Persius/hicric huggingface dataset:
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 
June 7, 2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you went to the ER for arm pain.  
You stated that the only thing the doctor asked you was what type of pain medication worked for you.  You 
stated that you did not have an exam, x-ray, or medications, so you should not have to pay a copayment. 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 $75 
copayment for emergency room visits.  
 
You have been asked to pay a $75 copayment for the ER visit. This copayment applies each time you visit the 
ER, regardless of the extent of services you receive. 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 June 7, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from June 26, 2021, 
through June 30, 2021. 
 
You asked the Plan to pay for the self-administered drugs. You say that your primary care office recommended 
you go to the emergency room. You say that you were told insurance would cover your stay and you have no 
way to pay the denied hospital bill. The Plan denied your request. The Plan says self-administered drugs aren't 
covered under your medical coverage. 
  
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided from June 26, 2021, through June 30, 2021.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the telehealth services provided on June 29, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you were unaware of the provider's network status. 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the telehealth services provided on June 29, 2021 
by an out-of-network (OON) provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for Shoulder orthosis (L3650) provided on July 25, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the orthosis. You say that you are a DME supplier only and is separate from the hospital. You provide your products to the office and you are not contracted with the hospital. 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 Shoulder orthosis (L3650) provided on July 25, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the endoscopy procedure coded as 33508 provided on May 
28, 2021. 
 
You asked the Plan to pay for the endoscopy procedure. You say that you would like this claim reprocessed for 
medical necessity. The Plan denied your request. The Plan says the claim has denied correctly in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 33508 
is a column II code to column I code 33533. 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 endoscopy procedure coded as 33508 provided on May 28, 
2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided from June 5, 2021, to July 
2, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the home health services. You say that you would like this claim to be 
reconsidered for payment. The Plan denied your request. The Plan says the services were rendered by a non-
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 home health services provided from June 5, 
2021, to July 2, 2021 by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF 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 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 based on the medical records provided, you do 
not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in a long-term 
care facility on a part time basis appear appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the amalgam filling provided on July 20, 2020. 
 
You asked the Plan to pay for the amalgam filling. You say that you did everything the representative told you 
to do and hope you will get allowance on the invoice. The Plan denied your request. The Plan says amalgam 
fillings are not covered. 
 
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, amalgam fillings are not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the amalgam filling 
provided on July 20, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoperative neuromonitoring services (95939, 95938, 
95870, 95869, 95940, A4215 and A4556) provided on February 23, 2021. 
 
You asked the Plan to pay for the intraoperative neuromonitoring services. You say that you would like 
reconsideration because these services were authorized and should be paid. The Plan denied your request. The 
Plan says the services provided represents a duplication of effort and an overlap of services. 
 
The Plan must follow Medicare rules. Medicare rules say that all items and non-physician services furnished to 
inpatients must be furnished directly by the hospital or billed through the hospital under arrangements. The 
rules also say that radiology and other diagnostic services furnished to hospital outpatients are paid under the 
Outpatient Prospective Payment System (OPPS) to the hospital. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the intraoperative neuromonitoring services have not been met. Specifically, this claim includes the 
technical component for the neuromonitoring services. Payment for the technical component of these services 
is the responsibility of the facility to any vendor. Therefore, we decided that the Plan does not have to pay for 
the intraoperative neuromonitoring services (95939, 95938, 95870, 95869, 95940, A4215 and A4556) provided 
on February 23, 2021.
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
July 23, 2021.
You asked the Plan to waive the copayment for the ER visit. You say that you had to go to the ER because the
urgent care center was closed. You stated that had the urgent care center been open at their posted hours, you
would not have had to go to the ER. 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 $120
copayment for emergency room visits.
You have been asked to pay a $120 copayment for the ER visit. This copayment applies regardless of the
reason for your ER visit. 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 July 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental service represented by dental code D9310 provided on July 8, 2021.
You asked the Plan to pay for dental code D9310. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says dental code D9310 is not covered under the Plan's supplemental dental 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, dental code D9310 is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental service represented by dental code D9310 provided on July 8, 2021.
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 9, 2020.
You asked the Plan to pay for the physical therapy services. You say that plans are required to pay non-contracted providers at the preferred provider rate when services are not available in the service area. You say that the in-network benefits should be honored, and the claim processed for payment. The Plan denied your request. The Plan says the code is not appropriate for the service billed.
The Plan must follow Medicare rules. Medicare rules say that the services of a physical therapy assistant (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 9, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the Laparoscopy, surgical, repair of paraesophageal hernia represented by code 43281 provided on December 23, 2019.
You asked the Plan to pay for code 43281. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not covered.
The Plan follows Medicare rules. Medicare rules say that for procedures with an assistant surgery indicator of 2, the payment restriction for assistants at surgery does not apply and the assistant surgeon services will be paid. In this case, you billed assistant surgery services for CPT code 43281. The Medicare Fee Schedule Database contains a surgical indicator of 2 for this procedure. Based on this information, we decided that Medicare rules for coverage of code 43281 have been met. Therefore, we decided that the Plan has to pay for the Laparoscopy, surgical, repair of paraesophageal hernia represented by code 43281 provided on December 23, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided on April 5, 2021.
You asked the Plan to pay for the SNF care provided on April 5, 2021. You say that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says while on hospice, skilled nursing facility (SNF) level services are not a covered benefit.
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 skilled nursing facility (SNF) care provided on April 5, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the myocardial imaging, positron emission tomography (PET) scan you had on May 4, 2021.
You asked the Plan to waive the deductible for the PET scan. You say that the plan did not give you information regarding your financial obligations before you received this service. The Plan denied your request. The Plan says you were assessed this deductible correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $1000 deductible which applies to outpatient diagnostic radiological services. The PET scan falls within the benefit category for outpatient diagnostic radiological services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1000 deductible which applies to outpatient diagnostic radiological services. This cost sharing is a contractual obligation that had not been met at the time the PET scan was received on May 4, 2021. Therefore, we decided that the Plan does not have to
waive the deductible for the myocardial imaging, positron emission tomography (PET) scan you had on May 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical and imaging services rendered on November 19, 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 are not covered.
The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is always bundled into payment for other services not specified. We looked at the file and Medicare rules. Billed procedure code G0269 (placement of occlusive device into either a venous or arterial access site, post surgical or interventional procedure) has a status indicator of B and no separate Medicare payment. 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 75726 (angiography, visceral, selective or supraselective (with or without flush aortogram), radiological supervision and interpretation), 75774 (angiography, selective, each additional vessel studied after basic examination, radiological supervision and interpretation [List separately in addition to code for primary procedure]), and 37243 (vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; for tumors, organ ischemia, or infarction). Codes 75726 and 75774 are column II codes with a modifier indicator of 1 when billed with column I code 37243. Codes 75726 and 75574 were not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the surgical and imaging services rendered on November 19, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on June 29, 2021.
You asked the Plan to pay for physical therapy services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 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 physical therapy services provided on June 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you have severe degenerative arthritis in your hip, knee and ankle making it difficult to walk, this affects your balance and gait causing much pain in your feet. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the laboratory services provided on March 17, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the enrollee was inpatient at the time the laboratory services took place on March 17, 2021.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. In this case, the Plan denied payment for the laboratory services stating the enrollee was inpatient on the date of service at issue in this appeal. However, the case file provided by the Plan contains no evidence of the enrollee being listed as inpatient on March 17, 2021. We find that the Plan has not substantiated their reasoning for the denial of payment based on inpatient status as the Plan provided no documentation verifying inpatient status. Therefore, we decided that the Plan has to pay for the laboratory services provided on March 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy (PT) services provided on June 24, 2021 
to June 30, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the PT services. You say that you have attached all the clinical documentation to 
support this physical therapy and ask for reconsideration of the claim. The Plan denied your request. The Plan 
says enrollee's must receive their medical services from an in-network provider with the exception being 
urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization 
before services being rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the physical therapy (PT) services provided on 
June 24, 2021 to June 30, 2021 by an out-of-network (OON) provider.