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

We decided that the Plan does not have to pay for a tissue exam (88305) and moderate sedation services (99152, 99153) provided on February 11, 2021.

You asked the Plan to pay for outpatient service procedures. You say that authorization was not required for the denied service. The Plan denied your request. The Plan says services should be received from network providers who are listed in the provider directory, except when urgent or an emergency.

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. The records provided for review do not show that the services at issue were urgent or emergent. 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 tissue exam (88305) and moderate sedation services (99152, 99153) provided on February 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on June 2, 2021.

You asked the Plan to pay for the limited oral evaluation. You say that you believe you should be covered for this service. The Plan denied your request. The Plan says this procedure exceeds the frequency limitations.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the limited oral evaluation when the services are medically necessary and reasonable. 

We looked at the file and Medicare rules. In this case, you last received an oral evaluation on May 26, 2021. Therefore, you had exhausted the benefit when you received this service on June 2, 2021. Based on this information, we decided that the Plan's rules for coverage of the limited oral evaluation have not been met.

Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on June 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on May 5, 2021 to May 13, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.

Therefore, we decided that the Plan does not have to pay for the office visit provided on May 5, 2021 to May 13, 2021 by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) stay provided from November 23, 2020, to December 22, 2020.

You asked the Plan to pay for the SNF stay. You say that the enrollee was independently evaluated to show that she needed skilled nursing services. You say that the enrollee was admitted to the SNF as self-pay. You also say that the enrollee was not aware that her insurance could be used to cover these services. The Plan denied your request. The Plan says the SNF stay is not medically necessary.

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 pay for the SNF stay. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF stay have not been met. Specifically, the file shows that the enrollee did not require daily skilled services. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) stay provided from November 23, 2020, to December 22, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the skin graft provided an assistant surgeon on May 10, 2021.

You asked the Plan to pay for the skin graft. You say that this is a participating facility and were advised authorization was not required. You say that if the facility is reimbursed the provider should be reimbursed as well. The Plan denied your request. The Plan says an assistant surgeon cannot be paid for this procedure.

The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current Procedural Terminology (CPT) code 15275. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure.

This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the skin graft have not been met. Therefore, we decided that the Plan does not have to pay for the skin graft provided an assistant surgeon on May 10, 2021.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that you disagree with the denial. The Plan denied your request. The Plan says that the services are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the services are medically necessary. Our physician reviewer found the records show that you were admitted to the hospital on September 26, 2021 with a heart attack. You have no skilled nursing needs. The physical therapy notes show that you are functioning below your baseline level of function. You have skilled therapy needs and require skilled therapy on a daily basis. As a practical matter, you require the necessary services on an inpatient basis at the SNF level of care. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care.

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on March 2, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the lab services. You say that these services should be paid because you are an independent laboratory that processes specimens and tests from an ordering facility. You do not see enrollees directly. The Plan denied your request. The Plan says neither the lab nor the ordering provider in this case are contracted with the Plan. Out-of-network care is only covered in limited circumstances. The requested services were not emergent or pre-approved, and they were not referred by an in-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, and the provider who referred for services, are not network providers with the Plan. The Plan had network providers available who could have provided or referred the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the lab services provided on March 2, 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 tooth addition to existing partial denture (D5650) provided on April 27, 2021.

You asked the Plan to pay for the tooth addition to existing partial denture (D5650). You say that you broke the front tooth on your bridge while eating. You say that this claim is for replacing a tooth that broke not for adding an additional tooth. The Plan denied your request. The Plan says the service is not a covered benefit.

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 tooth addition to existing partial denture (D5650) provided on April 27, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergent ambulance services (A0428 and A0425) provided on April 13, 2021.

You asked the Plan to pay for the non-emergent ambulance services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says a physician's office is not a covered destination for ambulance transport.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the non-emergent ambulance services. Our reviewer says that ambulance transport to or from an outpatient office or facility for a scheduled wound care appointment is not a Medicare covered benefit. Our physician reviewer found after reassessing the entire clinical situation, information provided at the time of the appeal does not support the medical necessity of ambulance transport. 

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 non-emergent ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the non-emergent ambulance services (A0428 and A0425) provided on April 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a copayment provided to the enrollee on January 12, 2021.

You asked the Plan to pay for the copayment. You say that you had already achieved your out-of-pocket
maximum. The Plan denied your request. 

The rules say that a Cost plan must disclose in writing all benefits available under the Plan. The health plan
contract says that enrollees must pay $50 copayment for services rendered on January 12, 2021.

You have been asked to pay $50 copayment for the services rendered on January 12, 2021. The copayment
falls within the your out of pocket maximum. 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 pay for a copayment provided to the
enrollee on January 12, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the outpatient hospital and drug injection services rendered on May 20, 2021 to June 3, 2021.

You asked the Plan to waive the cost sharing for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the cost sharing was applied correctly.

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 $750 yearly deductible which applies to your covered medical services, a $125 copayment after the deductible is met for outpatient hospital observation services, and a 20% coinsurance for Medicare Part B prescription drugs.

Review of the file shows that you received outpatient hospital services from May 20, 2021 to June 3, 2021. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $750 yearly deductible which applies to your covered medical services. This cost sharing is a contractual obligation that had not been met at the time these services were received on May 20, 2021 to June 3, 2021. The Plan applied $750 towards your deductible for these services. At this time, your yearly deductible had been met.

The file shows that you also received chemotherapy services on May 20, 2021 and June 3, 2021. You have been asked to pay a 20% coinsurance for these services. These services fall within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount for these services based on the contract with the Plan. This cost sharing is a contractual obligation that you agreed to pay when you enrolled in the Plan.

Therefore, we decided that the Plan does not have to waive the cost sharing for the outpatient hospital and drug injection services rendered on May 20, 2021 to June 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2740), provisional crown (D2799) and core buildup (D2950) provided on June 17, 2021.

You asked the Plan to pay for the crown (D2740), provisional crown (D2799) and core buildup (D2950). You say that you were told that crowns were covered. You say that you saved the dental benefit to cover the codes and you should be reimbursed. The Plan denied your request. The Plan says the services are not covered 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 crown (D2740), provisional crown (D2799) and core buildup (D2950) provided on June 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital admission provided on May 6, 2021.

You asked the Plan to waive the copayment for the inpatient admission. You say that you are incorrectly being billed as an inpatient. You say you should be billed an observation copayment. 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 $325 copayment per admission for each medically necessary inpatient stay.

You have been asked to pay a $325 copayment for the inpatient admission. The inpatient admission falls within the "Inpatient hospital care" benefit category. The record shows a place of service code of 21 which is an inpatient hospital. 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 provided on May 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) provided June 29, 2021.
You asked the Plan to pay for the limited oral exam. You say that you wanted a second opinion about your tooth and feel you still don't have a solution to your problem. The Plan denied your request. The Plan says you have exceeded the frequency limit for this service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the limited oral exam once per plan year. We looked at the file and Medicare rules. The Plan provided documentation showing that a limited oral exam was previously covered on June 15, 2021. Based on this information, we decided that the Plan's frequency limit
for coverage of the limited oral exam has been exceeded. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) provided June 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; each additional vertebral segment (CPT code 22216) provided to the enrollee on March 15, 2021.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not covered as billed by the provider.
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 code was denied per Medicare's Medically Unlikely Edits as the units billed for procedure code 22216 exceeds the allowed number of units of 6 in 1 day. Additionally, based on the medical records received the procedures and modifiers were not billed correctly for a co-surgeon. Therefore, we decided that the Plan does not have to pay for osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; each additional vertebral segment (CPT code 22216) provided to the enrollee on March 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit you had with a nurse practitioner at a cancer center on April 14, 2021.
You asked the Plan to waive the copayment for the office visit. You say that you have never had to pay a copayment in the past for this service. The Plan denied your request. The Plan says you were charged this copayment 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 a $30 copayment for visits with a specialist. You have been asked to pay a $30 copayment for the office visit. This copayment applies regardless of whether or not you have had a copayment in the past. 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 office visit you had with a nurse practitioner at a cancer center on April 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pathology services (CPT code(s): 87481, 88311, 88305, 87798) provided on March 25, 2021, by an out-of-network provider.
You asked the Plan to pay for the pathology services. You say that your services should be covered. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the pathology services (CPT code(s): 87481, 88311, 88305, 87798) provided on March 25, 2021, by an out-of-network provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services rendered on May 6, 2021.
You asked the Plan to pay for these services. You say that you were told you were covered. The Plan denied your request. The Plan says the provider is not Medicare-certified.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers supplemental dental services from a Medicare-certified provider.
We looked at the file and the Plan's rules. The file shows that the provider is not an in-network or out-of-network provider with the Plan. The provider was not Medicare-certified for the date of service at issue. Therefore, we decided that the Plan does not have to pay for the dental services rendered on May 6, 2021