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

We decided that the Plan does not have to reduce the cost sharing for ultrasound-guided injection procedures you had at an outpatient hospital facility on April 13, 2021, and April 20, 2021.

You asked the Plan to reduce the cost sharing for the injection procedures. You say that when you had these injections in a provider's office before, you paid much less. You said that the injections you had at the hospital were much more expensive and you would like the copayment reduced. The Plan denied your request. The Plan says you were charged this cost sharing correctly. The Plan says that because the allowed amounts for these injections ($168.12) is less than your copayment obligation, you are responsible for the full allowed 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 $300 copayment for outpatient surgery (including injection procedures) at an outpatient hospital facility.

You have been asked to pay a $300 copayment for the injection procedures. Cost sharing is based on the location where the services are provided. In this case, you received these procedures at an outpatient hospital setting, so the outpatient hospital copayment applies. 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 cost sharing for ultrasound-guided injection procedures you had at an outpatient hospital facility on April 13, 2021, and April 20, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for infectious agent screening (87150, 87500, 87640, 87653,
87798, 87799) provided on April 12, 2021.

You asked the Plan to pay for infectious agent screening. You say that this testing was ordered by the
physician. The Plan denied your request. The Plan says this testing was a screening service.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.

The test at issue in this appeal, infectious agent screening, was requested solely for screening purposes.
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not
have to pay for infectious agent screening (87150, 87500, 87640, 87653, 87798, 87799) provided on April 12,
2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the Application of skin substitute graft represented by code 15271 provided on December 14, 2020.

You asked the Plan to pay for code 15271. 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.

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 15271. 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 code 15271 have not been met. Therefore, we decided that the Plan does not have to pay for the Application of skin substitute graft represented by code 15271 provided on December 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and related services provided on April 30, 2021 to May 28, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the office visit and related services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.

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 and related services provided on April 30, 2021 to May 28, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pay for the anesthesia services coded as 00142. We decided that the Plan does not have to pay for the special anesthesia services coded as 99100.
You asked the Plan to pay for the anesthesia services coded as 00142. You say that this should be paid. The Plan says that code 99100 is not separately payable, and the decision for the payable code is not being made under this case.
We decided that the Plan has to pay for the anesthesia services coded as 00142.
The Plan follows Medicare rules. Medicare plans must make reasonable and diligent efforts to gather and forward information to the Independent Review Entity (IRE). In this case, the Plan has made no effort to provide information to support the denial of code 00142. The claim denied stating the records did not support the service. The appeal included medical records clearly showing that anesthesia was provided for 38 minutes during an eye surgery. Therefore, we decided that the Plan has to pay for the anesthesia services coded as 00142.
We also decided that the Plan does not have to pay for the special anesthesia services coded as 99100.
The Plan must follow Medicare rules. The rules say that providers must report services correctly. CPT code 99100 has a status indicator of "B" on the Physician Fee Schedule. This means that payment for this service is bundled in payment for other services. No additional payment can be made for this code. Therefore, we decided that the Plan does not have to pay for the special anesthesia services coded as 99100.
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 drug testing provided on January 19, 2021.
You asked the Plan to pay for drug testing. You say that you are appealing with supporting records. The Plan
denied your request. The Plan says the denial of payment for this testing is correct, because the documentation
submitted does not support the Place of Service (POS) code billed on this claim.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for service, the place
where the sample was taken is reported as the Place of Service (POS).
We looked at the file and Medicare rules. The documentation shows that the sample for this testing was taken
in an office setting, therefore the POS code 81 - indicating an independent lab setting - is not appropriate for
this claim. Based on this information, we decided that Medicare rules for coverage of drug testing have not
been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on January 19,
2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an unlisted cardiovascular service (93799) provided on July 29, 2020.
You asked the Plan to pay for cardiovascular service. You say that this treatment fully complies with medical necessity and should be reimbursed as a separate procedure. The Plan denied your request. The Plan says the denial of payment for this service is correct, because there is no necessity to use an unlisted procedure code and it is inappropriate to bill this code.
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 93799 is unlisted cardiovascular service or procedure. We asked our coder 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 cardiovascular service. Our reviewer says that this code does not meet the criteria for payment. Our reviewer found the records provided do not include sufficient documentation to validate that an unlisted cardiovascular service or procedure was performed on July 29, 2020; therefore, this code cannot be verified.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of cardiovascular service have not been met. Therefore, we decided that the Plan does not have to pay for an unlisted cardiovascular service (93799) provided on July 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an occlusal guard (D9944) provided on April 29, 2021.
You asked the Plan to pay for an occlusal guard. You say that this should be covered as a medical item. The Plan denied your request. The Plan says this is not covered.
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 an occlusal guard (D9944) provided on April 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for moderate sedation services (99153) provided on March 8,
2020.
You asked the Plan to pay for the moderate sedation services. You say that you would like reconsideration
based on the records submitted. The Plan denied your request. The Plan says Medicare criteria for coverage
have not been met.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT code 99153 is not supported in the medical record. Specifically, CPT code 99153 is a technical component only code. This means that payment for this service is the responsibility of the facility to any vendor. Based on this information, we decided that Medicare rules for coverage of the moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay for moderate sedation services (99153) provided on March 8, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric treatment.

You asked the Plan to pre-approve inpatient psychiatric treatment. You say that the services are necessary. The
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been
met.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.

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 inpatient psychiatric treatment. Our
reviewer says that the services are not medically necessary. Our physician reviewer found based upon review
of the records provided, the enrollee does not meet criteria for acute inpatient mental health treatment as she
was not shown to be a danger to herself or others and was not experiencing auditory or visual hallucinations.
She is noted to be cooperative and compliant with treatment while not showing any acute threat to safety.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of inpatient psychiatric treatment have not been met. Therefore, we decided that
the Plan does not have to pre-approve inpatient psychiatric treatment.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on June 14, 2021.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you had inpatient surgery, but your surgery was considered outpatient. You also say you should not have to pay an additional charge. The Plan denied your request. The Plan says the copayment you are being charged is correct.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 copayment per admission for each medically necessary inpatient stay. You have been asked to pay a $325 copayment for inpatient hospital care. The records confirm that an inpatient hospital stay was approved prior to your surgery. The records also show that you had inpatient level of care. The EOC confirms that $325 is the required copayment for this service. 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 inpatient hospital care provided on June 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids and accessories provided on November 3, 2020.
You asked the Plan to reimburse you for hearing aids and accessories. You say that your daughter initially called the Plan on November 20, 2020 inquiring about reimbursement for hearing aids. You also say that after several calls were made by your daughter, you feel that your daughter was not provided with satisfactory information to get a hearing aid claim processed correctly. The Plan denied your request. The Plan says there is no coverage if hearing aids, or related services are received from an out-of-network provider.
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 by the Plan's hearing aid provider. We looked at this physician's review, the file, and the Plan's rules. The records shows that the hearing aids were provided by an out-of-network provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids and accessories have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids and accessories provided on November 3, 2020.
Your complaint about your concerns with customer service 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to further pay for the dental services (D1110, D0120, D0274) provided
July 1, 2021.

You asked the Plan to further pay for the dental services. You say that you are not able to use the Plan's innetwork
dentists. The Plan denied your request. The Plan says the Plan has paid the correct amount and no
further reimbursement will be made.

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 dental
services received from an out-of-network provider by paying the Medicare-allowed amount. You will be
responsible for the difference between this amount and what the provider is charging.

We looked at the file and Medicare rules. In this case, the Plan has paid the Medicare-allowed amount. You are
responsible for the additional charges the provider has made greater than this amount. Based on this
information, we decided that the Plan's rules for coverage of the dental services have not been met. Therefore,
we decided that the Plan does not have to further pay for the dental services (D1110, D0120, D0274) provided
July 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on May 29, 2020.

You asked the Plan to pay for the laboratory services. 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. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on May 29, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded 80307 and G0483 provided on February 8, 2021.

You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.

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 80307 and G0483 are not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11.

Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded 80307 and G0483 provided on February 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 87486, 87496, 87498, 87532,
87541, 87581, 87634, 87640, and 87798 provided on September 21, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services are not 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.
We find that CPT codes 87486, 87496, 87498, 87532, 87541, 87581, 87634, 87640 and 87798 are not
supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect
the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory
specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation
and/or claim history indicates that the specimen was obtained in nursing facility place of service 32. Based on
this information, we decided that Medicare rules for coverage of the laboratory services have not been met.
Therefore, we decided that the Plan does not have to pay for the laboratory services coded 87486, 87496,
87498, 87532, 87541, 87581, 87634, 87640, and 87798 provided on September 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for lab services you received on March 19, 2021, and May 17, 2021.

You asked the Plan to waive the deductible for the lab services. You say that you have been going to this doctor for years for lab services and never had to pay a deductible before. The Plan denied your request. The Plan says at the time of these services, you had only met $173.15 towards the annual $250 deductible. That is why you are being charged the remaining $76.85 of your deductible for these lab services.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $250 annual deductible which applies to lab services. 

The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $250 annual deductible which applies to lab services. This cost sharing is a contractual obligation that had not been met at the time the lab services were received on March 19, 2021 to May 17, 2021. Therefore, we decided that the Plan does not have to waive the deductible for lab services you received on March 19, 2021, and May 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gingivectomy or gingivoplasty (D4212) provided on July
9, 2021.

You asked the Plan to pay for the gingivectomy or gingivoplasty (D4212). You say that you needed this work
done for medical reasons. 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
gingivectomy or gingivoplasty (D4212) provided on July 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services (D5110, D5120) provided on February 2, 2021, by a provider who has opted-out of Medicare.

You asked the Plan to pay for the dental services. You say that you would like these claims fully covered by the Plan. The Plan denied your request. The Plan says no payment can be made to a provider who is not contracted with Medicare.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. 

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. Therefore, we decided that the Plan does not have to pay for the dental services (D5110, D5120) provided on February 2, 2021, by a provider who has opted-out of Medicare.