Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

e decided that the Plan does not have to pay for the oral exam (D0120) and prophylaxis (D1110) provided on
July 15, 2021.
You asked the Plan to pay for the dental services. You say that you have received services from this provider in
the past that have been paid. You also say that the services should be covered. The Plan denied your request.
The Plan says the provider in this case has opted out of Medicare. The Plan says that services performed by a
dentist that has opted out of Medicare are not payable. The Plan also says that there is no record that you did
not contact the Plan prior to the date of service to verify provider eligibility.
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 services performed by a dentist
that has opted out of Medicare are not among those covered under this benefit. Therefore, we decided that the
Plan does not have to pay for the oral exam (D0120) and prophylaxis (D1110) provided on July 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the culture provided on September 1, 2020.
You asked the Plan to pay for the culture. 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 87150 is culture, typing; identification by nucleic acid
(DNA or RNA) probe, amplified probe technique, per culture or isolate, each organism probed.
We find that CPT code 87150 is not supported in the medical record. Specifically, the documentation did not
include a lab report or lab results for the billed test. The submitted lab results are for a stool specimen and not
blood; therefore, the billed service and place of service cannot be verified.
Based on this information, we decided that Medicare rules for coverage of the culture have not been met.
Therefore, we decided that the Plan does not have to pay for the culture provided on September 1, 2020.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (47000) provided on March 18, 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 providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 47000 is a column II code to column I code 47382. 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 (47000) provided on March 18, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the refraction provided on June 29, 2021.
You asked the Plan to pay for the refraction. You say that you are appealing the denied services. The Plan
denied your request. The Plan says that the vision exam was overturned. The Plan also says that the refraction
is not separately payable, and the maximum benefit has been exceeded.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers a refraction when provided with a routine eye exam once every calendar year.
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for
coverage of the refraction have been met. Specifically, the Plan agreed to pay for the eye exam as a routine
exam. A refraction is covered when billed with a routine eye exam and should be paid. Therefore, we decided
that the Plan has to pay for the refraction provided on June 29, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance services (A0428 and A0425) provided on December 30, 2020.  You asked the Plan to pay for the ambulance services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the member's claims history indicates they were in an inpatient hospital status on this date of service.  The Plan must follow Medicare rules. Medicare rules say that transportation to and from another hospital or freestanding facility to receive specialized diagnostic or therapeutic services not available at the facility where the patient is an inpatient is covered by the prospective payment rate or reimbursed as reasonable costs under Part A to hospitals excluded from PPS.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. Specifically, the record indicates that the member was inpatient on the billed date of service. Payment for this transportation is included in the payment for the inpatient admission and is not separately reimbursable. Therefore, we decided that the Plan does not have to pay for the ambulance services (A0428 and A0425) provided on December 30, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee was medically stable with debility with no evidence of need for supervision by a physical, medicine, and rehabilitation (PMR) Physician or needs acute rehab nursing care. Functionally the enrollee needs physical therapy (PT) and occupational therapy (OT), but does not require IRF level of therapies. IRF admission is not medically necessary based on the enrollee's current functional status and lack of medical complexity. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided May 1,
2020 to May 8, 2020.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to
the service provided.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees
must pay a $300 a day copayment for days 1-5 for each inpatient hospital admission.
The enrollee has been asked to pay a $1,500 copayment ($300 copayment x 5 days) for the inpatient hospital
admission. This means that the enrollee has been asked to pay the correct amount based on the contract with
the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.
Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital care
provided May 1, 2020 to May 8, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray provided on August 9, 2019.
You asked the Plan to pay for the chest x-ray. You say that the x-ray was completed prior to the enrollee
beginning the hospice election. The Plan denied your request. The Plan says Original Medicare would be
responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal
condition.
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 dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for the chest x-ray provided on August 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the five Telehealth psychiatry visits you
had between April 6, 2021, and July 20, 2021.
You asked the Plan to waive the copayments for the five telehealth psychiatry visits. You say that each time the
doctor's office called, they never asked you for a credit card. You said that you were never told that you had a
copayment. The Plan denied your request. The Plan says you were charged these copayments 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 $40
copayment per visit for specialist visits (including telehealth services).
You have been asked to pay a $40 copayment per visit for the five telehealth psychiatry visits. The five
telehealth psychiatry visits falls within the specialist visits (including telehealth 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 copayments for the five Telehealth psychiatry visits you had between April
6, 2021, and July 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a manual wheelchair (K0195) provided May 7, 2020.
You asked the Plan to waive the coinsurance for the manual wheelchair. You say that the coinsurance should be waived. The Plan denied your request. The Plan says the correct cost sharing was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a 20% coinsurance for Durable Medical Equipment. The enrollee has been asked to pay a 20% coinsurance ($8.13) for the manual wheelchair. The manual wheelchair falls within the Durable Medical Equipment benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for a manual wheelchair (K0195) provided May 7, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the required services cannot be safely met with home
health or skilled nursing facility services. The Plan denied your request. The Plan says the enrollee's medical
conditions are not yet stable.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found
that the enrollee was admitted to the acute care hospital for sepsis, respiratory failure, urinary tract infection,
anemia, and cholecystitis. His medical problems are stable. The complexity of the enrollee's nursing, medical
and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to
rehabilitation care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for mammography services (77067, 77063) provided July 12, 2021.  You asked the Plan to pay for the mammography services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim is a duplicate.  The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code.  We find that 2 units of CPT codes 77067, and 77063 are not supported in the medical record. The medical record only supports 1 unit of each code.     Based on this information, we decided that Medicare rules for coverage of the mammography services have not been met. Therefore, we decided that the Plan does not have to pay for mammography services (77067, 77063) provided July 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213) rendered by the out-of-network
(OON) provider on August 19, 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 (99213) rendered by the out-of-network (OON) provider on August 19,
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for pneumatic compression devices (E0675, E0673) provided on
June 11, 2021.
You asked the Plan to pay for pneumatic compression devices. You say that the items at issue were a medical
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the
purpose of prevention of venous thromboembolism is a preventive service. The rules also say that a PCD coded
as E0675 to treat peripheral arterial disease is not eligible for reimbursement.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for
coverage of the PCDs have not been met. Specifically, these items are not a covered benefit of Medicare or the
Plan. PCDs are not covered for prevention of venous thromboembolism nor for treatment of peripheral artery
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to
pay for pneumatic compression devices (E0675, E0673) provided on June 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on April 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 15823 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 15823 is blepharoplasty, upper eyelid; with excessive
skin weighting down lid.
We find that CPT code 15823 is not supported in the medical record. Specifically, there is no complete
operative report of an upper eyelid blepharoplasty. 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 surgical services rendered on April 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee exceeds the clinical
capabilities of all lower levels of care. The Plan denied your request. The Plan says the enrollee is currently
unstable for transfer.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services. Our physician
reviewer found that in this case, the enrollee was admitted with acute hypoxic respiratory failure due to Covid-
19 pneumonia. The enrollee is medically unstable with increased oxygen requirements and the need for acute
care services. The enrollee continues to receive acute care services, and these have not been denied. The
medical record does not indicate that the enrollee requires services that she is not currently receiving but that
would be available at the LTACH facility.
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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on June 22, 2020 by an
out-of-network (OON) provider.
You asked the Plan to pay for the Guardant360 testing. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
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 Guardant360 testing provided on June 22,
2020 by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided by physical therapy
assistant on May 15, 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 if services are not available from preferred providers 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 records do not support the code 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 physician
assistant, 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 physical therapy assistant on May 15, 2020.
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 there is
inadequate information to certify that you require the services on an inpatient basis, only in a skilled nursing
facility setting.
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.