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

We decided that the Plan does not have to pay for the telehealth office visit (99214) provided on January 7, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the telehealth visit. You say that please review the information and reconsider the claim. 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 the telehealth office visit (99214) provided on January 7, 2021 by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the endoscopy services coded 33508 provided on January 5, 2021.
You asked the Plan to pay for the endoscopy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately 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. In this case, we have confirmed that code 33508 for the endoscopy services has a bundled relationship with code 33534 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 the endoscopy services coded 33508 provided on January 5, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room services provided on
June 4, 2021.
You asked the Plan to waive the copayment for the emergency room services. You say that you do not believe
you should be charged for a copayment. The Plan denied your request. The Plan says the copayment has
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 $90
copayment for Medicare-covered emergency room visits.
You have been asked to pay a $90 copayment for the emergency room services. These services fall within the
Medicare-covered emergency room visits 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 emergency room services provided on June 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on March 2, 2021 by an out-
of-network (OON) provider. 
 
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 rendered 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 laboratory services provided on March 2, 2021 
by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary for more physical 
therapy to prevent a decline in mobility. The Plan denied your request. The Plan says the records do not support 
a need for daily therapy on an inpatient basis. 

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 the admission. Our reviewer says that 
the requested admission is not medically reasonable or necessary. Our physician reviewer found there are no 
identifiable skilled nursing service or skilled therapy service needs. You do not require skilled nursing or 
therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an 
inpatient basis in a skilled nursing facility 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 the admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), prophylaxis (D1110) and 
a bitewing x-ray (D0274) provided on April 6, 2021. 
 
You asked the Plan to pay for a periodic oral evaluation, prophylaxis and a bitewing x-ray. You say that you 
are requesting reconsideration for the denied claim. The Plan denied your request. The Plan says the requested 
provider has opted out of Medicare. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a periodic 
oral evaluation, prophylaxis and a bitewing x-ray when the services are medically necessary and reasonable.

We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a periodic oral evaluation, prophylaxis and a bitewing x-ray have not been met. We have 
confirmed that the provider opted out of Medicare on December 7, 2015. This means that the provider was 
opted out of Medicare for the date of service at issue. Therefore, we decided that the Plan does not have to pay 
for a periodic oral evaluation (D0120), prophylaxis (D1110) and a bitewing x-ray (D0274) provided on April 6, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on December 5, 2020, by an OON
provider.
You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the services rendered 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 must 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 provided on December 5, 2020, by
an OON provider
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (87486, 87496, 87498, 87541, 87581,
87631, 87640, 87798, U0003, U0005) provided on January 14, 2021.
You asked the Plan to pay for laboratory services. You say that this is supported by the records. The Plan
denied your request. The Plan says this must be billed through the skilled nursing facility.
The Plan must follow Medicare rules. Medicare rules say that a skilled nursing facility (SNF) must submit all
Medicare claims for all the services that its residents receive under Part A, except for certain excluded services.
We looked at the file and Medicare rules. The records show that the enrollee was an SNF resident at the time of
service, meaning this must be billed through the SNF. Based on this information, we decided that Medicare
rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have
to pay for laboratory services (87486, 87496, 87498, 87541, 87581, 87631, 87640, 87798, U0003, U0005)
provided on January 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for bone length studies (orthoroentgenogram, scanogram) (CPT code 77073-26-LT), the x-ray of ankle (CPT code 73610-26-LT and RT X 2), and the x-ray of foot (CPT code 73630-26-LT and RT X 2) provided to the enrollee on May 24, 2021.
You asked the Plan to pay for the services. You say that the enrollee had multiple exams on this date of service. The Plan denied your request. The Plan says these services were previously paid for the same date of service. The Plan states the reports submitted are duplicates of each other.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Review of the file shows that one (1) unit of each CPT code(s): 77073-26-LT, 73610-26-LT and RT X 2, and 73630-26-LT and RT X 2, which were previously paid. There is no additional documentation supporting additional studies which were billed and remain denied. 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 bone length studies (orthoroentgenogram, scanogram) (CPT code 77073-26-LT), the x-ray of ankle (CPT code 73610-26-LT and RT X 2), and the x-ray of foot (CPT code 73630-26-LT and RT X 2) provided to the enrollee on May 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from
March 31, 2021, through April 2, 2021.
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient admission was medically necessary. The Plan denied your request. The Plan says the inpatient admission was not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee is a 63-year-old female with end stage renal disease who presented to the hospital with a thrombosed fistula. Examination did not clearly show decreased perfusion to the affected arm, but her blood pressure was 99/75. Urinalysis positive for LE. It was noted that hypotension (orthostatic) was a chronic issue for the enrollee. She was treated with Florinef and midodrine, which she was taking chronically. The enrollee was admitted to inpatient status. The enrollee was treated for a urinary tract infection and underwent thrombectomy without complication and dialysis without complication. The enrollee's vitals remained stable throughout the stay. No signs of sepsis were noted. Based on the clinical stability of the enrollee, at baseline for her chronic issues, tolerating thrombectomy without issue, and tolerating initial treatment overall, it was not expected that the enrollee would require hospital services that would likely cross
2 midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from March 31, 2021, through
April 2, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90792) provided on March 25, 2021, by a provider who has opted out of the Medicare program.
You asked the Plan to pay for psychotherapy services. You say that finding an in-network provider in your area proved impossible and that it makes no sense to have any barriers to accessing competent, targeted medical professionals to meet member needs. The Plan denied your request. The Plan says rules for payment have not been met because the provider at issue has opted out of 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 psychotherapy services (90792) provided on March 25, 2021, by a provider who has opted out of the Medicare program.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an anesthetic injection (64421) provided on January 21, 
2021. 
 
You asked the Plan to pay for an anesthetic injection. You say that this was a distinct procedure and should be 
paid. The Plan denied your request. The Plan says this was not billed with an appropriate primary procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. An add-on code is eligible for payment only if it 
is reported with an appropriate primary procedure performed by the same practitioner. 
 
In this case, the CPT Code Manual definition of code 64421 is injection(s), anesthetic agent(s) and/or steroid; 
intercostal nerve, each additional level (List separately in addition to code for primary procedure). 
 
We find that CPT code 64421 is not supported in the medical record. Specifically, this is an add-on code that 
was not billed with a primary procedure. Based on this information, we decided that Medicare rules for 
coverage of an anesthetic injection have not been met. Therefore, we decided that the Plan does not have to pay 
for an anesthetic injection (64421) provided on January 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reprocess the copayment for the medical eye exam and diagnostic imaging services (92014, 92134) provided on June 4, 2021.
You asked the Plan to reprocess the copayment for the medical eye exam and diagnostic imaging services. You say that you were under the impression you would be charged a lower copayment. The Plan denied your request. The Plan says the copayment has processed correctly in this case.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for Medicare-covered eye exam services. You have been asked to pay a $40 copayment for the medical eye exam and diagnostic imaging services. These
services fall within the Medicare-covered eye exam services 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 reprocess the copayment for the medical eye exam and diagnostic imaging services (92014, 92134) provided on June 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
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 the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for rhabdomyolysis and hypocalcemia. Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for observation discharge services (99217) provided May 13, 2021.
You asked the Plan to pay for the observation discharge services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.
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 99217 is not supported in the medical record. Specifically, the records do not show any initial or subsequent observation codes billed for the dates of service at issue. Based on this information, we decided that Medicare rules for coverage of the observation discharge services have not been met. Therefore, we decided that the Plan does not have to pay for observation discharge services (99217) provided May 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam provided on June 25, 2021.
You asked the Plan to waive the copayment for the eye exam. You say that you were advised eye exams are covered 100% every year. You say that the same tests are done every year and he did not tell you a medical exam was done. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment per Medicare-covered eye exam from a network provider.
You have been asked to pay a $40 copayment for the eye exam. The eye exam falls within the "Vision care" benefit category. The records show a medical eye exam was performed. 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 eye exam provided on June 25, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on April 1, 2021. 
 
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 billed are not a covered benefit. 
 
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 laboratory services at issue in this appeal were 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 the 
laboratory services provided on April 1, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
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 there is no documentation that the patient requires skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and effectively provide medically necessary and reasonable treatment. This patient does require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified therapist are required to safely and effectively provide medically necessary and reasonable treatment. Daily skilled services are not required. This patient does not require the services on an inpatient basis, only in a SNF setting. Services in a long-term care facility on a part time basis appear appropriate in this case. 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 SNF care.