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

We decided that the Plan does not have to pay for an outpatient mental health visit (99214, 96127) provided on
March 9, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for an outpatient mental health visit. You say that you are appealing with supporting
records. The Plan denied your request. The Plan says these services were not authorized. The Plan also says
that the rendering provider is a non-participating provider and there is no referring provider in these services.
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 outpatient mental health visit (99214, 96127)
provided on March 9, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the interim partial denture (including retentive/clasping materials, rests, and teeth), maxillary (D5820) provided September 15, 2021.

You asked the Plan to pay for the interim partial upper denture. You say that you believe this service is covered. The Plan denied your request. The Plan says this service is not covered under your 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. 

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 interim partial denture (including retentive/clasping materials, rests, and teeth), maxillary (D5820) provided September 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for nitrous oxide analgesia (D9230), and composite fillings
(D2391 and D2392) provided by an out-of-network provider on September 8, 2021.
You asked the Plan to pay for nitrous oxide analgesia, and composite fillings. You say that you have had no
dental expenses whatsoever. You say that you are on a fixed income, and you are not financially prepared for
this. The Plan denied your request. The Plan says the $1,500 combined allowance for dental services has
already been met.
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.
We looked at the file and Medicare rules. Based on this information, we decided that the combined allowance
of $1,500 was fully exhausted on August 23, 2021. Therefore, we decided that the Plan does not have to pay
for nitrous oxide analgesia (D9230), and composite fillings (D2391 and D2392) provided by an out-of-network
provider on September 8, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the
enrollee from July 15, 2021 to July 31, 2021.
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your
request. The Plan says no daily skilled needs were identified.
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 the services. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found the enrollee did not require skilled nursing
services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and
effectively provide medically necessary and reasonable treatment in a SNF July 15, 2021 to July 31, 2021. The
documentation did not reveal evidence of complex wound care, or other skilled nursing SNF need during these
dates. The enrollee's functional level did not require skilled therapy services with the specialized skill,
knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and
reasonable treatment in a SNF from July 15, 2021 to July 31, 2021. The patient did not require skilled nursing
or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical
matter, the enrollee did not require the necessary services on an inpatient basis, in a skilled nursing facility
setting from July 15, 2021 to July 31, 2021.
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 services have not been met. Therefore, we decided that the Plan does not
have to pay for skilled nursing facility (SNF) services provided to the enrollee from July 15, 2021 to July 31,
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (CPT code 99214) provided to the enrollee on
October 1, 2021, by an out-of-network provider.
You asked the Plan to pay for the out-of-network services. You say that the claim should be paid. The Plan
denied your request. The Plan says this provider is out-of-network, the services were not referred by a network
provider, and the services were not urgent or emergent, nor were they 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 the office visit (CPT code 99214) provided to the
enrollee on October 1, 2021, by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia for the enrollee.
You asked the Plan to pre-approve Prolia. You say that Prolia is medically necessary for the patient's treatment
for age-related osteoporosis without current pathological fracture. The Plan denied your request. The Plan says
that the member has not tried and failed zoledronic acid.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
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 Prolia. Our reviewer says that Prolia is
not medically reasonable and necessary. The enrollee does not have a history of osteoporotic fracture or tried
and cannot use zoledronic acid. The documentation does not support that zoledronic acid would likely be less
effective, and/or would likely have adverse effects for the enrollee in this case. Our physician reviewer found
that the enrollee's condition does not meet step therapy criteria for Prolia.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to
pre-approve Prolia for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the visit (99205) provided on July 25, 2021.
You asked the Plan to pay for the visit. The Plan denied your request. The Plan says the services were billed
incorrectly.
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 99205 is "Office or other outpatient visit for the
evaluation and management of a new patient, which requires a medically appropriate history and/or
examination and high level of medical decision making. When using time for code selection, 60-74 minutes of
total time is spent on the date of the encounter".
We find that CPT code 99205 is not supported in the medical record. Specifically, the records show that hte
enrollee was seen in the emergency department on the date of service in question. It is inappropriate to bill
code 99205 for an emergency department visit. Based on this information, we decided that Medicare rules for
coverage of the visit have not been met. Therefore, we decided that the Plan does not have to pay for the visit
(99205) provided on July 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual wellness visit (CPT code G0439) provided on October 18, 2021.

You asked the Plan to pay for the annual wellness visit. You say that you had a telehealth visit with this provider and it was not a wellness exam. The Plan denied your request. The Plan says you have exceeded limits set in the subscriber agreement. The Plan states they called the provider's office and were advised that you had an annual wellness visit conducted over the phone with their nurse. The Plan states the provider's office said they are unable to recode it as that was the service that was performed.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

Review of the file shows that the service was already billed and paid for on May 10, 2021, it would no longer be covered for the remainder of the year and would fall to your responsibility. Per Medicare guidelines, annual wellness (G0439) is covered one time annually. The claim for your second wellness exam this year, from date of service October 18, 2021, has processed correctly. 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 annual wellness visit have not been met. Therefore, we decided that the Plan does not have to pay for the annual wellness visit (CPT code G0439) provided on October 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the total hysterectomy (58575) provided from April 8, 2021,
through April 9, 2021.
You asked the Plan to pay for the total hysterectomy (58575). You say that the claim denied incorrectly
because there is no inpatient stay for this patient. The Plan denied your request. The Plan says CPT code 58575
is only paid as an inpatient procedure.
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that
CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the
OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule.
The service at issue in this appeal was billed with CPT code 58575. This code is listed with a status indicator of
"C" on Addendum B of the 2021 OPPS/ASC final rule. This means the service has been designated as
"inpatient only", and therefore must be billed as part of an inpatient admission. Therefore, we decided that the
Plan does not have to pay for the total hysterectomy (58575) provided from April 8, 2021, through April 9,
2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF services provided from July 15, 2021, through
August 1, 2021.

You asked the Plan to pay for SNF services. The Plan denied your request. The Plan says the SNF services were 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 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 not require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified therapist were not 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. Services in the nursing facility appear custodial in this case from July 15, 2021, through August 1, 2021. 

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 services have not been met. Therefore, we decided that the Plan does not have to pay for SNF services provided from July 15, 2021, through August 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic mammogram you had on
September 20, 2021.
You asked the Plan to waive the copayment. You say that this was a screening test. The Plan denied your
request. The Plan says you have been asked to pay the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $175
copayment for each Medicare-covered diagnostic radiology service in an outpatient facility.
Review of the file shows that you were provided a diagnostic mammogram on September 20, 2021. You have
been asked to pay a $175 copayment for the mammogram. The mammogram falls within the outpatient
diagnostic tests 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 diagnostic
mammogram you had on September 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for contact lens fitting provided on September 20, 2021.
You asked the Plan to pay for contact lens fitting. The Plan denied your request. The Plan says this service is an
exclusion on your policy.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
We looked at the file and the Plan's rules. The file shows that contact lens fitting is an exclusion on your policy.
Therefore, we decided that the Plan does not have to pay for contact lens fitting provided on
September 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia for transurethral procedures (including
urethrocystoscopy); transurethral resection of prostate (CPT code 00914 QK, P2) provided to the enrollee on
August 12, 2021.
You asked the Plan to pay for the service. You say that modifiers used are substantiated by the records
attached. The Plan denied your request. The Plan says the procedure code billed is missing a required modifier.
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 asked our coder 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 service. Our reviewer found the documentation submitted
was reviewed and does not meet criteria. Provider reported Z00.6 Encounter for examination for normal
comparison and control in clinical research program. Services reported requires an additional modifier per
Centers for Medicare & Medicaid Services (CMS).
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not
have to pay for the anesthesia for transurethral procedures (including urethrocystoscopy); transurethral
resection of prostate (CPT code 00914 QK, P2) provided to the enrollee on August 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99053) provided on June 17, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.

The Plan must follow Medicare rules. Medicare rules say that a status indicator of "B" under the Physician Fee Schedule indicates that payment for covered services are always bundled into payment for other services not specified. 

We looked at the file and Medicare rules. Code 99053 is assigned a status indicator of "B" under the Physician Fee Schedule, which means that this is a bundled service. Payment for this service is bundled into payment for other services. No separate payment can be made for this service. 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 the services (99053) provided on June 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on March 19, 2021.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the lab services
were not approved by the ordering provider.
The Plan must follow Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory
tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary.
We looked at the file and Medicare rules. The records do not show that the testing in question was ordering by
the enrollee's treating physician.
Based on this information, we decided that Medicare rules for coverage of the lab services have not been met.
Therefore, we decided that the Plan does not have to pay for the lab services provided on March 19, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services received from June 18,
2020, to July 26, 2020.
You asked the Plan to waive the copayment for the services. You say that the copayment should be waived.
The Plan denied your request. The Plan says the copayment was applied correctly 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 a $275
copayment for ambulance services.
You have been asked to pay a $275 copayment for the services. the services fall within the ambulance services
benefit category. This means that you have been asked to pay the correct amount based on your contract with
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.
Therefore, we decided that the Plan does not have to waive the copayment for ambulance services received
from June 18, 2020, to July 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an unspecified removable prosthodontic procedure (D5899)
provided by a participating provider on March 4, 2021.

You asked the Plan to pay for an unspecified removable prosthodontic procedure. You say that these services
were necessary. You say that you believe the Plan should pay for this. The Plan denied your request. The Plan
says D5899 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 an
unspecified removable prosthodontic procedure (D5899) provided by a participating provider on March 4,
2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99201, 99250) provided on August 25, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are
bundled.
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 99201
is a column II code to column I code 99250. We have also confirmed that code 99250 is a column II code to
column I code 92134. 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 services (99201, 99250) provided on August 25, 2021.