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

We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 80164, P9604 and
36415) provided to the enrollee on April 5, 2021, by an out-of-network provider.
You asked the Plan to pay for the laboratory services. You say that there was no payment on this claim, and
you would like the claim to be reprocessed and paid. The Plan denied your request. The Plan says this provider
is out-of-network, the services were not referred by a network provider, and the services were not urgent or
emergent, nor were they approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code(s): 80164, P9604 and 36415) provided to the enrollee on April 5, 2021, by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient admission and services provided on April 9, 2021 to April 15, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the inpatient care. You say that these services were medically necessary, reasonable, and appropriate. The Plan denied your request. The Plan says the enrollee was transferred from one out-of-network hospital on April 9, 2021, to another out-of-network hospital without prior authorization to receive ongoing out-of-network inpatient 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. Prior authorization rules apply for out-of-network inpatient 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 inpatient admission and services provided on April 9, 2021 to April 15, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Mohs surgery (17311) and adjacent tissue transfer or rearrangement (14061) provided on May 22, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the outpatient procedure. You say that due to the current pandemic, the enrollee was unable to obtain a referral. Please review, reconsider and reprocess based on medical necessity. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered. 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 Mohs surgery (17311) and adjacent tissue transfer or rearrangement (14061) provided on May 22, 2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting
from March 19, 2021, to March 21, 2021. You asked the Plan to pay for the self-administered drugs. You say that you did not receive most of the
medication for which you are being charged. The Plan denied your request. The Plan says the requested drug is
considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D
prescription drug plan. The Plan also says the requested drug is not covered under Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 pay for the self-administered drugs
provided in an outpatient setting from March 19, 2021, to March 21, 2021.
Benefits for the self-administered drugs 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the porcelain/ceramic crown (D2740) provided on April 20,
2021, and the periodic oral evaluation (D0120) and dental cleaning (D1110) provided on June 2, 2021.
You asked the Plan to pay for the dental services. You say that you were unhappy with the services provided
and feel you should be reimbursed for your share of the cost so that you can afford additional treatment
options. The Plan denied your request. The Plan says your dental benefit has an annual maximum allowance of
$1,000 for services. An annual maximum is the maximum dollar amount the dental plan will pay toward the
cost of covered dental care within the calendar year. After this maximum is exhausted, any remaining charges
are your responsibility. You have exhausted your annual maximum for supplemental dental care. 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 can cover a
maximum of $1,000 for supplemental dental care per year. After this maximum is exhausted, any remaining
charges are your responsibility.
Though the Plan offers a dental benefit in excess of Medicare coverage, items or services that exceed the Plan's
$1,000 annual maximum for supplemental dental care are not covered under this benefit. Therefore, we decided
that the Plan does not have to pay for the porcelain/ceramic crown (D2740) provided on April 20, 2021, and the
periodic oral evaluation (D0120) and dental cleaning (D1110) provided on June 2, 2021.
Your complaint about your dissatisfaction with the care received from a Plan-contracted provider 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 moderate sedation services (code 99156) provided on March 6, 2021.
You asked the Plan to pay for sedation. You say that you disagree with the Plan's decision and believe these codes are appropriately identified as separate services. The Plan denied your request. The Plan says the denial of payment for this service is correct, because a procedure-to-procedure (PTP) edit exists between codes 27265 and 99156 which does not allow payment of this code pair 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. In this case, we have confirmed that code sedation has a bundled relationship with code 27265 and cannot be paid as billed. This code cannot be paid as a separate line item without an appropriate modifier, which was not billed. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for moderate sedation services (code 99156) provided on March 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and
services provided from May 23, 2021, to May 26, 2021.
You asked the Plan to waive the copayment for the inpatient care. You say that you have been hospitalized in
the past and did not have to pay this copayment. The Plan denied your request. The Plan says this claim was
processed correctly, and your copayment was assessed 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 each of the first five days of an inpatient hospital admission. You have been asked to pay a $975 copayment for three days of inpatient care ($325 x 3 days = $975). This
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that
the Plan does not have to waive the copayment for the inpatient hospital admission and services provided from
May 23, 2021, to May 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for infectious agent detection (CPT code(s): 87496, 87498, 87541, 87631, 87640, 87798 and 87532) provided to the enrollee on May 6, 2021.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not covered.
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 services have not been met. Codes 87631, 87486, 87496, 87498, 87541, 87581, 87631, 87640, 87798, 87532, U0003, and U0005, were submitted for a Respiratory and COVID19 Molecular Pathogen Panel. The submitted documentation indicates more than five (5) targets. There is a more appropriate code to describe the services provided. Multiplex PCR respiratory viral panels of 6 or more pathogens are non-covered. The pathogen targets that compose the panels are determined by the manufacturers that make them, and do not represent specific pathogens that cause a common syndrome, or the organisms that commonly are found in a specific sample type or patient population or reflect seasonal variations. The fixed nature of these multiplex panels includes pathogens that cause infections different enough that simultaneous testing for these pathogens should be rare. This is not a Coronavirus test. Therefore, we
decided that the Plan does not have to pay for infectious agent detection (CPT code(s): 87496, 87498, 87541, 87631, 87640, 87798 and 87532) provided to the enrollee on May 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the mounted bracket assembly for push button access, controller graphical display, figure 8 bracket, and 9-inch extension cable all coded as K0108.
You asked the Plan to pre-approve the components for use with the expandable controller. You say that these items are medically necessary. The Plan denied your request. The Plan says the remaining denied components are all considered part of the expandable controller. No separate reimbursement is allowed for these components.
The Plan must follow Medicare rules. Medicare rules say that payment for the harness and expandable controller includes all of the wires, fuse boxes, fuses, circuits, switches, etc. that are required for the operation of an expandable controller. We looked at the file and Medicare rules. The denied items are all components which are required for the operation of the expandable controller. Based on this information, we decided that Medicare rules for coverage of the components for use with the expandable controller have not been met. Therefore, we decided that the Plan does not have to pre-approve the mounted bracket assembly for push button access, controller graphical display, figure 8 bracket, and 9-inch extension cable all coded as K0108.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on April 21,
2021.
You asked the Plan to pay for the limited evaluation. You say that these services are necessary, and you cannot
afford them. You feel the frequency limit should be bypassed. The Plan denied your request. The Plan says you
had a previous limited oral evaluation on April 9, 2021, which was paid for by the Plan. Only one limited oral
evaluation is covered per plan year. Therefore, the requested exam exceeds the Plan's frequency limitation for
this service and will not be 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. The Plan can cover one
limited exam to evaluate a problem (D0140) per plan year. Though the Plan offers a dental benefit in excess of Medicare coverage, the limited exam is requested in a
frequency that exceeds what is covered under this benefit. Documentation shows that the Plan has already
covered one limited exam within the current plan year. Therefore, we decided that the Plan does not have to
pay for the limited oral evaluation (D0140) provided on April 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgical procedure provided on November 4, 2020.
You asked the Plan to waive the copayment for the outpatient surgical procedure. You say that that you have never had to pay for this procedure in the past. The Plan denied your request. The Plan says that the claim processed 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 $250 copayment for each Medicare-covered outpatient hospital or ambulatory surgical center visit. You have been asked to pay a $250 copayment for the outpatient surgical procedure. The outpatient surgical procedure falls within the Medicare-covered outpatient hospital or ambulatory surgical center visit 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 the outpatient surgical procedure provided on November 4, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the private transportation services provided from February
10, 2021, to February 23, 2021.
You asked the Plan to pay for the private transportation services. You say that you had to pay out of pocket for
someone to take you to your procedures. The Plan denied your request. The Plan says there is no evidence of
receipts for the services received and the provider used for these services is non-contracted.
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is
due and the amount of payment.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the private transportation services have not been met. Without receipts showing how much money
was paid, it cannot be determined if payment is due. Therefore, we decided that the Plan does not have to pay
for the private transportation services provided from February 10, 2021, to February 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network orthopedic doctor.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there are in-network providers available and accepting new patients.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network orthopedic doctor.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care (99232) and hospital discharge
day management (99239) provided on November 13, 2020, and November 14, 2020.
You asked the Plan to pay for the subsequent hospital care and hospital discharge day management. You say
that you had billed hospice and the claim was denied stating the enrollee was not enrolled at the time of service.
The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all
Medicare covered services related or unrelated to the enrollee's terminal condition. Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Original Medicare is responsible for payment for services until the first day of the month after the
hospice election has been revoked or terminated.
The enrollee ended Medicare Hospice benefits on November 3, 2020. The services in question were provided
before the end of that month. Therefore, we decided that the Plan does not have to pay for the subsequent
hospital care (99232) and hospital discharge day management (99239) provided on November 13, 2020, and
November 14, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. 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 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 documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of the enrollee's condition. 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 skilled nursing facility (SNF) care.
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 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 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 IRF admission is not medically necessary based on lack of medical complexity, skilled rehabilitation nursing or therapy needs. The enrollee's therapy needs can be addressed at a lower
intensity and alternate 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 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a retainer crown (D6750) and pontic (D6240).
You asked the Plan to pre-approve a retainer crown, and pontic. You say that you want the Plan to cover the
services. The Plan denied your request. The Plan says the services at issue are not covered benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a
retainer crown (D6750) and pontic (D6240).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes (CPT code 99291) provided to the enrollee on March 24, 2021.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records. 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 code 99291 is not supported in the medical record. Specifically, the documentation submitted did not support a critical care visit of 30-74 minutes was performed on the billed date of service. The documentation does not include the time spent providing this service; therefore, the billed Critical Care Evaluation and Management code cannot be verified. 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 pay for critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes (CPT code 99291) provided to the enrollee on March 24, 2021.