Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent observation care and observation care
discharge day management provided on March 1, 2021, and March 2, 2021 by an OON provider.
You asked the Plan to pay for the subsequent observation care and observation care discharge day
management. You say that the enrollee was seen through the emergency room and evaluated by the physician
for medically necessary reasons. The Plan denied your request. The Plan says the services were rendered by a
non-participating provider, and the enrollee was not referred by a network provider. The Plan also says that the
services were not 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 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 subsequent observation care and observation
care discharge day management provided on March 1, 2021, and March 2, 2021 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services represented by codes 99152 and 99153 provided on October 1, 2020.
You asked the Plan to pay for codes 99152 and 99153. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the codes are not covered.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99152 is Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older.
The definition of code 99153 is Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List separately in addition to code for primary service). We find that CPT codes 99152 and 99153 are not supported in the medical record. Specifically, there is no documentation of an independent trained observer to assist in monitoring the patient's consciousness and physiological status for the first 15 minutes and an additional 15 minutes. Based on this information, we decided that Medicare rules for coverage of codes 99152 and 99153 have not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services represented by codes 99152 and 99153 provided on October 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on January 10, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for office visit. You say that the enrollee chose to visit a local immediate care center instead of an emergency room. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was not obtained.
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 an office visit provided on January 10, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to provide additional reimbursement for the chiropractic care (98941 and 97763), orthotic (L3002) and medical supplies (99070) provided on April 5, 2021, through May 1, 2021.
You asked the Plan to provide additional reimbursement for the chiropractic care, orthotic and medical supplies.. You say that you would like reconsideration because you should be reimbursed for 70% of the charges. The Plan denied your request. The Plan says the amount that you have been reimbursed is correct.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.
The rules also say that a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information. A 30% coinsurance has been applied to the covered chiropractic services. The allowed amount for the covered chiropractic services is $96.53. 96.53x0.3 = 28.99. The coinsurance applied is correct. The orthotic and medical supplies are not manual manipulation of the spine and are not covered services under Medicare or the Plan. You are responsible for the payment of these supplies. We looked at your request, the file and rules. Based on this information we decided that the correct reimbursement has been assessed. Therefore, we decided that the Plan does not have to provide additional reimbursement for the chiropractic care (98941 and 97763), orthotic (L3002) and medical supplies (99070) provided on April 5, 2021, through May 1, 2021.
Appeal type: Testing
Decision: Partially Favorable

We decided that the Plan has to reduce the cost-sharing charges for a colonoscopy. We decided that the Plan does not have to reduce the cost-sharing charges for a colonoscopy.
You asked the Plan to reduce the cost-sharing charges for a colonoscopy. You say that this was a colonoscopy screening and you should not owe anything. The Plan says that the claims were processed correctly and you are being charged the correct amount.
We decided that the Plan has to reduce the cost-sharing charges for a colonoscopy from $309.46 to $295.
Your contract with the Plan says that you must pay a $295 copayment for outpatient surgery, including services provided at ambulatory surgical centers. The Plan says that you must pay $309.46 for a diagnostic colonoscopy. However, you cannot be asked to pay more than the $295 copayment for a colonoscopy provided in an ambulatory surgical center. Therefore, we decided that the Plan has to reduce the cost-sharing charges for a colonoscopy from $309.46 to $295.
We also decided that the Plan does not have to reduce the cost-sharing charges for a colonoscopy to the amount you requested.
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 $295 copayment for a colonoscopy provided in an ambulatory surgical center. The medical records show that you had polyps removed during a colonoscopy provided on June 24, 2021. This means that the colonoscopy is considered diagnostic, not preventative. Therefore, we decided that the Plan does not have to waive the $295 copayment for a colonoscopy.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on March 22, 2021.
You asked the Plan to pay for the physical therapy services. You say that the claim was denied incorrectly without appropriate review of the medical records. You say that the records should be reviewed, and the claim processed toward necessary payment. The Plan denied your request. The Plan says the records do not support the service billed.
The Plan must follow Medicare rules. Medicare rules say that the services of a PTA shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the physical therapy services have not been met. Specifically, the billing provider is a nurse practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on March 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on March 3, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for lab test. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this provider is out-of-network with the Plan and the ordering physician is also out-of-network with the Plan.
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 laboratory testing provided on March 3, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for hereditary cardiovascular screening testing provided on
January 22, 2021.
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan
denied your request. The Plan says this testing is not covered for screening purposes.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.
The test at issue in this appeal, genetic testing, was requested for screening purposes. Medicare does not cover
this test for screening purposes. Therefore, we decided that the Plan does not have to pay for hereditary
cardiovascular screening testing provided on January 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on January 29,
2021.
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 the records do not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT code 80307 and Healthcare Common Procedure Coding System (HCPCS) G0483 is not
supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the
location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a
laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). 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 drug testing services provided to the enrollee on January 29,
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental cleaning (D1110) and periodic oral exam (D0120) provided on June 15, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the OON dental care. You say that you know this provider is out-of-network, but in the past, you were able to be reimbursed for 50% of the cost. The Plan denied your request. The Plan says out-of-network dental care is not covered by your Plan in 2021.
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. Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage.
Though the Plan offers a dental benefit in excess of Medicare coverage, items and services received from out-of-network providers are not covered under this benefit. 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. 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 dental cleaning (D1110) and periodic oral exam (D0120) provided on June 15, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on March 3, 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 are not payable as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.
We find that CPT codes 81238, 81404, 81405, 81407, 81408, 81411, and 81439 are not supported in the medical record. Specifically, the documentation does not include a written order from the ordering physician. All diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating the enrollee, that is, the physician who furnishes a consultation or treats an enrollee for a specific medical problem and who uses the results in the management of the enrollee's specific medical problem. Tests not ordered by the physician who is treating the enrollee are not reasonable and necessary. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on March 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for individual psychotherapy services, 45 minutes duration (90834) provided on April 5, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the psychotherapy services. You say that this provider is out of network and you need an approved referral. 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 individual psychotherapy services, 45 minutes duration (90834) provided on April 5, 2021 by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on May 20, 2021.
You asked the Plan to waive the copayment for the ER visit. You say that you did not go to the hospital on this date of service. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that the allowed amount for this service ($64.03) is less than your copayment obligation, so you are responsible for the full allowed amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copayment for emergency room visits. You have been asked to pay a $90 copayment for the ER visit. The facility confirmed that you were seen on
this date and triaged by the hospital staff, but that you left before being seen by a physician. This copayment applies regardless of the extent of services you receive in the ER. 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 (ER) visit you had on May 20, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided from January 15,
2021, through January 29, 2021.
You asked the Plan to waive the copayment for physical therapy. You say that this is a participating provider
and accepts payment from the Plan as fully paid. The Plan denied your request. The Plan says the claims
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 $35
copayment for each therapy visit.
The Evidence of Coverage says that you pay a $35 copayment for each therapy visit. Please note, you are only
being billed $78.92, which is less than the standard cost share. Contact the Plan or provider to verify the total
remaining amount owed.
Physical therapy falls within the "Outpatient rehabilitation 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 waive the copayment for physical therapy provided from January 15, 2021, through January 29, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for cerebrospinal fluid flow imaging provided on April 2, 2021.
You asked the Plan to waive the copayment for cerebrospinal fluid flow imaging. You say that you were told that you would not owe a copayment. 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 $110 copayment for radiological diagnostic services. You have been asked to pay a $110 copayment for cerebrospinal fluid flow imaging. Cerebrospinal fluid flow imaging falls within the outpatient diagnostic tests and therapeutic services and supplies 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 cerebrospinal fluid flow imaging provided on April 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the lesion destruction procedure you had at an outpatient hospital facility on April 30, 2021.
You asked the Plan to waive the copayment for the lesion destruction procedure. You say that you don't agree with the charges for the treatment room because you had other 'treatment room" charges on your invoice that were much less. The Plan denied your request. The Plan says you were charged this copayment 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 $270 copayment for outpatient hospital surgery. You have been asked to pay a $270 copayment for the lesion destruction procedure. This copayment applies even if you received other services on different dates that may have been charged a different rate. 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 lesion destruction procedure you had at an outpatient hospital facility on April 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the special anesthesia (99100) and emergency anesthesia (99140) provided on January 24, 2021.
You asked the Plan to pay for the anesthesia services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT codes 99140 and 99100 have a status indicator of 'B' on the CMS Physician Relative Value File and are always bundled into payment for other services not specified and no separate payment is made.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes 99140 and 99100 are not supported in the medical record. Specifically, per the Fee Schedule, CPT codes 99140 and 99100 have a status indicator of B. This means that these codes are always bundled into another service and no separate payment is made. Based on this information, we decided that
Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the special anesthesia (99100) and emergency anesthesia (99140) provided on January 24, 2021