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 March 5, 2021.

You asked the Plan to waive the copayment for the ER visit. You say that you went to the ER due to a reaction you had to the Coronavirus (COVID-19) vaccine. You said that you thought all costs related to COVID-19 were waived. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that there are no copayments for COVID-19 screening and testing. In addition, the Plan has waived cost sharing for all COVID-19 diagnostic treatment from April 1, 2020, to June 30, 2021. However, this ER visit was not to treat COVID-19, but for a reaction to the vaccine. That is not covered under the copayment waiver.

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 $90 copayment for emergency room visits.

You have been asked to pay a $90 copayment for the 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 March 5, 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 December 21, 2020.
You asked the Plan to waive the copayment for the ER visit. You say that you thought that you had the Coronavirus (COVID-19) and were feeling sick, so you went to the ER. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that you were not seen in the ER for COVID-19.
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. The billing records show that you were seen in the ER for knee swelling and pain, not for COVID-19. You
have been asked to pay a $120 copayment for the 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 December 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the authorization of a left atrial appendage closure (LAAC) (33340).

You asked the Plan to pre-approve the surgical service. You say that the requested service is medically necessary. The Plan denied your request. The Plan says the requested service is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that LAAC is only covered as a second line therapy to oral anticoagulants. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LAAC. Our reviewer says that the LAAC is not medically necessary. Our physician reviewer found the provided documentation shows that the requested inpatient hospital admission is for a percutaneous left atrial appendage closure (LAAC) procedure. The reviewer found that the enrollee has been tolerating anticoagulation without bleeding episodes and has not had frequent falls. The reviewer found that there is no documentation of a shared decision-making discussion on anticoagulation risk with an independent non-interventional physician using the evidence-based risk tool as required by CMS rules. Therefore, the reviewer found that based on the lack of documentation of either a contraindication to taking long-term anticoagulation as well as the appropriate shared decision-making discussion with the independent non-interventional provider, the enrollee would not meet the applicable CMS criteria for medical necessity for implantation of the Watchman device at this time. 

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 inpatient hospital admission. have not been met. Specifically, the file does not indicate a contraindication to taking long-term anticoagulation. Therefore, we decided that the Plan does not have to pre-approve the authorization of a left atrial appendage closure (LAAC) (33340).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (83735) provided on March 20, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
billed 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.

We find that CPT code 83735 is not supported in the medical record. Specifically, code 83735 has a PC/TC
indicator of "9." This means that the concept of a professional/technical component does not apply. As there is
no professional or technical component to this service, it is inappropriate for this code to be billed with
modifier -26. 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 (83735) provided on March
20, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) provided on May 7, 2021.

You asked the Plan to pay for the computed tomography (CT). 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 70450 for the computed tomography (CT) has a bundled relationship with code 70496 and cannot be paid as billed. This code cannot be paid as a separate line item. 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 computed tomography (CT) provided on May 7, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for individual psychotherapy session (90837) provided on January 4, 2021 to March 2, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the psychotherapy services. You say that you were told that back dated claims for clients on a Medicare managed care plan would be paid in full once the contract was in the system. 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. This provider was not contracted until 03/15/2021.

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 individual psychotherapy session (90837) provided on January 4, 2021 to March 2, 2021 by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the four BIS, extracellular fluid analyses (93702 x4).

You asked the Plan to pre-approve the BIS services. The Plan denied your request. The Plan says there is not enough support in the medical journals that this service is helpful for you.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 the BIS services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee underwent a partial mastectomy. The provided medical records do not indicate the presence of lymphedema. Our reviewer found that there is insufficient literature to establish the requested test as safe and effective, as defined by Medicare rules, for the enrollee's specific clinical condition. Our physician reviewer also found that the elements of the coverage criteria are not satisfied.

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 BIS services have not been met. Therefore, we decided that the Plan does not have to pre-approve the four BIS, extracellular fluid analyses (93702 x4).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hereditary cardiovascular screening provided on January 5, 2021.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says screening genetic testing 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 testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the hereditary cardiovascular screening provided on January 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the laparoscopic services coded as 51999 and 55866 provided March 1, 2021.

You asked the Plan to pay for the laparoscopic services. You say that these codes are supported by the medical records submitted. The Plan denied your request. The Plan says the record submitted 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 51999 is Unlisted laparoscopy procedure, bladder and 55866 is Laparoscopy, surgical prostatectomy, retropubic radical, including nerve sparing, includes robotic assistance, when performed.


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 laparoscopic services. Our reviewer says that the medical records do not support the services as billed. Our reviewer found for CPT 55866, the operative report does not include enough documentation to confirm surgical prostatectomy, retropubic radical was performed. All criteria in description for CPT 55866 is not documented and therefore cannot be confirmed as performed. To report a cysto-prostatectomy should be reported with CPT codes 51595 and 55840. For CPT 51999, the documentation does not support an unlisted laparoscopic procedure of bladder. Operative report documents "Robotic Radical Cystoprostatectomy, Robotic Extended pelvic lymphadenectomy, and Robotic ileal conduit urinary diversion" was performed. CPT 51999 would not be reported for these procedures.

 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 laparoscopic services have not been met. Therefore, we decided that the Plan does not have to pay for the laparoscopic services coded as 51999 and 55866 provided March 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit for evaluation and management services for an established patient (99335) provided on April 20, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the domiciliary or rest home visit. You say that it was medically necessary for the enrollee to receive treatment and you did not know that the facility failed to get pre-authorization for tor this enrollee. 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 domiciliary or rest home visit for evaluation and management services for an established patient (99335) provided on April 20, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on February 2, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not billed correctly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on February 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the partial ostectomy/sequestrectomy for removal of non-vital bone (D7550) provided on April 2, 2021.
You asked the Plan to pay for the dental service. You say that a number of your teeth were cracked and broken off. You say that the fillings you had done many years ago had falling out. You say that this left your gums exposed with open sores. You also say that this treatment was essential. The Plan denied your request. The Plan
says partial ostectomy/sequestrectomy for removal of non-vital bone is not listed as a covered service. The Plan also says that this service is not covered by Medicare.
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 dental service is not among those covered under this benefit. Additionally, the service you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the partial ostectomy/sequestrectomy for removal of non-vital bone (D7550) provided on April 2, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve twenty (20) additional PT visits.

You asked the Plan to pre-approve twenty (20) additional PT visits. You say that additional PT is medically necessary. The Plan denied your request. The Plan says additional PT is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.

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 twenty (20) additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health Plan. The enrollee has had prior therapy for her vertigo and back pain and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The enrollee can continue her home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of twenty (20) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve twenty (20) additional PT visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services coded 99152 provided on November 13, 2020.

You asked the Plan to pay for the moderate sedation 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 99152 is moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older.

We find that CPT code 99152 is not supported in the medical record. Specifically, the documentation does not indicate that the presence of an independent trained observer to assist in the monitoring of the enrollee's level of consciousness and physiological status; therefore, the billed service cannot be verified. Based on this information, we decided that Medicare rules for coverage of the moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services coded 99152 provided on November 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing (80307) rendered by the out-of-network (OON) provider on May 3, 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 drug testing (80307) rendered by the out-of-network (OON) provider on May 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

Explanation of decision


We decided that the Plan does not have to pre-approve three consultations to be provided by an OON provider.

You asked the Plan to pre-approve the consultations. You say that you would like reconsideration because the
member would prefer the requested provider to the Plan's recommended provider. The Plan denied your
request. The Plan says these services are available in-network.

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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
three consultations to be provided by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency ambulance transportation (A0427, A0425) provided on December 21, 2020.

You asked the Plan to waive the copayment for emergency ambulance transportation. You say that you were not aware the services would not be covered. You cannot afford the copayment. The Plan denied your request. The Plan says the copayment was applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $265 copayment for ambulance services.

You have been asked to pay a $265 copayment for emergency ambulance transportation. The services at issue 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 emergency ambulance transportation (A0427, A0425) provided on December 21, 2020.