Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extractions (D7210) and core buildup (D2950) provided on June 25, 2021.

You asked the Plan to pay for the dental services. You say that these were simple extractions, not surgical. The Plan denied your request. The Plan says Medical records from the provider support the billing of surgical extractions (D7210) on the date in question. Surgical extractions and core buildups are not covered by your dental 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 surgical extractions (D7210) and core buildup (D2950) provided on June 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the supplies rendered on June 30, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes. 

We looked at the file and Medicare rules. Billed procedure codes S1015 (intravenous tubing extention set) and S8301 (infection control supplies) have a status indicator of I and are not valid for Medicare purposes. Therefore, we decided that the Plan does not have to pay for the supplies rendered on June 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible and coinsurance for outpatient services provided on August 6, 2021, and August 12, 2021.  You asked the Plan to waive the deductible and coinsurance for the outpatient services. You say that you have never paid for these services. The Plan denied your request. The Plan says the out-of-network deductible was not met and once it was met the proper coinsurance was applied.   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 $1000 deductible before the Plan will pay their share for enrollees covered medical services from an out-of-network provider. Prior to the date of service of August 6, 2021, $46.05 was paid towards the $1000 deductible. Since the deductible was not met the full amount allowed was $554.12 which went towards deductible paid. With the balance of the deductible now being $399.83 ($1000 starting deductible - $46.05 paid deductible - $554.12 paid deductible). With only $399.83 left of the $1000 deductible that was charged on August 12, 2021.  Your contract with the Plan also clearly says that you must pay a 30% coinsurance for Basic Radiological Services. With $554.12 being the allowed amount charged on August 12, 2021, and a balance of $399.83 of the deductible that left the billable amount of $154.29 ($554.12 - $399.83 deductible amount left). With a 30% coinsurance billed at $46.29 ($154.29 x 30% coinsurance).   You have been asked to pay a $953.95 deductible. The deductible falls within the Understanding your out-of-pocket costs for covered services benefit category. You have also been asked to pay a 30% coinsurance for the outpatient services. The outpatient service 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 deductible and coinsurance for outpatient services provided on August 6, 2021, and August 12, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ambulance transportation services (A0429, A0425) provided on July 23, 2021.  You asked the Plan to waive the copayment for the ambulance services. You say that this service should be covered, and you were told there would be no charge. You are surprised by this bill and unable to pay it. The Plan denied your request. The Plan says these services are covered, and your copayment was applied in accordance with 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 $325 copayment for ambulance services.    You have been asked to pay a $325 copayment for the ambulance services. 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 ambulance transportation services (A0429, A0425) provided on July 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for primary care physician (PCP) visit provided on August 13, 2021.  You asked the Plan to waive the copayment for the PCP visit. You say that you went for your annual physical and did not have any extra services performed. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $0 copayment for an annual physical. If you receive services that address a medical condition during the same visit, additional cost-sharing may apply.  Your contract with the Plan also clearly says that you must pay a $10 copayment for each visit with your PCP.   The record shows you had services to treat a medical condition, which goes beyond the scope of an annual physical. Therefore, you have been asked to pay a $10 copayment for the PCP visit. PCP visits fall 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 primary care physician (PCP) visit provided on August 13, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the psychotherapy services coded 90832 provided on July 21, 2021.  You asked the Plan to pay for the psychotherapy services. You say that you would like the plan to reconsider their denial The Plan denied your request. The Plan says the documentation does not include required information.  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 90832 is psychotherapy, 30 minutes with patient.    We find that CPT code 90832 is not supported in the medical record. Specifically, the documentation does not include contact in the enrollee record to support that the provider attempted to consult with the attending or primary care physician about the services furnished and document the consent or declination date to consultations, and the date of consultations in the enrollee's medical record. Based on this information, we decided that Medicare rules for coverage of the psychotherapy services have not been met. Therefore, we decided that the Plan does not have to pay for the psychotherapy services coded 90832 provided on July 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for portable x-ray services provided to the enrollee on September 20, 2021.  You asked the Plan to pay for the services. You say that the services are treated as emergency service in the nursing home and home health setting, as these facilities are required to treat potential fractures and other conditions within a four hour window. The Plan denied your request. The Plan says there was no authorization for these services.  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 portable x-ray services provided to the enrollee on September 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does require physical therapy and occupational therapy services but based on the medical records provided the enrollee does not require an intensive inpatient rehabilitation therapy program. Medically necessary services can be provided in a different 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the additional supplies and materials rendered on August 24, 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 Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is always bundled into payment for other services not specified.  We looked at the file and Medicare rules. Billed procedure code 99072 (additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease) has a status indicator of B and no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for the additional supplies and materials rendered on August 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for dialysis treatments provided from February 1, 2021, to March 10, 2021.  You asked the Plan to waive the copayments for the dialysis treatments. You say that you feel that these charges are too much. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 copayment for each dialysis treatment.   You have been asked to pay a $30 copayment for each dialysis treatment. The record shows you had a total of 38 treatments, resulting in a total of $1140 for the treatments ($30 copayment x 38 treatments = $1140). However, your maximum out of pocket expense limit had been met during this time, therefore you are only responsible for the remaining $909. The dialysis treatments falls within the Services to Treat Kidney Disease 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 copayments for dialysis treatments provided from February 1, 2021, to March 10, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the ultrasonic guidance for biopsy rendered on March 15, 2021.  You asked the Plan to pre-approve 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, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.  The provider submitted a claim for procedure codes 76942 (ultrasonic guidance for biopsy) and 36556 (insertion of non-tunneled centrally inserted central venous catheter). Code 76942 is a column II code with a modifier indicator of 1 when billed with column I code 36556. Code 76942 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pre-approve the ultrasonic guidance for biopsy rendered on March 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an x-ray of the shoulder provided on August 31, 2021.  You asked the Plan to waive the copayment the x-ray of the shoulder. You say that the services should be covered as you already paid for the office visit. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.  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 Outpatient Diagnostic Tests and Therapeutic Services and Supplies.       You have been asked to pay a $15 copayment for an x-ray of the shoulder. X-rays fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. The $25 copayment that you agreed to pay applies to the office visit, there is a separate copayment for x-rays. 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 an x-ray of the shoulder provided on August 31, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ground mileage (A0425) and emergency ambulance transportation (A0427) provided on May 13, 2021.  You asked the Plan to pay for the ground mileage and emergency ambulance transportation. You say that you would like this claim to be reprocessed for payment. The Plan denied your request. The Plan says on this date of service the patient's claims history indicates they were in an inpatient hospital status. The Plan must follow Medicare rules. Medicare rules say that hospital bundling rules exclude payment to independent suppliers of ambulance services for beneficiaries in a hospital inpatient stay.   We looked at the file and Medicare rules. The record shows that the enrollee had been at an inpatient hospital status from May 12, 2021, to May 18, 2021. Based on this information, we decided that Medicare rules for coverage of the ground mileage and emergency ambulance transportation have not been met. Therefore, we decided that the Plan does not have to pay for the ground mileage (A0425) and emergency ambulance transportation (A0427) provided on May 13, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a home health aide for the enrollee.  You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the information does not support the need for a home health aide to make visits.  The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.  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 services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found that in this case, the documentation doesn't support that the enrollee requires skilled nursing services or skilled rehab services to provide treatment that is medically necessary. The enrollee does not require skilled nursing or rehab services to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, perform a maintenance program to maintain the member's condition and/or prevent deterioration. The enrollee has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. He requires custodial care. The requested home health services are not medically 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a home health aide for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids provided on May 12, 2021.

You asked the Plan to pay for hearing aids. You say that the hearing aids were provided by an in-network
hearing doctor, and you were under the impression that the hearing aids would be covered by the Plan since the
doctor was in-network. The Plan denied your request. The Plan says the hearing aids were not purchased
through the Plan's hearing aid vendor.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for
hearing aids only when provided through the Plan's hearing aid vendor.

We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided by the Plan's
hearing aid vendor. Based on this information, we decided that the Plan's rules for coverage of hearing aids
have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids provided on
May 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for an alveoloplasty with extraction (D7210, D7310, and D7311) provided by a participating provider on September 8, 2021.  You asked the Plan to pay for an alveoloplasty with extraction. You say that you think the Plan should pay for this. The Plan denied your request. The Plan says the maximum benefit allowance has already been met.  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 a maximum benefit limit of $2,500.      We looked at the file and Medicare rules. Based on this information, we find that the maximum benefit limit has already been exhausted. Therefore, we decided that the Plan does not have to pay for an alveoloplasty with extraction (D7210, D7310, and D7311) provided by a participating provider on September 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for skilled nursing facility physician visit (99309) provided on November 25, 2020, by an OON provider.  You asked the Plan to pay for skilled nursing facility physician visit. You say that you strongly advise that these denied charges were medically necessary. The Plan denied your request. The Plan says both the physician and the facility are non-contracted provider and there is no documentation in this physician's note of an urgent or emergent need.  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 skilled nursing facility physician visit (99309) provided on November 25, 2020, by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998)
provided on August 15, 2021.

You asked the Plan to pay for ambulance response and treatment, no transport. You say that you were home
alone, and you became ill with dizziness and vomiting. You say that you were not sure if you were having a
seizure, so you called for emergency services and you took your medication and when the ambulance arrived,
they took your vitals and they were normal. The Plan denied your request. The Plan says per Medicare
guidelines, the ambulance benefit is a transport benefit. If there is no transport, then there is no Medicare-covered
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 August 15, 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 ambulance response and treatment, no transport
(A0998) provided on August 15, 2021.