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

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on May 30, 2021.
You asked the Plan to waive the copayment for the emergency room visit. You say that you should not be charged a copayment on May 30, 2021, when your other visits were covered. 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 $90 copayment for each emergency care visit.
You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. The record shows you were discharged from the emergency room on May 30, 2021, and not admitted as an inpatient within 3 days for the same condition. 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 emergency room visit provided on May 30, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory work provided on March 23, 2021, to May 24, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the laboratory work. 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 record shows the referring provider was also out-of-network. Therefore, we decided that the Plan does not have to pay for the laboratory work provided on March 23, 2021, to May 24, 2021 by an out-of-network (OON) provider
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied
your request. The Plan says needs can be met in a lower level of care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing
service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity
of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 the admission have not been met. Therefore, we decided that the Plan does not
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for 1 additional periapical x-ray (D0230) provided on June 15, 2021.

You asked the Plan to pay for 1 additional periapical x-ray. You say that the services were needed to ensure that you remain healthy. You also say that you are on a medication that is causing gum disease. The Plan denied your request. The Plan says 2 preventive x-rays are covered per calendar year. The Plan also says the frequency limit 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.

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of 1 additional periapical x-ray have not been met. Specifically, the file shows that the frequency limit has been exceeded. The record shows that the Plan reprocessed the claim and paid for the initial periapical x-ray and 1 additional periapical x-ray. Therefore, we decided that the Plan does not have to pay for 1 additional periapical x-ray (D0230) provided on June 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for out of network services provided on June 30, 2021.

You asked the Plan to pay for these services. 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 must 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 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 services provided to the enrollee on 
June 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Sanexas machine provided to the enrollee on April 22, 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 is engaged in fraudulent and/or abusive billing practices.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.
After a review of the file and publicly available records, we find that the physical therapy services at issue in this case (G0283, 97016, 97150) were rendered by an NP/PA who is not licensed to provide physical therapy. Additionally, multiple drug codes reported on this claim refer to a pre-filled compounded drug/vitamin syringe. The rules require that any compounded drug be billed using the not otherwise classified code J7999. As this compounded drug was not billed properly, payment cannot be made. Because the drugs are not paid as billed, the drug administration code, 96372, also cannot be paid. 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 Sanexas machine provided to the enrollee on April 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Sanexas electrical stimulation rendered on May 12, 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 the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation. The rules say that beginning in July 2015, claims for
compounded drugs shall be submitted using a compounded drug, not otherwise classified (NOC) code
The records show that the service at issue is not manual manipulation of the spine. The file shows that the
provider billed Sanexas electrical stimulation services. These services are not covered when billed by a
chiropractor.
Furthermore, the file shows that the services were not billed with the required NOC compounded drug code. Therefore, we decided that the Plan does not have to pay for the Sanexas electrical stimulation rendered on May 12, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the pontic (D6245) and comprehensive oral evaluation (D0150) provided on June 22, 2021.

You asked the Plan to pay for the pontic and comprehensive oral evaluation. You say that you would like to know where your other allowance amount went. You also say that crowns are a covered benefit, and you did not utilize your $3,000 benefit amount. The Plan denied your request. The Plan says that your $3,000 comprehensive dental allowance for the 2021 benefit period had already been utilized prior to the receipt of this claim.

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. 

We looked at the file and Medicare rules. The Plan says that you have a $3,000 dental allowance, you are responsible for a 50% coinsurance (totaling $1,500), and you had exhausted this benefit for the 2021 Plan year. The Plan contract says that the Plan offers a maximum $3,000 allowance with 50% coinsurance every year for supplemental comprehensive dental services. According to the information provided, the Plan had only paid $1,545.50 toward the $3,000 benefit limit as of the June 22, 2021 date of service. We found that you have a remaining allowance of $1,454.50 from the $3,000 dental allowance for the 2021 plan year that has not been paid by the Plan. Based on this information, we decided that the Plan's rules for coverage of the pontic have been met. Therefore, we decided that the Plan has to pay for the pontic (D6245) and comprehensive oral evaluation (D0150) provided on June 22, 2021.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the Sanexas treatment provided on May 10, 2021.
You asked the Plan to pay for the Sanexas treatment. You say that the service is medically necessary. The Plan
denied your request. The Plan says the service is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that Medicare Part B pays for outpatient physical
therapy services only if they are furnished by, or under the direct supervision of a physical therapist in private
practice; or by, or incident to the service of a nurse practitioner (NP) or physician assistant (PA) only when that
NP/PA may perform physical therapy services under State law. The rules also say that beginning in July 2015,
claims for compounded drugs shall be submitted using a compounded drug, not otherwise classified (NOC)
code.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the Sanexas treatment have not been met. Review of the file and publicly available records, we
find that the physical therapy services at issue in this case were rendered by an NP/PA who is not licensed to
provide physical therapy in the State of Wisconsin. The multiple drug codes reported on this claim refer to a
pre-filled compounded drug/vitamin syringe. The rules require that any compounded drug be billed using the
not otherwise classified code J7999. As this compounded drug was not billed properly, payment cannot be
made. Because the drugs are not paid as billed, the drug administration code, 96372, also cannot be paid.
Therefore, we decided that the Plan does not have to pay for the Sanexas treatment provided on May 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Zostavax vaccine rendered on August 19, 2021.
You asked the Plan to pay for these services. You say that the doctor told you it would be good to get the shingles vaccine. The Plan denied your request. The Plan says the services are not covered.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide these services. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to these services. Therefore, we decided that the Plan does not have to pay for the Zostavax vaccine rendered on August 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Sanexas therapy rendered on May 11, 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 the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The rules say that beginning in July 2015, claims for compounded drugs shall be submitted using a compounded drug, not otherwise classified (NOC) code

The records show that the service at issue is not manual manipulation of the spine. The file shows that the provider billed Sanexas electrical stimulation services. These services are not covered when billed by a chiropractor. Furthermore, the file shows that the services were not billed with the required NOC compounded drug code. Therefore, we decided that the Plan does not have to pay for the Sanexas therapy rendered on May 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the brief face-to-face behavioral counseling for alcohol misuse (G0443) provided on June 30, 2021.

You asked the Plan to pay for the behavioral counseling. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service 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 G0443 is not supported in the record. Specifically, the documentation does not show that behavioral counseling was rendered on the billed date of service. There is insufficient information to determine if Medicare coverage criteria have been met. Based on this information, we decided that Medicare rules for coverage of the behavioral counseling have not been met. Therefore, we decided that the Plan does not have to pay for the brief face-to-face behavioral counseling for alcohol misuse (G0443) provided on June 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services provided on February 10, 2021.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says no separate payment is made per Medicare.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

In this case, the CPT Code Manual definition of code 99100 is anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure). We find that CPT code 99100 is a bundled code. When these services are covered, payment for them is subsumed by the payment for the services to which they are incident. 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 anesthesia services provided on February 10, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services coded 71045 provided on April 1, 2021.
You asked the Plan to pay for the x-ray services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not 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, the CPT Code Manual definition of code 71045 is radiologic examination, chest; single view. We find that CPT code 71045 is not supported in the medical record. Specifically, the documentation supports one unit of this code, which was previously approved and paid by the plan. There is no additional documentation supporting an additional study which was billed.
Based on this information, we decided that Medicare rules for coverage of the x-ray services have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray services coded 71045 provided on April 1, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) provided on May 12, 2021.
You asked the Plan to pay for the ambulance service. You say that the nurse called 911 because they could not find find your pulse. You say that you were okay by the time the ambulance arrived. The Plan denied your request. The Plan says there was no transport provided on the date of service in this case. The Plan also says that since there was no transport provided, there is no payable service.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on May 12, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) provided on May 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on April 13, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on April 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Cxbladder testing rendered on July 19, 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 testing is not covered.
The Plan must follow Medicare rules. The rules say that the Cxbladder testing is non-covered. We looked at the file and Medicare rules. The test at issue is Cxbladder. This test is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the Cxbladder testing rendered on July 19, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion services provided on February 26, 2021.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the code is invalid for usage.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes 99601 and 99602 are not valid for Medicare purposes. Medicare uses another code for the reporting of, and payment for, these services. 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 home infusion services provided on February 26, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (99601) provided on March 31, 2021.

You asked the Plan to pay for home infusion therapy. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed with a valid code.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that CPT code 99601 is not supported in the medical record. Specifically, this code has a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of home infusion therapy have not been met.

Therefore, we decided that the Plan does not have to pay for home infusion therapy (99601) provided on March 31, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid services coded 87798 provided on August 3, 2021.
You asked the Plan to pay for the infectious agent detection by nucleic acid services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. Review of the file shows that the testing provided was multiplex polymerase chain reaction (PCR) respiratory viral panel. This type of test must be ordered either in a healthcare setting that is equipped to care for and routinely does care for critically ill enrollee, or it must be ordered by an infectious disease specialist. Multiplex PCR respiratory viral panels of six or more pathogens are non-covered. The documentation shows that the services rendered were not Coronavirus testing. The testing provided was billed with diagnoses Z20.822 (Contact with and suspected exposure to COVID-19), R06.9 (Unspecified abnormalities of breathing), R53.82 (chronic fatigue, unspecified), and R09.81 (nasal congestion). This means the test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the infectious agent detection by nucleic acid services coded 87798 provided on August 3, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transport rendered on April 27, 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 payment is included in the inpatient facility payment.

The Plan must follow Medicare rules. The rules say that the applicable payments made under the prospective
payment systems are payment in full for all inpatient hospital services.

We looked at the file and Medicare rules. The file shows that the ambulance transport was for a patient
transport to a second hospital. Payment for these services is included in the inpatient facility payment. 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 ambulance transport rendered on April 27, 2021.