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

We decided that the Plan does not have to pay for electrocardiogram, routine ECG with at least 12-leads, interpretation and report only (93010) moderate sedation services (99513) provided February 8, 2021.
You asked the Plan to pay for the diagnostic and sedation services. You say that that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says place of service is inappropriate for procedure and unbundled service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 93010 has a bundled relationship with the primary procedure 23650 and cannot be paid as billed. This code cannot be paid as a separate line item. procedure code 99153 describes a diagnostic procedure that is not eligible for separate reimbursement in the billed place of service 23. Procedure code 99153 has a PC/TC indicator of 3, technical component only codes. The facility is reimbursed for the technical component of this service. Based on this information, we decided that Medicare rules for coverage of the diagnostic and sedation services have not been met. Therefore, we decided that the Plan does not have to pay for electrocardiogram, routine ECG with at least 12-leads, interpretation and report only (93010) moderate sedation services (99513) provided February 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to an LTACH does not meet criteria.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found you are receiving appropriate care at the present acute care hospital. There are no services available at the LTACH that you require that are not available at the health care setting being offered by the health plan. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on April 20, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for out of network physician services provided to the enrollee on April 20, 2021.
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 5, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for out of network services provided to the enrollee on January 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on February 9, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for out of network physician services provided to the enrollee on February 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on May 3, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on May 3, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (76857) provided May 17, 2021.
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The Plan denied your request. The Plan says this CPT code shares a bundled relationship with another CPT code 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. In this case, we have confirmed that code 76857 has a Column One/Column Two relationship with code 76775 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for radiology services (76857) provided May 17, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) provided March 31, 2021.
You asked the Plan to pay for the ambulance response and treatment. You say that if the enrollee had taken the ambulance ride it would have led to additional costs at the hospital. The Plan denied your request. The Plan says the ambulance response is not covered because there was no transport.
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 March 31, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. The trip report in this case shows that the enrollee refused transport to the hospital because he said it was not necessary and thus the wavier criteria is not met. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) provided March 31, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic exercises (97110 x7), neuromuscular
reeducation (97112), gait training therapy (97116 x10), and therapeutic activities (97530) provided from May
4, 2021, to May 28, 2021 by an OON provider.
You asked the Plan to pay for the therapeutic exercises, neuromuscular reeducation, gait training therapy, and
therapeutic activities (97530). You say that [Enter appellant's argument from appeal letter, e.g. "...you need
SNF care."] The Plan denied your request. The Plan says the enrollee was not referred by a network provider
for these services. The Plan also says that these services were not authorized.
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 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 therapeutic exercises (97110 x7),
neuromuscular reeducation (97112), gait training therapy (97116 x10), and therapeutic activities (97530)
provided from May 4, 2021, to May 28, 2021 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the seat lift chair provided on April 3, 2021.
You asked the Plan to pay for the seat lift chair. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says they paid for the seat lift mechanism you received; however, the chair to house a seat lift mechanism is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pay for the seat lift chair provided on April 3, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a SNF stay provided from March 20, 2021, to March 30, 2021.
You asked the Plan to waive the copayment for a SNF stay. You say that you were only inpatient for three days and disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $20 copayment for days 1-20 and a $0 copayment for days 21-100 for SNF care. The medical records show that you had a SNF stay from March 20, 2021, to March 30, 2021. Therefore, you
are responsible to pay a $20 copayment for days 1-10 (March 20, 2021, to March 29, 2021). The total amount you owe is: $20 (copayment) x 10 (SNF days) = $200. You have been asked to pay the total copayment amount of $200 for a SNF stay. A SNF stay falls within the SNF care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a SNF stay provided from March 20, 2021, to March 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extractions, erupted tooth requiring removal of bone
and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210), intraoral -
periapical first radiographic image (D0220), bitewing - single radiographic image (D0270), and limited oral
evaluation - problem focused (D0140) provided June 23, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the tooth extractions, intraoral x-rays, bitewing x-rays and limited oral exam.
You say that you needed an emergency extraction, and it should be covered. The Plan denied your request. The
Plan says these services are not covered when provided OON.
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 tooth
extractions, intraoral x-rays, bitewing x-rays and limited oral exam when the services are rendered by a dentist
in the Plan's dental vendor network.
We looked at the file and Medicare rules. The requested provider in this case is not a network provider with the
Plan. Based on this information, we decided that the Plan's rules for coverage of the tooth extractions, intraoral
x-rays, bitewing x-rays and limited oral exam have not been met. Therefore, we decided that the Plan does not
have to pay for the extractions, erupted tooth requiring removal of bone and/or sectioning of tooth and
including elevation of mucoperiosteal flap if indicated (D7210), intraoral - periapical first radiographic image
(D0220), bitewing - single radiographic image (D0270), and limited oral evaluation - problem focused (D0140)
provided June 23, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a health club membership (S9970) for the 2020 benefit allowance.
You asked the Plan to reimburse you for a health club membership. You say that you did not know there was a deadline. You also say you would like this reimbursement honored because this is part of your Plan coverage. The Plan denied your request. The Plan says your reimbursement request was received after the March 31st deadline.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan contract says reimbursement requests must be received by the Plan no later than March 31st of the following year.
The Plan's rules for coverage of gym benefits have not been met because your reimbursement request was received May 3, 2021. The EOC confirms that reimbursement requests must be received by the Plan no later than March 31st of the following year. Therefore, we decided that the Plan does not have to reimburse you for a health club membership (S9970) for the 2020 benefit allowance.
Appeal type: Testing
Decision: Unfavorable

November 6, 2020.
You asked the Plan to waive the copayment for an EGD. You say that the procedure was done during a colonoscopy and you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $400 copayment for outpatient surgery, including services provided at hospital outpatient facilities. You received an EGD at an outpatient hospital facility on November 5, 2020. An EGD is considered an
outpatient surgical procedure. Therefore, you are responsible to pay the $400 copayment. You have been asked to pay a $400 copayment for an EGD. An EGD 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 waive the copayment for an EGD provided from November 5, 2020, to November 6, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the nuclear stress test and the Regadenoson injection you received on March 25, 2021.
You asked the Plan to waive the cost sharing for the nuclear stress test and Regadenoson injection. You say that you do not believe this procedure needed to be done, so you don't think you should have to pay the cost sharing. The Plan denied your request. The Plan says you were charged this cost sharing correctly. Please note that the Plan is handling your appeal request regarding procedure code A9502 in a separate case, so we are not addressing that issue here.
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 $125 copayment for nuclear studies and 20% coinsurance for Medicare Part B drugs.
You have been asked to pay a $125 copayment for the nuclear stress test and 20% coinsurance for the Regadenoson injection. These cost sharing amounts apply regardless of the reason for these 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 cost sharing for the nuclear stress test and the Regadenoson injection you received on March 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the prosthetic eye provided on September 24, 2020.
You asked the Plan to waive the cost share for the prosthetic eye. You say that you paid $3,000 out-of-pocket and should be reimbursed more. 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. Your contract with the Plan says that there is a $500 deductible that applies to the prosthetic eye and 20% coinsurance for to an out-of-network prosthetics provider.
The prosthetic eye you asked the Plan to waive the cost share for falls within the "Durable medical equipment (DME) and related items" benefit category an out-of-network prosthetics provider. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible that applies to the prosthetic eye and 20% coinsurance for an out-of-network prosthetics provider. See chart below.
Date of Service
Service
Allowed Amount
Deductible/Coinsurance
Member Liability
September 24, 2020
Prosthetic eye
$895.82
$500.00
$500.00
$395.82 - This is the remaining allowed amount.
20%
$79.16
Total
$579.16
This cost sharing is a contractual obligation that had not been met at the time the prosthetic eye was received on September 24, 2020. Therefore, we decided that the Plan does not have to waive the cost share for the prosthetic eye provided on September 24, 2020.
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 November 9, 2020.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The 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 out of network services provided to the enrollee on November 9, 2020.
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 November 24, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for out of network services provided to the enrollee on November 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99214) provided on February 9, 2021.
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were non-emergent and not pre-authorized. There were network providers available.
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 services 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 these services. Therefore, we decided that the Plan does not have to pay for physician services (99214) provided on February 9, 2021.