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

 
We decided that the Plan does not have to pay for the laboratory services (80307) provided on  
January 13, 2021, by an out-of-network (OON) provider. 
You asked the Plan to pay for code 80307 provided by an OON provider. You say that you would like the Plan 
to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were 
neither emergent nor urgent and prior authorization was not obtained to provide 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 the laboratory services (80307) provided on 
January 13, 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 the arthrocentesis (20610) provided on May 25, 2021. 
 You asked the Plan to pay for the arthrocentesis. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says this claim has not been billed correctly. 
 
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 there is insufficient 
information in the record to determine if Medicare rules for coverage of the arthrocentesis (20610) provided on 
May 25, 2021. have been met. Specifically, the documentation submitted does not include any medical records. 
Without medical records we are unable to confirm how many units of CPT code were provided on the billed 
date of service. Therefore, we decided that the Plan does not have to pay for the arthrocentesis (20610) 
provided on May 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the computerized knee/foot (CPT code L5828, L5845, 
L5848, L5850, and L5856). 
 
You asked the Plan to pre-approve the items. You say that the items are necessary. The Plan denied your 
request. The Plan says the leg prosthesis will be covered except for the computerized knee because the 
computerized knee exceeds the enrollee's medical need. The Plan states there are other knees that can meet the 
enrollee's needs. 
 
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 items. Our physician reviewer 
found a leg prosthesis with computerized knee/foot was requested, but only the prosthesis without the 
computerized knee/foot was approved. The records do not support that the enrollee requires the computerized 
knee/foot and the treating physician did not explain why a prosthesis without computerization would not be 
appropriate or effective for this enrollee's needs. The enrollee appears to be more appropriate for a K3 
mechanical knee prosthesis due to the recent activity and examination notes and history of vascular disease. 
 
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 items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the computerized knee/foot (CPT code L5828, L5845, L5848, L5850, and L5856).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), complete series of intraoral x-rays (D0210), and prophylaxis (D1110) provided on April 1, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the periodic oral evaluation, complete series of intraoral x-rays, and prophylaxis. You say that you were advised by your dentist office that this visit was going to be 100% covered with your insurance. You also say that you cannot afford to pay the $120 you owe the dentist office at this time, due to them telling you that you would be covered 100%. The Plan denied your request. The Plan says services performed by an OON provider are not covered because your healthcare plan does not have OON benefits. The Plan also says that you did not contact the Plan prior to the date of service to verify benefits and provider eligibility.
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, you are responsible for 100% of the cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120), complete series of intraoral x-rays (D0210), and prophylaxis (D1110) provided on April 1, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from February 16, 2020, to February 20, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says upon appeal, medical records were not provided after multiple attempts to obtain.
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 there is insufficient information in the record to determine if Medicare rules for coverage of inpatient hospital services provided to the enrollee from February 16, 2020, to February 20, 2020. have been met. Despite multiple attempts, the provider did not send any valid medical records to support the DRG that was billed in this case.. Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from February 16, 2020, to February 20, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Mass spectrometry and tandem mass spectrometry 
(83789-59) provided on June 30, 2021. 
 
You asked the Plan to pay for code 83789-59. You say that the medical records support the use of modifier 59 
with the billing of code 83789. The Plan denied your request. The Plan says the medical records do not support 
the use of modifier 59 with the billing of code 83789. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   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 pay for code 83789-59. Our reviewer says that the medical records do not support the use of modifier 59 with the billing of code 83789. Our physician reviewer found code 83789 received from National Labs, INC on June 30, 2021, remains denied. The review has 
determined that the medical records did not support the use of modifier 59 with the billing of code 83789. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 83789-59 have not been met. Therefore, we decided that the Plan does not 
have to pay for the Mass spectrometry and tandem mass spectrometry (83789-59) provided on June 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for additional units of codes 74176 and 73700 provided on July 29, 2021.
You asked the Plan to pay for the additional units. The Plan denied your request. The Plan says only one unit of each code is 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. We find that additional units of CPT codes 74176 and 73700 are not supported in the medical record. Specifically, the records show that only one unit of code 74176 and one unit of code 73700 were provided on the date of service in question. These services were previously processed and paid by the Plan. The additional billed units are not supported. Based on this information, we decided that Medicare rules for coverage of the additional units have not been met. Therefore, we decided that the Plan does not have to pay for additional units of codes 74176 and 73700 provided on July 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) of the abdomen 
(74181) provided on October 7, 2021. 
 You asked the Plan to pay for the MRI of the abdomen. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says an edit exists between CPT codes 74181 
and 74183. 
 
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 74181 
is a column II code to column I code 74183. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) of the abdomen (74181) 
provided on October 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental exam (CPT code D0150) and the dental 
extraction (CPT code D7210) to be provided by an oral surgeon. 
 
You asked the Plan to pre-approve the dental services. You say that the Plan should at least pay for partial of 
the extraction. The Plan denied your request. The Plan says the services are not a covered benefit under the 
plan when performed by an oral surgeon. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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. Your 2022 EOC says that services must be performed by a participating general dentist. You 
are requesting an oral surgeon, which not a general dentist. Therefore, we decided that the Plan does not have 
to pre-approve the dental exam (CPT code D0150) and the dental extraction (CPT code D7210) to be provided 
by an oral surgeon.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health physical therapy visits (CPT code G0151 x3).
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the services are not necessary. The Plan states the approved visit(s) should be enough to complete the enrollee's goals, teach them a home exercise program, and establish a safe discharge plan. The Plan states after this, it is not likely that more home physical therapy visits will be medically necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our physician reviewer found the enrollee appears to have improved with therapy. As of February 1, 2022, the enrollee was walking 500 feet with a walker with stand-by assistance and was independent/modified independent with transfers with no reported pain. Further skilled therapy at this point does not appear necessary to improve their symptoms or functional status. Further utilization of the home exercise program appears appropriate at this point. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health physical therapy visits (CPT code G0151 x3).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fluoride (D9630), prophylaxis (D1110), and periodic oral 
evaluation (D0120), provided on August 26, 2021. 
 
You asked the Plan to pay for the routine dental services. You say that the service is medically necessary. The 
Plan denied your request. The Plan says you received care from 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 Plans 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 
fluoride (D9630), prophylaxis (D1110), and periodic oral evaluation (D0120), provided on August 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the duplex scan of extremity veins including responses to compression and other maneuvers (93971) provided January 10, 2021.
You asked the Plan to pay for the duplex scan. You say that per Medicare, the enrollee was not covered under hospice on the date of service. Please review and process the claim for payment. 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 member's terminal condition until the first day of the month following the month in which hospice was revoked or discharged.
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 January 9, 2021. 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 duplex scan of extremity veins including responses to compression and other maneuvers (93971) provided January 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the simple extraction (D7140) provided on February 23, 
2021 by a Medicare opt out provider. 
 
You asked the Plan to pay for the extraction. You say that no one informed you that the treating provider had 
opted out of Medicare. You also say that if they had told you the treating provider no longer accepted 
Medicare, you would not have used his service. The Plan denied your request. The Plan says you received this 
service from a provider who chose not to receive Medicare funds. The Plan also says that they contacted the 
provider's office and were advised that you were verbally informed that the treating provider had 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 Plans 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 
covered when they are received by a provider who has opted out of Medicare. Therefore, we decided that the 
Plan does not have to pay for the simple extraction (D7140) provided on February 23, 2021 by a Medicare opt 
out provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a home health visit provided on September 10, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for a home health visit. You say that it is the facilities responsibility to get the authorization and the service provided was medically necessary. The Plan denied your request. The Plan says the rendering provider is an out-of-network provider with no approved authorization. Also, the service provided was not urgent or emergent in nature.
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 a home health visit provided on September 10, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a medical eye exam (92012), eye photography (92285) and a visual field examination (92082) provided on October 26, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for a medical eye exam, eye photography and a visual field examination. You say that you relocated, and the services were referred by your provider. You were under the impression that since the services were referred, you would have no issues. The Plan denied your request. The Plan says you are required to get care from network providers. The Plan also says that you can get care from an OON provider only in cases involving emergencies, out of area urgent care and pre-approved care.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when it is provided by an in-network provider. We looked at the file and the Plan's rules. The records show that the services at issue were provided by an OON provider. This service is not covered by the Plan when provided by an OON. Based on this information, we decided that the Plan's rules for coverage of a medical eye exam, eye photography and a visual field examination have not been met. Therefore, we decided that the Plan does not have to pay for a medical eye exam (92012), eye photography (92285) and a visual field examination (92082) provided on October 26, 2021, by an out-of-network (OON) provider.
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 LTACH is the most appropriate level of 
care for this enrollee. The Plan denied your request. The Plan says all services that would be provided in the 
LTACH are being provided in the current acute care setting which is already approved. 
 
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 the enrollee appears to be improving but requires short-term additional acute care 
services that can safely be administered at the current facility until more stable. The enrollee does not require 
services at the LTACH that are not already available at the current facility. There are no services at the LTACH 
that the enrollee requires that are not already available and covered at the current facility. Transfer to an 
LTACH is not medically necessary as it would not be clinically advantageous. Transfer to a lower level of care 
may be considered when treatment is completed and the enrollee is more stable. 
 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from March 7, 2022, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from March 7, 2022, forward. You say that the 
services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are 
not medically necessary. 
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 care from March 
7, 2022, forward. Our reviewer says that the enrollee does not meet the criteria for acute inpatient mental health 
treatment beyond the date in question of March 7, 2022, forward. Our physician reviewer found the enrollee 
did not require inpatient mental health treatment beyond March 7, 2022, as she was not a danger to herself or 
others. She does have auditory, no visual hallucinations but realizes that she has the hallucinations. It did not 
appear that active treatment was taking place beyond the date in question. It did not appear that the services for 
the dates in question were reasonably expected or medically necessary to improve the enrollee's condition or 
for the purpose of diagnosis. 
 
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 care from March 7, 2022, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from March 7, 
2022, forward.