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

We decided that the Plan does not have to pay for a revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed (37226) provided on July 16, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for a revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent placement(s), includes angioplasty within the same vessel, when
performed. You say that you were given incorrect insurance information at the time of service. The Plan denied your request. The Plan says the provider was non-contracted with the Plan and prior authorization is required and was not 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 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 revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed (37226) provided on July 16, 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 unspecified preventative procedure (D1999), comprehensive periodontal exam (D0180), intraoral x-rays (D0220, D0230) and periodontal maintenance (D4910) provided on October 27, 2021.

You asked the Plan to pay for the dental services. You say that this service was billed incorrectly and should be paid. The Plan denied your request. The Plan says this service is not covered by your dental benefit. The Plan confirmed with the provider that this service was billed correctly, and you had other periodontal services provided on the date in question.

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 unspecified preventative procedure (D1999), comprehensive periodontal exam (D0180), intraoral x-rays (D0220, D0230) and periodontal maintenance (D4910) provided on October 27, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for colonoscopy services (procedure code 45830) provided to the enrollee on August 19, 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 provider did not bill as required by Medicare coding regulations.
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 45380 is a column II code to column I code 45385. 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 colonoscopy services (procedure code 45830) provided to the enrollee on August 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on January 6, 2021.  You asked the Plan to pay for the dental service. You say that You say that you were advised to opt out of Medicare because you had no interactions with Medicare at all since 2007. You say that you are now receiving notification that your patient's reimbursements are being denied. You also say that the services should be covered until you are able to opt back in to the Medicare program. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan also says payment cannot be made to a provider that has opted out of Medicare.  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, dental services performed by a dentist that has opted out of Medicare are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on January 6, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided from May 16, 2021, to June 14, 2021.

You asked the Plan to pay for the home health services. You say that the claim should be paid. The Plan denied your request. The Plan says the initial Request for Anticipated Payments (RAP) claim was not received within 5 calendar days from the start of care.

The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day periods and within 5 calendar days after the "from date" for each subsequent 30-day period of care, which is set at 0 percent at the beginning of every 30-day period. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home health services have not been met. Specifically, the record indicates the RAP was not submitted within 5 days of the from the start of care date, May 16, 2021. Therefore, we decided that the Plan does not have to pay for the home health services provided from May 16, 2021, to June 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (62320) provided on October 25, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says the records do not support the billed service.  The Plan must follow Medicare rules. Medicare rules say that in order for code 62320 to be covered, certain documentation requirements must be met. The documentation must include the legible signature of the physician or non-physician practitioner responsible for providing the care to the patient.  In addition, the procedure report should clearly document the indications and the medical necessity for the blocks along with the pre and post percent pain relief achieved immediately post-injection.  The medical records in this case do not meet Medicare's documentation requirements. Specifically, the record is not signed and there is no notation of the percent of pain relief achieved either before or after the injection. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of procedure code 62320 have not been met Therefore, we decided that the Plan does not have to pay for the services (62320) provided on October 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on December 20, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure codes 44140, 44120, and 44310 are not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 44140 is colectomy, partial; with anastomosis. The definition of code 44120 is enterectomy, resection of small intestine, single resection and anastomosis. The definition of code 44310 is ileostomy or jejunostomy, non-tube.
We find that CPT codes 44140, 44120, and 44310 are not supported in the medical record. Specifically, there is
no documentation of a partial colectomy with anastomosis to support code 44140. There is no documentation
of an enterectomy, resection of small intestine, to support code 44120. There is no documentation of an
ileostomy or jejunostomy, non-tube, as a separate procedure, to support code 44310. Based on this information,
we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that
the Plan does not have to pay for the surgical services rendered on December 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional intraoral periapical x-ray (D0230) provided on October 21, 2021.
You asked the Plan to pay for the additional intraoral periapical x-ray. You say that it has been years since you have seen a dentist, but the dentist does not take x-rays for nothing. You also say that you need the help to get better and would like the Plan to pay this claim for you. The Plan denied your request. The Plan says benefits for this service have been satisfied and the frequency limitation has been exceeded.
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, intraoral x-rays are limited to one procedure code per calendar year. The record shows that you received a first intraoral x-ray (D0220) on October 21, 2021 which was covered by the Plan and your intraoral x-rays benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the additional intraoral periapical x-ray (D0230) provided on October 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on September 27, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for laboratory services. You say that you were not aware of the requirement of obtaining a prior authorization, specifically for this member's plan type at the time of rendering services. You also say you conducted in good faith the laboratory testing ordered by the referring provider, who deemed the services to be medically necessary. The Plan denied your request. The Plan says this was not an emergency, urgently needed care, or out-of-area dialysis, and an authorization was not obtained prior to services rendered from this out-of-network 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 laboratory services provided on September 27, 2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services rendered on September 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 are not covered.
The Plan must follow Medicare rules. The rules say that a clinical psychologist must have a referral and consult from the beneficiary's primary care physician (PCP). We looked at the file and Medicare rules. There is no documentation of a referral and consult from the enrollee's PCP. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the outpatient mental health services rendered on September 8, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency room services rendered on June 21, 2021.
You asked the Plan to waive the copayment for emergency room services. You say that you were admitted to the hospital less than 24 hours after you went to the emergency room. 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 observation services
are hospital outpatient services given to determine if you need to be admitted as an inpatient or can be discharged. The Plan contract also says that unless the provider has written an order to admit you as an inpatient to the hospital, you are an outpatient and pay the cost-sharing amounts for outpatient hospital services, and even if you stay in the hospital overnight, you might still be considered an "outpatient." The Plan contract also says that enrollees must pay a $120 copayment for emergency room services. You have been asked to pay a $120 copayment for emergency room services. Emergency room services falls within the emergency care services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. The record shows the member was kept for observation. 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 emergency room services rendered on June 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the ConfirmMDx testing rendered on March 25, 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 covered.

The Plan must follow Medicare rules. The rules say that ConfirmMDx testing is covered for males with previous negative prostate biopsy who are being considered for repeat biopsy. 

We looked at the file and Medicare rules. The file does not contain documentation of a previous prostate biopsy. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the ConfirmMDx testing rendered on March 25, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on May 17, 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 denied codes remain not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

We find that the denied codes are not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of the inpatient setting (POS 21). 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 laboratory services provided to the enrollee on May 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on June 4, 2021.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or proprietary laboratory analysis CPT code. We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple codes. Per Medicare rules, the testing should be reported with one unit of one CPT code.
Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on June 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided by a network physician on December 13, 2021.
You asked the Plan to waive the copayment for the specialist office visit. You say that you should not be responsible for the copayment because you were told there was nothing that the provider could do for the bump on your eyelid. 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 $35 copayment for provider and professional services at an in-network specialist's office.
You have been asked to pay a $35 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" 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 specialist office visit provided by a network physician on December 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for nail debridement and office visits provided by a network provider from February 11, 2019, to December 20, 2019.
You asked the Plan to waive the copayments for the nail debridement and the office visits. You say that you never missed paying your copayments. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $45 copayment for each Medicare-covered visit in an office or home setting and a $10 copayment for services obtained from a primary care provider or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals in a primary care provider's office. The enrollee has been asked to pay a $41.71 copayment for the nail debridement which is less than the standard copayment amount and a $10 copayment for the office visits on each date of service. The nail debridement falls within the "Podiatry Services" benefit category. The office visits fall within the "Physician/Practitioner Services, Including Doctor's Office Visits" benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for nail debridement and office visits provided by a network provider from February 11, 2019, to December 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you by an out-of-network provider on July 14, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 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 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 services provided to you by an out-of-network provider on July 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory work provided on October 12, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the laboratory work. You say that the doctor's office failed to send the prior authorization form for approval. 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 laboratory work provided on October 12, 2021, by an out-of-network (OON) provider.