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

We decided that the Plan does not have to pay for out of network medical services provided to the enrollee on
October 8, 2021.
You asked the Plan to pay for out of network services. You say that this claim should be paid. The Plan denied
your request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for out of network medical services provided to the
enrollee on October 8, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for occupational therapy services you received at an outpatient hospital facility on September 8, 2021, and September 22, 2021.
You asked the Plan to waive the copayment for the occupational therapy services. You say that these visits are very helpful, but you cannot afford these copayments. The Plan denied your request. The Plan says you were charged these copayments 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 $40 copayment per visit for occupational therapy services.
You have been asked to pay a $40 copayment per visit for the occupational therapy 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 occupational therapy services you received at an outpatient hospital facility on September 8, 2021, and September 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to reduce the copayments for cataract surgery performed from August 25, 2021, to September 8, 2021.  You asked the Plan to reduce the copayments for the cataract surgery. You say that you were quoted for a $295 copayment for each eye. 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 $345 copayment for surgery or services provided at an outpatient hospital, or a $295 copayment when provided at an ambulatory surgical center.   We looked at the file. The Plan has indicated that they received a corrected claim for the surgery performed on August 25, 2021, reflecting a location code for an ambulatory surgical center. The Plan has already reprocessed the claim to reflect the correct $295 copayment. However, the Plan has also indicated that they have not yet received a corrected claim for the surgery performed on September 8, 2021. This procedure still reflects a location code for an outpatient hospital. Therefore, you have been asked to pay a $345 copayment for the cataract surgery. The cataract surgery falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 copayments for cataract surgery performed from August 25, 2021, to September 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120), panoramic radiographic image (D0330), prophylaxis - adult (D1110) provided May 10, 2021.  You asked the Plan to pay for the periodic oral exam, panoramic x-ray and dental cleaning. You say that you paid the provider, and the Plan should reimburse you. The Plan denied your request. The Plan says these services are not covered when rendered by a provider who has opted out of Medicare.  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 periodic oral exam, panoramic x-ray and dental cleaning when you see any licensed dental provider who accepts Medicare patients in the United States and has not opted out of Original Medicare.  We looked at this physician's review, the file, and Medicare rules. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Based on this information, we decided that the Plan's rules for coverage of the periodic oral exam, panoramic x-ray and dental cleaning have not been met. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120), panoramic radiographic image (D0330), prophylaxis - adult (D1110) provided May 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic comprehensive preventive medicine
reevaluation and management service (99397) rendered by the out-of-network (OON) provider on April 16,
2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was 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 service provided in this case was a telehealth visit rendered by an out-of-network provider. The Plan
contract states that an enrollee has the option of getting covered services through an in-person visit or by
telehealth. If the enrollee chooses to get one of these services by telehealth, they must use a network provider.
The Plan had network providers available who could have provided the service at issue in this appeal. The Plan
did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this
service. Therefore, we decided that the Plan does not have to pay for the periodic comprehensive preventive
medicine reevaluation and management service (99397) rendered by the out-of-network (OON) provider on
April 16, 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),
extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of
mucoperiosteal flap if indicated (D7210), and unspecified adjunctive procedure, by report (D9999) provided
August 2, 2021.
You asked the Plan to pay for the limited oral exam, tooth extraction and unspecified adjunctive procedure.
You say that your annual notice of changes did not tell you that opt out providers are excluded. The Plan
denied your request. The Plan says these services are not covered because the provider has opted out of
Medicare.
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, tooth extraction and unspecified adjunctive procedure when you see any licensed dental provider
who accepts Medicare patients in the United States and has not opted out of Original Medicare.
We looked at this physician's review, the file, and Medicare rules. The services at issue in this appeal were
provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program.
Based on this information, we decided that the Plan's rules for coverage of the limited oral exam, tooth
extraction and unspecified adjunctive procedure have not been met. Therefore, we decided that the Plan does
not have to pay for the limited oral evaluation - problem focused (D0140), extraction, erupted tooth requiring
removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated
(D7210), and unspecified adjunctive procedure, by report (D9999) provided August 2, 2021.
Your complaint about feeling that you were not properly informed about the coverage rules is not a valid
appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan.
Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for out of network services provided to the enrollee on September 2, 2021.  You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for out of network services provided to the enrollee on September 2, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transfer to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that you are appealing this denial. The Plan denied your
request. The Plan says the denial of authorization for SNF care is correct.
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 daily
skilled services are not necessary. Our physician reviewer found the enrollee does not have daily skilled
nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The
enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment
of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on
an inpatient basis in a skilled nursing facility (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 SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve transfer to a skilled nursing facility (SNF).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug test (G0480) rendered by the out-of-network (OON)
provider on April 16, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was 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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan
does not have to pay for the drug test (G0480) rendered by the out-of-network (OON) provider on April 16,
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the reline complete maxillary denture (direct) (D5730) and gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant (D4210) provided October 8, 2021.  You asked the Plan to pay for the complete upper denture reline and gingivectomy or gingivoplasty. You say that these were necessary services and should be covered. The Plan denied your request. The Plan says you were not enrolled in supplemental dental coverage at the time of the services and these services were not included in your 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 reline complete maxillary denture (direct) (D5730) and gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant (D4210) provided October 8, 2021.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for computed tomography (CT) (74176) provided on July 13, 2021.
You asked the Plan to pay for CT 74176. You say that you are appealing with records to support this level of
service. The Plan denied your request. The Plan says that the denial of payment for this service is correct,
because code 74176 has a Procedure-to-Procedure (PTP) edit of 1 with code 74178 so is not separately payable
without an appropriate modifier.
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. Medicare rules say that providers must report services correctly. Providers must report services with
the appropriate CPT code.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan denied payment for code 74176 on the basis that it has a PTP edit of 1
with code 74178 so is not separately payable. However, code 74178 was not billed on this claim, nor did the
Plan submit evidence showing that code 74178 was billed by the provider in a manner that would result in a
PTP edit between these codes. Codes 70450 and 71045 were billed on this claim; however, neither of these
codes has a PTP edit with code 74176.
The Plan provided no other rationale or evidence to support a denial of payment. Therefore, the Plan has not
shown that its decision to deny payment for code 74176 is correct or justified according to Medicare billing and
coding rules. Therefore, we decided that the Plan has to pay for computed tomography (CT) (74176) provided
on July 13, 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 the office visit rendered on October 5, 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 were not billed correctly.  The Plan must follow Medicare rules. The rules say that Current Procedural Terminology (CPT) modifier -25 should only be used on claims for evaluation and management (E/M) services, and only when these services are provided by the same physician (or same qualified nonphysician practitioner) to the same patient on the same day as another procedure or other service.  We looked at the file and Medicare rules. Procedure code 99213 (office visit) was billed with modifier -25. The file shows that the services did not include a different anatomical site, different condition, or related but unusual condition to support the billing of this modifier. 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 office visit rendered on October 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on September 8, 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 code 22854 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.
In this case, the CPT Code Manual definition of code 22854 is insertion of intervertebral biomechanical device into site of complete resection of vertebral body, each contiguous defect. We find that CPT code 22854 is not supported in the medical record. Specifically, the operative report does not include insertion of of an intervertebral biomechanical device. 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 September 8, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection (CPT code 62320) provided to the enrollee on October 25, 2021, by an out-of-network provider.

You asked the Plan to pay for the injection. You say that the service is medically necessary. The Plan denied your request. The Plan says this provider has not submitted any clinical records to support the medical necessity of the service(s). The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the injection have not been met. Medical records were not provided to verify if the services were medically necessary. Therefore, we decided that the Plan does not have to pay for the injection (CPT code 62320) provided to the enrollee on October 25, 2021, by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing (CPT code G0483) provided to the enrollee on February 17, 2021.  You asked the Plan to pay for the drug testing. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not supported by the records.  The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. CPT code G0483 (1 Unit) remains not supported. The place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11. Also, the laboratory results submitted indicate the specimen was collected on February 17, 2021, and received by the lab on February 24, 2021. Of note, the enrollee resides in Alabama (AL) and the billing laboratory is located in Tennessee (TN); therefore, the billed code cannot be verified. It is noted multiple attempts were made to obtain additional information from the provider. Therefore, we decided that the Plan does not have to pay for the drug testing (CPT code G0483) provided to the enrollee on February 17, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Jardiance 25mg tablets.  You asked the Plan to pre-approve the Jardiance tablets. You say that this is needed to treat the enrollee's diabetes. The Plan denied your request. The Plan says this is an oral drug that must be covered by Medicare Part D.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Jardiance 25mg tablets.   Benefits for the Jardiance tablets may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network services provided to the enrollee on January 27, 2021.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.

Therefore, we decided that the Plan does not have to pay for out of network services provided to the enrollee on January 27, 2021.