Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for occupational therapy services provided by an occupational therapist on December 23, 2019.
You asked the Plan to pay for the occupational therapy services. You say that plans are required to pay non-contracted providers at the preferred provider rate if services are not available in the service area. 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 services of an occupational therapist billed as services incident to a physician/non-physician practitioner's service must meet all incident requirements. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the occupational therapy services have not been met. Specifically, the billing provider is a nurse practitioner. As such, occupational therapy services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for occupational therapy services provided by an occupational therapist on December 23, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on September 22, 2020.
You asked the Plan to pay for lab tests. You say that you do not personally see the patient and are dependent on receiving patient information from the ordering provider. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the documentation submitted does not support the Place of Service (POS) code billed on this claim.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the Place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The documentation submitted shows that the sample for this testing was taken in a nursing facility setting, therefore the POS code 11 - indicating an office setting - is not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on September 22, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the 
enrollee. 
 
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 are considered custodial. 

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 
the requested admission is not medically reasonable or necessary. Our physician reviewer found the enrollee 
does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled 
professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. 
The documentation reveals that the enrollee's wound vac is changed every three days. You do not require a 
SNF admission for every 24-hour intravenous antibiotics. Furthermore, the enrollee has had recent new 
hypoxia requiring oxygen, and there are no results of the chest x-ray that was ordered to evaluate for this, or 
reveal that the hypoxia is improving. The enrollee's functional level does not require skilled therapy services 
with  the specialized skill, knowledge and judgment of a qualified therapist  to safely and effectively provide 
medically necessary and reasonable treatment in a SNF. The enrollee does not require skilled nursing or skilled 
therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, this 
enrollee does not require the necessary services on 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) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and 
services provided from February 3, 2021, to February 5, 2021. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that you were not admitted as an 
inpatient and should not have this copay. The Plan denied your request. The Plan says documentation shows 
that you were admitted as an inpatient on the days in question and were given inpatient care. You are 
responsible for a $225 copayment for each of the first seven days of an inpatient hospital admission. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 
copayment for each of the first seven days of an inpatient hospital stay.

You have been asked to pay a $450 copayment for the two-day inpatient hospital stay ($225 x 2 = $450). 
Medical records were provided to verify the care provided. 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 inpatient hospital admission and services provided from February 3, 2021, to February 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on February 9, 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 procedure codes 62145 and 62100 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 62145 is cranioplasty for skull defect with reparative brain surgery. The definition of code 62100 is craniotomy for repair of dural/cerebrospinal fluid leak, including surgery for rhinorrhea/otorrhea.
We find that CPT codes 62145 and 62100 are not supported in the medical record. Specifically, there is no documentation of a cranioplasty for skull defect with reparative brain surgery to support code 62145. There is no documentation of a craniotomy for repair of dural/cerebrospinal fluid leak to support code 62100. 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 February 9, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided the Plan does not have to waive the copayment charged for ambulance transport. 
 
You asked the Plan to waive this copayment. You say that you do not believe you should have to pay this 
copayment. The Plan denied your request. The Plan says this copayment was applied based on the services 
provided and the Plan contract agreement. 
 
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 $225 
copayment for ambulance transport. 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 charged for ambulance transport 
provided on May 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on January 26, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for lab test. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this provider is out-of-network with the Plan and the ordering provider is also out-of-network with the Plan.
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 testing provided on January 26, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the surgical extraction (D7210) provided on June 4, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay more for the surgical extraction. You say that you have $2,000 worth of dental 
coverage yearly with 50% coverage of periodontic services. You also say that you expect the Plan to reimburse 
you $229.75 for the extraction. The Plan denied your request. The Plan says this service was rendered by an 
OON provider. The Plan also says that the amount the Plan paid for this service was correct. 
 
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, you are responsible for the $75 
deductible from the allowed amount, plus 50% of the remaining allowed amount, plus the difference between
the billed amount and allowed amount for dental services received OON. Therefore, we decided that the Plan 
does not have to pay more for the surgical extraction (D7210) provided on June 4, 2021 by an out-of-network 
(OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ankle foot orthosis (L1940) and 
addition to lower extremity orthosis (L2820) provided May 12, 2021. 
 
You asked the Plan to waive the copayment for the orthoses. You say that you do not agree with the cost share. 
The Plan denied your request. The Plan says the claim was processed with the correct cost share applied per the 
Evidence of Coverage. 
 
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 $0-20% 
coinsurance for each Medicare covered prosthetic or orthotic device, including replacement or repairs of such 
devices and related supplies for Prosthetic Devices and Related Supplies. 

You have been asked to pay $85.00 ($72.74 + $12.75) for the orthoses. The orthoses fall within the Prosthetic 
Devices and Related 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 ankle 
foot orthosis (L1940) and addition to lower extremity orthosis (L2820) provided May 12, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care provided on March 10, 2021.
You asked the Plan to pay for the nursing facility care. You say that hospice was revoked on March 1, 2021
and the claim should be reprocessed. The Plan denied your request. The Plan says Original Medicare is
responsible for payment.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Original Medicare is responsible for payment for services until the first day of the month after the
hospice election has been revoked or terminated.
The enrollee ended Medicare Hospice benefits on March 1, 2021. The services in question were provided
before the end of that month. Therefore, we decided that the Plan does not have to pay for the nursing facility
care provided on March 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for additional supplies, materials, and clinical staff time (99072) 
provided on January 22, 2021. 
 
You asked the Plan to pay for supplies, materials, and staff time. You say that the Plan has failed to process this 
claim in accordance with applicable standards. The Plan denied your request. The Plan says the denial of 
payment for this service is correct, because this code is always bundled into payment for other services and no 
separate payment is made per Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that code 99072 is always bundled for payment, and 
if it is covered payment for this code is subsumed by the payment for the services to which it is incident. 

We looked at the file and Medicare rules. This code is always bundled for payment and is not separately 
payable. Based on this information, we decided that Medicare rules for coverage of supplies, materials, and 
staff time have not been met. Therefore, we decided that the Plan does not have to pay for additional supplies, 
materials, and clinical staff time (99072) provided on January 22, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided on January 1 to July 13, 2020, 
by a provider not enrolled in the Medicare program. 
 
You asked the Plan to pay for home health services. You say that the services at issue were a medical necessity 
for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met because the 
provider of the services at issue is not enrolled in the Medicare program. 
 
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 home health services provided on 
January 1 to July 13, 2020, by a provider not enrolled in the Medicare program.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the antibody testing rendered on January 28, 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. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT code 86021 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. 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 antibody testing rendered on January 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit rendered on April 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 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 records show that the service at issue is not manual manipulation of the spine. The file shows that the 
chiropractor submitted a claim for procedure code 99203 (office visit). Therefore, we decided that the Plan 
does not have to pay for the office visit rendered on April 19, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the neurobehavioral status exam (96116) provided on April 9, 2021.
You asked the Plan to waive the cost share for the outpatient diagnostic test. You say that you paid the $25 copayment. You also say that you feel you are not responsible for the $82.67 deductible too. The Plan denied your request. The Plan says the claim was processed correctly with a $82.67 total deductible applied to the outpatient visit.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $150 deductible which applies to in network services. The item or service you asked the Plan to waive the cost share for falls within the benefit category for in network services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $150 deductible which applies to in network services. This cost sharing is a contractual obligation that had not been met at the time the outpatient diagnostic test was received on April 9, 2021. Therefore, we decided that the Plan does not have to waive the cost share for the neurobehavioral status exam (96116) provided on April 9, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the parasympathetic testing rendered on March 17, 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 if the modifier indicator is 0, the Column 2 code cannot be paid regardless of whether a
modifier is used.
The provider submitted a claim for procedure codes 95943 (paraysmpathetic testing) and 95921 (autonomic
nervous system testing). Code 95943 is a column II code with a modifier indicator of 0 when billed with
column I code 95921. Code 95943 is not separately payable. Therefore, we decided that the Plan does not have
to pay for the parasympathetic testing rendered on March 17, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound (76770) provided on June 4, 
2021. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that this was a laboratory service and 
not an x-ray service. The Plan denied your request. The Plan says this copayment was applied correctly based 
on your contract. 
 
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 Medicare-covered x-rays.  
 
You have been asked to pay a $15 copayment for the ultrasound. An ultrasound is a diagnostic imaging service 
similar to an x-ray. 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 ultrasound (76770) provided 
on June 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a urology office visit provided on June 11, 2021.
You asked the Plan to waive the copayment for specialist visit. You say that you understood this call as an approved safeguard procedure which would be covered with no copayment. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 $30 copayment for telehealth specialist visit. You have been asked to pay $30 copayment for specialist visit. Specialist 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 a urology office visit provided on June 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone and/or joint imaging (78315) provided on June 28, 2021.
You asked the Plan to pay for the diagnostic service. You say that the enrollee had multiple exams on this date of service. Please reconsider for processing. The Plan denied your request. The Plan says this procedure is not paid separately.
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 the diagnostic service has a bundled relationship with code 78803 and cannot be paid as billed. This code cannot be paid as a separate line item. 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 bone and/or joint imaging (78315) provided on June 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repeat lumbar medial branch blocks for the enrollee.
You asked the Plan to pre-approve the blocks. You say that this is medically necessary. The Plan denied your request. The Plan says the repeat procedure is not supported.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the blocks. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that in this case, the initial set of medial branch blocks yielded a 0% response during the duration of the anesthetic coverage. The enrollee did not receive 80% relief from the first injection. The review has determined that the service at issue in this case is not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the blocks have not been met. Therefore, we decided that the Plan does not have to pre-approve repeat lumbar medial branch blocks for the enrollee.