrollee on August 19, 2021.  You asked the Plan to pay for the vaccine. The Plan denied your request. The Plan says this is not a covered benefit.  In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The Plan follows the same rules.   The records do not show that you have been injured or directly exposed to any illness related to the vaccine. Therefore, we decided that the Plan does not have to pay for the Tdap vaccine provided to the enrollee on August 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for needle electromyography (95861) provided on August 16, 2021.  You asked the Plan to pay for needle electromyography. You say that this is supported in the records. The Plan denied your request. The Plan says this is not separately payable.  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 95861 is a column II code to column I code 51785. 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 needle electromyography (95861) provided on August 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for laboratory services (80061, 80050, 84439, 36415) rendered on February 23, 2021.  You asked the Plan to waive the copayment for laboratory services. You say that the claim lists diagnosis as essential primary hypertension and you do not hypertension. You also say that this procedure was routine. 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 $6 copayment for Medicare-covered laboratory tests.   You have been asked to pay a $6 copayment for laboratory services. Laboratory services 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 laboratory services (80061, 80050, 84439, 36415) rendered on February 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the tube placement (43752) provided on August 20, 2021.   You asked the Plan to pay for the tube placement (43752). You say that the patient was seen by different providers with different specialties. You say that the claim should be reprocessed for additional payment. The Plan denied your request. The Plan says an appropriate modifier was not billed with this code edit.  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 43752 is a column II code to column I code 99232. 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 tube placement (43752) provided on August 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an office visit provided to the enrollee on June 15, 2021.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the plan did not authorize 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 an office visit provided to the enrollee on June 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from
August 20, 2020, to August 24, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says the DRG was updated.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the
reported principal and secondary diagnosis codes.
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 services. Our reviewer says that the
services at issue in this case were not supported by the medical records. Our physician reviewer found that in
this case, provider documentation indicated that the patient was being admitted to inpatient care for acute
pancreatitis. ICD-10 CM code K85.10 was sequenced as the principal diagnosis and code K80.62 was
sequenced as a secondary diagnosis consistent with the documentation that was received. The review has
determined that the DRG was appropriately updated.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay
for inpatient hospital services provided to the enrollee from August 20, 2020, to August 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on June 8, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not billed correctly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on June 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the immediate denture - maxillary (D5130) and immediate
denture - mandibular (D5140) provided September 23, 2021.
You asked the Plan to pay for the immediate upper and lower dentures. You say that the dentures were
medically necessary. 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 immediate denture - maxillary (D5130) and immediate denture - mandibular (D5140) provided September 23, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the enrollee does
not have skilled nursing or therapy services that can only be provided on an inpatient basis.
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 SNF services. Our physician reviewer
found that from a nursing perspective, the enrollee received oral medication and had stable vital signs. There
are no identifiable skilled nursing service needs. Regarding rehabilitation services, the enrollee was non
ambulatory and depended for functional mobility. He required varying assist with activities of daily living.
There are no identifiable skilled therapy service needs. He does not require skilled nursing or therapy services
on a daily basis. He does not meet severity of illness or intensity of service criteria for an inpatient basis in a
SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit and comprehensive assessment (99328 and G0506) provided on August 31, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the home visit and comprehensive assessment. You say that you would like reconsideration because these services were requested by the member's facility and the documentation supports that they were medically necessary. The Plan denied your request. The Plan says this is a non-contracted provider who rendered services 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 home visit and comprehensive assessment (99328 and G0506) provided on August 31, 2021 by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Partially Favorable

We decided that the Plan has to pay for home care services provided from October 2, 2020, through
October 16, 2020. We also decided that the Plan does not have to pay for home care services provided from
September 17, 2020, through September 30, 2020.
You asked the Plan to pay for the home care services. You say that the patient was not enrollee in hospice on
these dates of service. The Plan says that Original Medicare would be responsible for payment of all Medicare
covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit,
through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of
discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services
and all care unrelated to the terminal illness until the first day of the month following the month in which
hospice was revoked or discharged.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance angiography (MRA) of the head
rendered on August 26, 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 70544 (MRA head) and 70551 (magnetic resonance
imaging, brain stem). Code 70544 is a column II code with a modifier indicator of 1 when billed with column I
code 70551. Code 70544 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 magnetic resonance angiography (MRA) of the head
rendered on August 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to reimburse you for hearing aids provided on August 17, 2021.  

You asked the Plan to reimburse you for hearing aids. The Plan denied your request. The Plan says the Plan does offer a supplemental benefit for hearing aids, but the enrollee would have to go to a Plan hearing provider and receive the Plan approved hearing aids.  

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 hearing aids were not purchased from the Plan's hearing aid provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids provided on August 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a periodic oral evaluation (D0120) and prophylaxis (D1110) provided on July 29, 2021, and October 7, 2021.
You asked the Plan to pay for a periodic oral evaluation and prophylaxis. You say that the claim should have been covered under the $1,500 additional dental coverage on your Plan. The Plan denied your request. The Plan says the requested services exceed the frequency limitation in your benefit plan.
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 a periodic oral evaluation and prophylaxis twice per plan year.
We looked at the file and Medicare rules. The records show that you received a periodic oral evaluation and a prophylaxis cleaning on January 21, 2021 and April 21, 2021. The EOC confirms you receive two periodic evaluations and two prophylaxis per plan year; therefore, you have exhausted your benefit for these services. Based on this information, we decided that the Plan's rules for coverage of a periodic oral evaluation and prophylaxis have not been met. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation (D0120) and prophylaxis (D1110) provided on July 29, 2021, and October 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visits (99214) rendered by the out-of-network (OON) provider from January 21, 2021, through March 31, 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 office visits (99214) rendered by the out-of-network (OON) provider from
January 21, 2021, through March 31, 2021.