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

We decided that the Plan does not have to pay for anesthesia for diagnostic or therapeutic nerve blocks and
injections (01992) provided on July 1, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for anesthesia. You say that the services were medically necessary. The Plan denied
your request. The Plan says services were provided by an OON provider without prior authorization.
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. The records provided for review do not show that the services at issue were urgent or emergent. 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 anesthesia for diagnostic or therapeutic nerve blocks and injections (01992) provided on July 1, 2021, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the colonoscopy you had on
June 10, 2021.
You asked the Plan to waive the coinsurance for the colonoscopy. You say that you believe that screening colonoscopies should not have a copayment. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for outpatient surgery. You have been asked to pay 20% coinsurance for the colonoscopy. According to your contract, you are entitled to one screening colonoscopy with no cost sharing once every ten years. Records show that you had your last screening colonoscopy in 2016, which is only 5 years ago. That means that the colonoscopy you had on June 10, 2021, is not a screening colonoscopy for which no cost sharing would apply.
Regular colonoscopies 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 coinsurance for the colonoscopy you had on June 10, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapy services (97110) provided May 29, 2020.
You asked the Plan to pay for the therapy services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the procedure code 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 97110 is not supported in the medical record. Specifically, the documentation shows this service was performed by a therapy assistant in the home setting. There is a more appropriate CPT code to describe this service (G0157). Based on this information, we decided that Medicare rules for coverage of the therapy services have not been met. Therefore, we decided that the Plan does not have to pay for therapy services (97110) provided May 29, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the application of hot or cold packs (97010) provided December 28, 2020.
You asked the Plan to pay for the application of hot or cold packs. You say that you would like these claims reprocessed and approved for payment. The Plan denied your request. The Plan says this code has denied correctly.
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 97010 is application of a modality to 1 or more areas; hot or cold packs. We find that CPT code 97010 is not supported in the medical record. Specifically, CPT code 97010 has a status indicator of B meaning that payment for this service is always bundled into another procedure. Separate payment is not made for CPT code 97010.
Based on this information, we decided that Medicare rules for coverage of the application of hot or cold packs have not been met. Therefore, we decided that the Plan does not have to pay for the application of hot or cold packs (97010) provided December 28, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998)
provided on May 4, 2021.
You asked the Plan to pay for the ambulance service. You say that you could not drive until after you received
the glucose treatment from the ambulance provider. You also say that you believe it should be considered an
emergency and should be paid. The Plan denied your request. The Plan says there was no transport provided.
The Plan also says Medicare does not cover
ambulance services when transportation is not provided.
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 May 4, 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, no
transport (A0998) provided on May 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services rendered on April 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 procedure code 99292 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 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 records document a total
of 40 minutes of critical care time; therefore, an additional 30 minutes beyond the first 30 minutes is not
supported. 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 critical care services rendered on
April 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99203) rendered by the out-of-network (OON) provider on August 4, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal.
The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for
this service. Therefore, we decided that the Plan does not have to pay for the office visit (99203) rendered by
the out-of-network (OON) provider on August 4, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the electroencephalogram (EEG) rendered on March 9, 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 95822 is 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 95822 (EEG, recording in coma or sleep only) and 95812
(EEG extended monitoring, 41-60 minutes). Code 95822 is a column II code with a modifier indicator of 1
when billed with column I code 95812. Code 95822 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 electroencephalogram
(EEG) rendered on March 9, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on December 28, 2020.
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 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 a nursing facility setting and should have been billed with POS code 32. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on December 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from
November 11, 2020, through November 20, 2020.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing your
cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim
was processed accordingly with your 2020 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).
Review of the file shows that you were admitted on November 11, 2020, and discharged on November 20, 2020.
You were asked to pay a $225 copayment per day from November 11, 2020, through November 16, 2020, days 1-6 of your inpatient stay. There were no copayment charges from November 17, 2020, day 7 of your inpatient hospital care until your day of discharge November 20, 2020. Per your contract there is a $225 copayment per day required for days 1-6. 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 inpatient hospital care provided from November 11, 2020, through November 20, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergency ambulance transport (A0428) and ground
mileage (A0425) provided on December 15, 2020.
You asked the Plan to pay for the ambulance services. You say that you were not able to walk to or sit in a car
without difficulty. You say that you had a large knee brace on. You also say that the transport was medically
necessary. The Plan denied your request. The Plan says the ambulance services were not medically necessary.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan
follows the same rules.
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 the ambulance services. Our reviewer says
that the ambulance services were not medically necessary.
Our physician reviewer found the provided documentation does not support that other means of transport
would be contraindicated, such as a stretcher or wheelchair van. The reviewer found that there was no
documentation showing the enrollee was unstable or required expertise or special equipment during transport.
The reviewer found The documentation did not support that the enrollee needed the expertise, services and
lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport on
December 15, 2020. The reviewer also found that the documentation did not support that the ambulance
transport on December 15, 2020 was medically reasonable and necessary for the enrollee.
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 ambulance services have not been met. Therefore, we decided that the Plan
does not have to pay for the non-emergency ambulance transport (A0428) and ground mileage (A0425)
provided on December 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the out of network cost share for the oral exam (D0120) and
prophylaxis (D1110) provided on June 3, 2021.
You asked the Plan to waive the out of network cost share for the dental services. You say that you have a $0
copayment for exams, cleanings, x-rays and fluoride for in and out of network benefits. You also say that the
plan did not cover 100% of the amount for preventive services. The Plan denied your request. The Plan says the
provider in this case is out of network. The Plan says that out of network providers may bill you for any
amount greater than what the Plan pays. The Plan also says that the claim was processed correctly.
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 and the services are listed as covered, out of network providers may bill you for any amount greater than what the Plan pays. Therefore, we decided that the Plan does not have to waive the out of network cost share for the oral exam (D0120) and prophylaxis (D1110) provided on June 3, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic exercises (97110) and the electrical stimulation (G0283) rendered by the out-of-network (OON) provider on October 22, 2020.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue.
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the therapeutic exercises (97110) and the electrical stimulation (G0283) rendered by the out-of-network (OON) provider on October 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2740) and to pay for periapical x-ray (D0220) provided on April 7, 2021.
You asked the Plan to pay for the periapical x-ray. You say that you have a $2,000 per year for dental services. You also say that this should be covered. The Plan denied your request. The Plan says 1 periapical x-ray is covered per calendar year. The Plan also says that the frequency limit has been exceeded.
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 and periapical x-ray is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a periapical x-ray that you received on February 10, 2021. Therefore, we decided that the Plan does not have to pay for the crown (D2740) and to pay for periapical x-ray (D0220) provided on April 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office or other outpatient visit (99202) provided
April 19, 2021.
You asked the Plan to pay for the office or other outpatient visit. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this service is not covered when provided by a chiropractor.
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 records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the office or other outpatient visit (99202) provided April 19, 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 it is not medically necessary for you to require daily inpatient physical/occupational therapy and your needs can be met with intermittent physical/occupational therapy 3-4 times per week at a lower level of care at home or a custodial level.
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 you do not qualify for SNF coverage. You do not have documented skilled nursing needs. You do not have documented skilled therapy needs. You appear to be functioning at/near your baseline. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. 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.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the skin graft application procedure (15275) and related procedures provided on May 21, 2021.
You asked the Plan to pay for the medical services. You say that these claims were submitted correctly. The Plan denied your request. The Plan says required information is missing from these claims submitted.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The rules also say that skin grafting application procedures must be reported in combination with skin substitute products. The rules also say that when skin substitute application procedure is submitted without a skin substitute product there will be an I/OCE edit of 87, meaning that the whole claim will be rejected and returned to the provider until the error is corrected. We looked at the file and Medicare rules. Code 15275 was reported without the necessary skin substitute product and is not payable. not supported in the medical record. We reviewed the I/OCE Specifications file for this date of service. OCE Edit 87 is invoked when a skin grafting application procedure has been reported without a skin substitute product. The required disposition for a claim with this edit is Return To Provider. This means the whole claim is returned to the provider. The provider can resubmit the claim once the problem is corrected. Based on this information, we decided that Medicare rules for coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay for the skin graft application procedure (15275) and related procedures provided on May 21, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the services provided on May 17, 2021, and
July 9, 2021.
You asked the Plan to waive the copayment for the services. You say that you have never had a nosebleed until
a week after receiving the Coronavirus vaccine.
You state you are requesting the copayments to be waived due to the nosebleed resulting from the vaccine. The
Plan denied your request. The Plan says the claims were processed accordingly with your 2021 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).
Review of the file shows that you received ambulance services and emergency care on May 17, 2021. You
were asked to pay a $275 copayment for ambulance services and a $90 copayment for emergency care.
Review of the file shows that you received specialist office services on July 9, 2021. You were asked to pay a
$50 copayment for the office services.
Your 2021 EOC states that enrollees must pay a $275 copayment for ambulance services, a $90 copayment per
emergency department visit and a $50 copayment per visit with a specialist (such as gynecology, cardiology,
orthopedics, gastroenterology, neurology, allergy testing and evaluation, and pain management injections.
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 services provided on May 17, 2021, and July 9, 2021.