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

We decided that the Plan does not have to pay for the external electrocardiographic recording (93226) provided March 8, 2019, by an out of network provider.
You asked the Plan to pay for the diagnostic service. You say that you received this bill from 2 years ago. You were told to pay $50 so you did. You were told you didn't have to pay anything more, but you keep getting bills. The Plan denied your request. The Plan says the claim was not billed to the primary insurance carrier.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. As the secondary insurer, the Plan cannot be held responsible for the diagnostic service until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the external electrocardiographic recording (93226) provided March 8, 2019, by an out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (81479) provided on October 29, 2020.
You asked the Plan to pay for laboratory services. You say that this is a Medicare-covered service. The Plan denied your request. The Plan says this is 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. The rules also say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We find that CPT code 81479 is not supported in the medical record. Specifically, no medical records documenting this service have been submitted. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (81479) provided on October 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), complete series of intraoral x-rays (D0210), two prophylaxes (D1110 x2), and resin-based composite (D2391) provided from September 15, 2020, to March 29, 2021 by an OON provider.
You asked the Plan to pay for the periodic oral evaluation, complete series of intraoral x-rays, prophylaxes, and resin-based composite. You say that not being in-network does not pay as well as being in-network, but some should be paid. The Plan denied your request. The Plan says services performed by an OON provider are not covered because your healthcare plan does not have OON 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 periodic oral evaluation (D0120), complete series of intraoral x-rays (D0210), two prophylaxes (D1110 x2), and resin-based composite (D2391) provided from September 15, 2020, to March 29, 2021 by an OON provider.
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 April 17, 2021.

You asked the Plan to pay for the ambulance service. You say that you have a brain tumor which causes balance issues. You say that when you fall you are not able to get back up without assistance. You say that this has always been covered for you. 
You also say that this should be continued to be covered now. The Plan denied your request. The Plan says the ambulance benefit is a transportation benefit. The Plan also says that without a transport, 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 April 17, 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 April 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on April 6, 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 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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for out of network physician services provided to the enrollee on April 6, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing care services in the home provided by a RN provided from January 1, 2021, to February 24, 2021.
You asked the Plan to pay for the nursing care services in the home provided by a RN. You say that the enrollee made the decision for you to provide the wound care services to him. The Plan denied your request. The Plan says these services were rendered by you, and you are not a certified Medicare provider.
The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered Medicare items or services, a provider or supplier must be enrolled in the Medicare program. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the nursing care services in the home provided by a RN have not been met. This provider is not part of the Medicare program and is not payable. Therefore, we decided that the Plan does not have to pay for the nursing care services in the home provided by a RN provided from January 1, 2021, to February 24, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for a genomic sequence analysis panel (0242U) provided on May 28, 2021.
You asked the Plan to pay for a genomic sequence analysis panel. You say that this was billed correctly. The Plan denied your request. The Plan says that this was not billed with an appropriate diagnosis.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan states that this was not billed with an appropriate diagnosis. However, a copy of the claim or other documentation showing what diagnosis was billed was not included in the case file. Without this information, the Plan's denial cannot be verified. Therefore, we decided that the Plan has to pay for a genomic sequence analysis panel (0242U) provided on May 28, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on March 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 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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for out of network physician services provided to the enrollee on March 30, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for radiation treatment provided from May 10, 2021, through May 28, 2021.
You asked the Plan to waive the copayment for radiation treatment. You say that you were advised that you were fully covered for these visits. You say that you are appealing the $60 copayment for each claim. The Plan denied your request. The Plan says the copayments applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $60 per day for Medicare-covered radiation therapy visits.
You have been asked to pay a total of $900 for the radiation treatment. ($60/visit x 15 visits = $900). Radiation treatment falls 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 radiation treatment provided from May 10, 2021, through May 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory work provided on May 17, 2021.

You asked the Plan to waive the copayment for the laboratory work. You say that the testing was not done correctly, and you were told the provider would not bill you for the service. 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 $10 copayment per visit for laboratory tests, non-radiological tests, flat film x-rays, and ultrasounds. 

You have been asked to pay a $10 copayment for the laboratory work. The laboratory work falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows you were charged for a lipid panel and comprehensive metabolic panel. 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 laboratory work provided on May 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for tubing (S1015) and infection control supplies (S8301) provided on December 2, 2020.
You asked the Plan to pay for tubing and infection control supplies. You say that this should be covered at the in-network rate. The Plan denied your request. The Plan says this was not billed with valid codes.
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 S1015 and S8301 are not supported in the medical record. Specifically, these code have 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 tubing and infection control supplies have not been met. Therefore, we decided that the Plan does not have to pay for tubing (S1015) and infection control supplies (S8301) provided on December 2, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the $238.01 copayment charged for ambulance transport provided to the enrollee on April 23, 2021.

You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The Plan denied your request. The Plan says this copayment is less than the normal $290 copayment expectation.

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 $290 copayment for ambulance transport. The enrollee is being charged $238.01 which is less than what is normally assessed. 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 $238.01 copayment charged for ambulance transport provided to the enrollee on April 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for equipment and services provided to the enrollee on August 10, 2020.
You asked the Plan to pay for this claim. You say that these items and services should be covered by the Plan. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The 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 equipment and services provided to the enrollee on August 10, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an ultrasound (76700) provided on May 3, 2021.
You asked the Plan to pay for an ultrasound. You say that the enrollee had multiple exams. 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 76700 has a bundled relationship with code 93976 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 an ultrasound (76700) provided on May 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services represented by code 81521 provided on January 16, 2020.
You asked the Plan to pay for code 81521. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. Medicare says genetic testing procedures submitted under code 81521 is unlikely to impact therapeutic decision-making in the clinical management of the patient and will be denied automatically as not medically necessary. Therefore, we decided that the Plan does not have to pay for the laboratory services represented by code 81521 provided on January 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on March 15, 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 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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for out of network physician services provided to the enrollee on March 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for a medical eye exam (92004) provided on March 26, 2021.
You asked the Plan to reduce the copayment for a medical eye exam. You say that you went in for an annual eye exam and normally the copayment is $15 but you are being charged $45. The Plan denied your request. The Plan says the services were rendered by an out-of-network provider.
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 $45 copayment for each Medicare-covered outpatient visit for services to diagnose and/or treat a disease or condition of the eye. Your contract with the Plan also clearly says that you pay a $15 copayment for one annual routine eye exam with a vision network provider.
You have been asked to pay a $45 copayment for a medical eye exam. The records show that the provider in this case is not part of the Plan's vision network. The EOC confirms that $45 is the required copayment for this service. A medical eye exam falls within the vision care 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 reduce the copayment for a medical eye exam (92004) provided on March 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the cervical spine.
You asked the Plan to pre-approve an MRI. The Plan denied your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. 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 an MRI. Our reviewer says that the requested MRI is not medically reasonable and necessary. Our physician reviewer found that detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures. The enrollee is noted to have been recommended to trial physical therapy. Reportedly, he did not attend and does not plan to attend physical therapy. There has not been documentation of any severe and/or progressive neurological abnormalities, as the objective findings show intact strength, sensation and reflexes. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for cervical spine MRI 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 an MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the cervical spine.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care to be provided following a
right reverse shoulder arthroplasty (23472).
You asked the Plan to pre-approve acute inpatient hospital care. You say that you cannot go home right after
surgery because it is an acute procedure on your prominent side. You feel that if inpatient care is not approved,
you will have to cancel your surgery. The Plan denied your request. The Plan says they have agreed to cover
the shoulder surgery as an ambulatory procedure. However, there is no documentation to support the
expectation that you will require a greater than two midnight stay at an inpatient level following the procedure.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
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 acute inpatient hospital care. Our
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this
case. Our physician reviewer found the planned procedure listed under procedure code 23472 is not listed on
the Centers for Medicare and Medicaid Services (CMS) Inpatient Only List. The procedure is currently
approved as an ambulatory procedure. There is no documentation provided to support the expectation that you
will require a greater than two-midnight stay for this procedure. The review has determined that the record does
not show that at the time of inpatient admission the admitting physician reasonably expects that your necessary
hospital care (including earlier emergency and/or observation care) would span two midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the
Plan does not have to pre-approve acute inpatient hospital care to be provided following a right reverse
shoulder arthroplasty (23472).