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

We decided that the Plan does not have to waive the copayment for the specialist office visit on August 16,
2021.
You asked the Plan to waive the copayment for the specialist office visit. You say that you should not have a
copayment because you were only there for two minutes. The Plan denied your request. The Plan says you
have been asked to pay the correct cost-sharing 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 $40
copayment per specialist visit.
You have been asked to pay a $40 copayment for the specialist office visit. The specialist office visit falls
within the "Physician/Practitioner services, including doctor's office 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 specialist office visit on August 16, 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 June 29, 2021, to June 30, 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 hospital care 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 provided documentation indicates that at the time of admission, the enrollee was alert and oriented, vitals were stable, and exam unremarkable. The reviewer found that the enrollee was hemodynamically stable and had no signs of a severe condition warranting inpatient care. The reviewer found that there was no indication that the enrollee would require hospital services that would likely cross 2 midnights, based on the provided documentation. Therefore, the reviewer found that the inpatient hospital care was not medically necessary. 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. Specifically, the file indicates that there was no indication that the enrollee would require hospital services that would likely cross 2 midnights. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from June 29, 2021, to June 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the interpretation of the chest x-ray provided on May 24, 2021.
You asked the Plan to pay for the chest x-ray interpretation. You say that multiple exams were performed on the same date. The Plan denied your request. The Plan says the record shows that one x-ray was performed, and payment has already been made for one x-ray.
The Plan must follow Medicare rules. Medicare rules say that duplicate claims must be denied but can be appealed. In this case, the Plan made payment on an identical claim on June 24, 2021. There is no evidence of a second x-ray interpretation to justify payment for the duplicate claim. This denial was correct. Therefore, we decided that the Plan does not have to pay for the interpretation of the chest x-ray provided on May 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (procedure code 99292) provided to the enrollee from April 19, 2021, to April 22, 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. In this case, the CPT Code Manual definition of code 99292 is "Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service)." We find that CPT code 99292 is not supported in the medical record. Specifically, the documentation does not include the time spent providing the service. This information is needed, as CPT 99292 is a time-based code. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for critical care services (procedure code 99292) provided to the enrollee from April 19, 2021, to April 22, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the imaging services provided on May 17, 2021.
You asked the Plan to pay for the imaging services. You say that the services should be covered. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the imaging services provided on May 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on February 25, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the drug testing. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was 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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent.

Therefore, we decided that the Plan does not have to pay for the drug testing provided on February 25, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient hospital observation services (G0378) provided from May 18, 2021, through May 21, 2021.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the services provided.

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 $225 copayment for outpatient hospital observation services.

You have been asked to pay a $225 copayment for the outpatient hospital observation services provided. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the outpatient hospital observation services (G0378) provided from May 18, 2021, through May 21, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on June 17, 2021.

You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you would like to appeal the bill you received. The Plan denied your request. The Plan says you refused transport to the hospital. The Plan also says that Medicare does not provide payment for ambulance response and treatment if there is no transport.

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 June 17, 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 the ambulance response and treatment with no transport (A0998) provided on June 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the molecular pathology procedure; physician interpretation and report services coded G0452 provided on June 28, 2021.
You asked the Plan to pay for the molecular pathology procedure; physician interpretation and report 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 supported by the documentation.
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 G0452 is molecular pathology procedure; physician interpretation and report. We find that CPT code G0452 is not supported in the medical record. Specifically, the lab results submitted do not include a separate physician interpretation of the enrollee specific results. Based on this information, we decided that Medicare rules for coverage of the molecular pathology procedure; physician interpretation and report services have not been met. Therefore, we decided that the Plan does not have to pay for the molecular pathology procedure; physician interpretation and report services coded G0452 provided on June 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2740), core buildups, including any pins when required (D2950), pontic (D6245), and retainer crowns (D6740) provided on August 25, 2021, and September 7, 2021.

You asked the Plan to pay for the crown, core buildups, pontic, and retainer crowns. You say that you spoke with a Plan representative and were advised your insurance would cover the dental work if you damaged your teeth due to a health condition. The Plan denied your request. The Plan says you have met the $1,000 annual maximum benefit for dental services.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan offers a $1,000 annual dental benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are responsible for the full charges of any additional dental services. The record shows that you met the annual maximum benefit on July 28, 2021 and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the crown (D2740), core buildups, including any pins when required (D2950), pontic (D6245), and retainer crowns (D6740) provided on August 25, 2021, and September 7, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the mass spectrometry and tandem mass spectrometry services coded 83789 provided on June 22, 2021.

You asked the Plan to pay for the mass spectrometry and tandem mass spectrometry 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 83789 for the mass spectrometry and tandem mass spectrometry services is a column II code to column I code 80307 and G0480. 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 mass spectrometry and tandem mass spectrometry services coded 83789 provided on June 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on July 28, 2021.
You asked the Plan to waive the copayment for the office visit. You say that you disagreed with the service and should not be responsible for the copayment. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing 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 $15 copayment per visit for in-network primary care physician.
You have been asked to pay a $15 copayment for the office visit. The office visit falls within the "Physician/
Practitioner services, including doctor's office 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 office visit provided on July 28, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room services provided on April 20, 2021 and April 21, 2021.
You asked the Plan to pay for the emergency room services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed were processed correctly per the enrollee's coverage.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has already accepted the claim. However, as the secondary insurer, the Plan cannot be held responsible for the emergency room services until the primary insurer has denied the claim for these services. Review of the file shows that as a Medicare secondary payer, a benefit is payable when the primary insurance payer's calculated amount is less than the Medicare allowed rate for the service. The primary carrier's payment is higher than the Medicare allowable fee maximum of $556.70 with an emergency room cost share of $120.00. This means the claim was completely paid by the enrollee's primary insurer and the Plan does not owe any additional amount. Therefore, we decided that the Plan does not have to pay for the emergency room services provided on April 20, 2021 and April 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive procedures (D1999) provided on July 28, 2021, and August 31, 2021.

You asked the Plan to pay for the preventive procedures. The Plan denied your request. The Plan says this service is not a covered benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the preventive procedures (D1999) provided on July 28, 2021, and August 31, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the tuberculosis skin test provided on June 18, 2021.

You asked the Plan to pay for the tuberculosis skin test. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided 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 tuberculosis skin test at issue in this appeal was requested solely for screening purposes. This service was provided in the absence of signs, symptoms, complaints or personal history of a disease or injury. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the tuberculosis skin test provided on June 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion supplies provided on March 5 to March 26, 2021.

You asked the Plan to pay for home infusion supplies. You say that the items at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. 

The record does not contain a valid proof of delivery for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for home infusion supplies provided on March 5 to March 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided on July 26, 2021.

You asked the Plan to pay for the comprehensive periodontal evaluation. You say that you do not understand why a comprehensive periodontal evaluation is not covered and would like to know where this is written under your dental plan. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided on July 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on September 4, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for an office visit. You say that the beneficiary presented with the Medicare insurance card. You say that it was not possible to obtain authorization. The Plan denied your request. The Plan says the services were provided out-of-network and 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 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 September 4, 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 acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found in this case, the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to
rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, at an intensive rehabilitation therapy program. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.