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

We decided that the Plan does not have to waive the copayment for imaging services provided on August 18,
2021.
You asked the Plan to waive the copayment for the imaging services. You say that because of your situation
you should not be charged a copayment every time for this service. The Plan denied your request. The Plan
says the proper copayment was applied for the service.
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 basic imaging service.
You have been asked to pay a $35 copayment for the imaging services. The imaging services 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 imaging services provided on August 18, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the GeneSight test provided to the enrollee on July 2, 2021.

You asked the Plan to pay for the testing. You say that this should be covered, as it is covered by Medicare.
The Plan denied your request. The Plan says this is not a covered test, as it is not considered medically
necessary, appropriate, useful or approvable.

The Plan must follow Medicare rules. Medicare rules say that the current evidence does not support the use of
GeneSight testing.

Medicare does not currently consider the denied testing to be reasonable or necessary. Based on this
information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we
decided that the Plan does not have to pay for the GeneSight test provided to the enrollee on July 2, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tempus Gene panel rendered on August 10, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services were not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that molecular pathology is covered when specific
criteria are met.
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 these services. Our reviewer says that the
services were not medically necessary. Our physician reviewer found the enrollee has a diagnosis of metastatic
chondrosarcoma to the lungs, T7, and the right iliac wing. The case file does not contain information that
supports that the requested testing would directly impact the treatment or management of the enrollee in this
case. Additionally, the testing would be covered only for the number of genes that are reasonable and necessary
to obtain the necessary information for therapeutic decision making; this has not been established.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pay for the Tempus Gene panel rendered on August 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that the care the enrollee requires is routinely managed at the LTACH level of care. The Plan denied your request. The Plan says that the member is receiving appropriate in-patient acute care and does not require transfer to an LTACH.

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. The patient appears to be more stable and improving overall and requires only short-term additional acute care services that can be safely administered at the current facility. The patient 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 patient requires that are not already available and covered at the current facility. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services.

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 for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998)
provided on August 8, 2021.
You asked the Plan to pay for ambulance response and treatment, no transport. You say that the ambulance
treated you successfully in your home and after 60 years of life as a Type 1 diabetes and you felt a trip to the
hospital was not needed. The Plan denied your request. The Plan says original Medicare doesn't cover
ambulance services if you're not transported. This means that we won't pay for ambulance services, including
treatment performed, if one is dispatched for you and you're not transported.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.
The ambulance company did not provide transport services on August 8, 2021. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport
(A0998) provided on August 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit coded 99213 provided on April 16, 2021.

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 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. 

In this case, the CPT Code Manual definition of code 99213 is office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter.

We find that CPT code 99213 is not supported in the medical record. Specifically, two evaluation and management services were reported by the same provider on the same date of service. This code was previously billed and paid by the Plan. No additional documentation was provided to support that more than one office visit was provided. Based on this information, we decided that Medicare rules for coverage of the office visit have not been met. Therefore, we decided that the Plan does not have to pay for the office visit coded 99213 provided on April 16, 2021.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for progressive lens, per lens (V2781) and tint, photochromatic, per lens (V2744) provided on September 3, 2021.

You asked the Plan to pay for progressive lens, per lens (V2781) and tint, photochromatic, per lens (V2744). The Plan denied your request. The Plan says eyeglasses are a covered benefit, however, upgrades are not covered.

Medicare covers one pair of conventional eyeglasses or contact lenses furnished after each cataract surgery with insertion of an intraocular lens implant. The Plan contract says covered eyeglasses after cataract surgery includes standard frames and lenses as defined by Medicare; any upgrades are not covered (including but not limited to deluxe frames, tinting, progressive lenses or anti reflective coating). 

We looked at the file, the Medicare rules and the Plan's rules. Medicare says that one pair of conventional eyeglasses or contact lenses furnished after each cataract surgery with insertion of an intraocular lens implant. The Plan covers eyeglasses after cataract surgery that includes standard frames and lenses as defined by Medicare; any upgrades are not covered (including but not limited to deluxe frames, tinting, progressive lenses or anti reflective coating). Therefore, we decided that the Plan does not have to pay for progressive lens, per lens (V2781) and tint, photochromatic, per lens (V2744) provided on September 3, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for continuation of SNF services provided from
February 5, 2021, through February 20, 2021.
You asked the Plan to pay for continuation of SNF services. The Plan denied your request. The Plan says
continuation of SNF services was 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 pay for continuation of SNF services. Our reviewer
says that daily skilled services are not medically necessary. Our physician reviewer found based on the medical
records provided there is no documentation that the enrollee required skilled nursing services, i.e., the
specialized skill, knowledge and judgment of a skilled professional nurse were not required to safely and
effectively provide medically necessary and reasonable treatment. The enrollee did require skilled therapy
services, i.e., the specialized skill, knowledge and judgment of a qualified therapist were required to safely and
effectively provide medically necessary and reasonable treatment. Daily skilled services were not required. As
a practical matter, the enrollee did not require the services on an inpatient basis, only in a skilled nursing
facility setting. The enrollee's needs in the nursing facility appeared to be custodial with a need for part time
skilled physical and occupational therapy.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of continuation of SNF services have not been met. Therefore, we decided that the
Plan does not have to pay for continuation of SNF services provided from February 5, 2021, through
February 20, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 5, 2021.
You asked the Plan to pay for physician's services. You say that the date of service is after the termination of
the patient's hospice period; therefore, the Plan is responsible for the payment of the claim. 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. The Medicare hospice benefit, through fee-
for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or
revocation. During the election, fee-for-service Medicare also covers attending physician services and all care
unrelated to the terminal illness 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 September 3, 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 physician's services
provided on September 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on March 8, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services are not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of
service (POS) code.
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory
services rendered on March 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician certification services rendered on July 23, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not separately payable.

The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. 

The provider submitted a claim for procedure codes G0180 (physician or allowed practitioner certification for Medicare-covered home health services) and 99336 (domiciliary or rest home visit). Code G0180 is a column II code with a modifier indicator of 1 when billed with column I code 99336. Code G0180 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the physician certification services rendered on July 23, 2021.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation and to waive the coinsurance for
the extractions received on September 24, 2021.
You asked the Plan to pay for the limited oral evaluation and to waive the coinsurance for the extractions. You
say that you were assured that the entire bill would be paid without your responsibility. The Plan denied your
request. The Plan says the claim has been processed correctly per your plan 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. 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 50% coinsurance for dental
extractions.
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. Review of the file shows that you previously received a limited oral
evaluation on August 2, 2021. This service is only covered once per plan year. One plan year had not passed
since you previously received this service. You have been asked to pay 50% coinsurance for dental extractions.
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 pay for the limited oral evaluation and to waive the coinsurance for the extractions
received on September 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the various services received between
February 5, 2021, and April 12, 2021.
You asked the Plan to waive the copayment for the services. You say that you should not have to pay these, as
you have been on a no cost-share plan as of September 1, 2021. The Plan denied your request. The Plan says
the claims were processed appropriately.
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 specialist office visits.
You have been asked to pay a $40 copayment for the services received on February 5, 2021. These services fall
within the specialist office visits benefit category. This means that you have been asked to pay the correct
amount based on your contract with the Plan.
You have been asked to pay a $10 copayment for the services received on March 17, 2021. These services fall
within the primary care physician services benefit category. This means that you have been asked to pay the
correct amount based on your contract with the Plan.
You have been asked to pay a $350 copayment for the services received on April 12, 2021. These services fall
within the outpatient surgery 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 various services received between February
5, 2021, and April 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for observation care discharge day management (99217)
provided on July 12, 2021.
You asked the Plan to pay for observation care discharge day management. You say that you would like this
claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says this claim
has not been billed as required by Medicare coding regulations.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. Medicare rules say that when a patient is
admitted for observation care and then is discharged on a different calendar date, the physician shall report
Initial Observation Care, from CPT code range 99218 - 99220, and CPT observation care discharge CPT code
99217
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of observation care discharge day management have not been met. Specifically, the enrollee was
admitted on July 11 and discharged on July 12. This would require that a CPT code indicating initial
observation care would need to have been submitted. This required code was not found in the claim history.
Therefore, we decided that the Plan does not have to pay for observation care discharge day management
(99217) provided on July 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an electrocardiogram (EKG) provided on
July 12, 2021.
You asked the Plan to waive the copayment for an EKG. You say that the plan did not pay all of the copayment
amount. The Plan denied your request. The Plan says the proper copayment was applied
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20
copayment for Medicare-covered non-radiological diagnostic services. The total amount allowed was $16.14
which is lesser than the copayment of $20. Therefore, only $16.14 was charged as the copayment amount.
You have been asked to pay a $16.14 copayment for an EKG. An EKG 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 an electrocardiogram (EKG) provided on July 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided on May 26, 2021, and August 18, 2021.

You asked the Plan to waive the copayment for the inpatient hospital care. You say that you should not have to pay. The Plan denied your request. The Plan says the cost share was 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 $200 for medically necessary inpatient hospital care. 

You have been asked to pay $200 for medically necessary inpatient hospital care. This service falls within the inpatient hospital care benefit category. The records indicate you were admitted for inpatient care on two separate occasions, each with a $200 copay. 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 care provided on May 26, 2021, and August 18, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit rendered on August 4, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says procedure code 99203 is not 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.
In this case, the CPT Code Manual definition of code 99203 is outpatient visit for evaluation and management
of new patient, including medically appropriate examination and low level of medical decision making, total
time 30-44 minutes.
We find that CPT code 99203 is not supported in the medical record. Specifically, the file shows that a
previous evaluation and management code was billed by the same provider TIN/specialty; therefore, a new
patient office visit does not apply. Based on this information, we decided that Medicare rules for coverage of
these services have not been met. Therefore, we decided that the Plan does not have to pay for the office visit
rendered on August 4, 2021.