Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. 
The Plan says rules for SNF care have 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 you are an 88-year-old female with congestive
heart failure and chronic obstructive pulmonary disease. While there are identifiable skilled therapy service 
needs, there are no identifiable skilled nursing needs. In addition, you do not require skilled nursing or therapy 
services on a daily basis. In conclusion, you do not meet the severity of illness or intensity of service criteria 
for an inpatient basis 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 admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by a participating provider on July 13, 2021.  You asked the Plan to pay for a limited oral evaluation. You say that you do not feel like you should be charged for this. The Plan denied your request. The Plan says a limited oral evaluation 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 a limited oral evaluation (D0140) provided by a participating provider on July 13, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from June 
6, 2021, to June 8, 2021.

You asked the Plan to waive the copayment for inpatient hospital care. You say that you received outpatient 
hospital services and disagree with the inpatient charges. The Plan denied your request. The Plan says the 
claims were processed correctly and you are being charged 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 $325 
copayment for days 1-5 for inpatient hospital care. 

The record shows that you were approved for inpatient hospital care provided from June 6, 2021, to June 8, 
2021. Therefore, you are responsible to pay the total amount of $600, which is less than the total copayment 
amount. 

You have been asked to pay the total copayment amount of $600 for inpatient hospital care. Inpatient hospital 
care falls within the inpatient hospital care 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 inpatient hospital care provided from June 6, 2021, to June 8, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the abdominal ultrasound provided on August 14, 2021.  

You asked the Plan to pay for the services provided. You say that the enrollee had multiple exams on this date of service. The Plan denied your request. The Plan says an appropriate modifier was not billed. 

 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.  

The file shows that CPT code 76705 was billed along with code 93976. We find that CPT code 76705 may be eligible for payment when billed with this code pair. The provided claim does not show that the code at issue was billed with a modifier suitable for payment. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the abdominal ultrasound provided on August 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the office visit you had with an out-of-network (OON) physical medicine and rehabilitation specialist on June 8, 2021.
You asked the Plan to reduce the copayment for the OON specialist visit. You say that you were told that this provider was in-network when you called, so you feel as though you should only have a $35 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 $55 copayment for office visits with an out-of-network specialist. You have been asked to pay a $55 copayment for the OON specialist visit. The Plan cannot be held responsible for incorrect information provided to you by an OON provider.
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 reduce the copayment for the office visit you had with an out-of-network (OON)
physical medicine and rehabilitation specialist on June 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for polymerase chain reaction (PCR) testing provided to the 
enrollee on July 27, 2021.

You asked the Plan to pay for the testing. You say that this is medically necessary. The Plan denied your 
request. The Plan says the clinical value and effectiveness of PCR testing in the setting of tinea unguium have 
not been demonstrated in the peer-reviewed literature.

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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. 

Our physician reviewer found the review indicates that the standard of care for verification of a fungal infection 
of the nail (tinea unguium or onychomycosis) remains direct microscopic examination with potassium 
hydroxide, fungal culture of desquamated subungual material, or fungal stain of a nail clippings fixed in
formalin. The clinical value and effectiveness of PCR testing in the setting of tinea unguium have not been 
demonstrated in the peer-reviewed literature. The review has determined that the services at issue in this case 
are not medically reasonable or necessary.

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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for polymerase chain reaction (PCR) testing provided to the enrollee on July 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services provided to the enrollee from March 11, 2020, to March 20, 2020.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the time limit for filing this claim has expired.  The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.  The record shows that a claim for the services was not filed until [enter date the claim was filed]. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the services provided to the enrollee from March 11, 2020, to March 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for magnetic resonance imaging (MRI) of the brain provided on September 18, 2021.
You asked the Plan to waive the coinsurance for the MRI. You say that you would like the test covered due to your coronavirus diagnosis. The Plan denied your request. The Plan says the correct coinsurance 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). Your contract with the Plan clearly says that you must pay a 20% coinsurance for diagnostic radiology services, not including X-rays. You have been asked to pay $44.68, which is 20% of the allowed amount for the MRI ($223.38 allowed amount x 20% coinsurance = $44.68). The MRI falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the correct amount based
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for magnetic resonance imaging (MRI) of the brain provided on September 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the CT scan, head or brain; without contrast material (CPT code 70450) provided to the enrollee on August 11, 2021.

You asked the Plan to pay for the CT scan. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not covered as billed.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met. Our records indicate a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 70450 and 70496. This PTP edit has a modifier indicator of 1, which indicates modifiers associated with NCCI are allowed, however, an appropriate NCCI modifier was not billed with this PTP code edit.

Therefore, we decided that the Plan does not have to pay for the CT scan, head or brain; without contrast material (CPT code 70450) provided to the enrollee on August 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for incontinence supplies.  You asked the Plan to pay for incontinence supplies. You say that when you signed up for the Plan you asked if your insurance would cover for incontinence supplies and they told you yes. The Plan denied your request. The Plan says this item is not a covered benefit.  The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable.   While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pay for incontinence supplies.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a spinal cord stimulator trial.  You asked the Plan to pre-approve the requested services. You say that a spinal cord stimulator would eliminate the need for further interventional procedures. The Plan denied your request. The Plan says the enrollee is not a good candidate for this procedure at this time.  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 requested services. Our physician reviewer found that the enrollee has chronic low back pain. He had an epidural steroid injection and diagnostic medial branch blocks. He has not had any prior spine surgery and does not have peripheral vascular or sympathetic dysfunction. He does not have any evidence-based indication noted in his history for the requested service. There is no documentation of a psychological evaluation. He has not had a multidisciplinary approach to management. Therefore, the requested services are not medically reasonable or necessary.  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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a spinal cord stimulator trial.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and lab services provided on September 14, 2020.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the enrollee's plan requires utilization of network providers and authorization for certain services.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care. The file shows that the enrollee received medication management services. We looked at the file, and Medicare rules. The need for services was known prior to the enrollee leaving the service area. The records do not show the services were urgently needed. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the office visit and lab services provided on September 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for dialysis services provided from January 3, 2021, to February 
27, 2021.

You asked the Plan to pay for dialysis services. You say that you are expecting payment for these claims. The 
Plan denied your request. The Plan says the denial of payment for these services is correct, because code 
J0604-AX is now included in the end-stage renal disease (ESRD) prospective payment system (PPS) base rate 
and the whole claim is returned to the provider when this code is billed on bill type 721.

The Plan must follow Medicare rules. Medicare rules say that oral calcimimetic (J0604) is now included in the 
ESRD PPS base rate and is not separately payable; therefore, claims with type of bill 721 including J0604-AX 
will be returned to the provider.

We looked at the file and Medicare rules. These bills include J0604-AX, which is no longer eligible for 
separate payment because it is now bundled in the ESRD PPS base rate payment. Therefore, these claims are 
returned to the provider and you can resubmit the claims once the problems have been corrected. Based on this 
information, we decided that Medicare rules for coverage of dialysis services have not been met. Therefore, we 
decided that the Plan does not have to pay for dialysis services provided from January 3, 2021, to February 27, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on August 30, 2021.
You asked the Plan to pay for the dental service. You say that you did not receive any x-rays on the date of
service in this case. The Plan denied your request. The Plan says 1 panoramic x-ray is covered every 3 plan
years. The Plan also says the frequency limit has been exceeded.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, and the service is listed as covered, the
frequency limit has been exceeded. The record shows that the Plan paid for a panoramic x-ray that you received
on February 24, 2021. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray
(D0330) provided on August 30, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (80307, G0480) rendered by the out-of-network (OON) provider on July 7, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue.
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the drug testing services (80307, G0480) rendered by the out-of-network (OON) provider on July 7, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99212), destruction, malignant lesion 
(17272), and tangential biopsy of skin (11102) provided on July 16, 2021.

You asked the Plan to pay for the outpatient services. You say that the services should be covered. The Plan 
denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is 
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.

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 office visit (99212), destruction, malignant lesion 
(17272), and tangential biopsy of skin (11102) provided on July 16, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (36415, 80053, 80061, 83036) provided on September 8, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for laboratory services. You say that the Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not referred by a network provider or rendered in an in-network facility. The Plan has also determined that these services are 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 laboratory services (36415, 80053, 80061, 83036) provided on September 8, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to issue reimbursement for the dental cleaning (D1110), the intraoral-periapical first radiographic image (D0220), and the extraction of an erupted tooth or exposed root (D7140) provided on April 8, 2021.  You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says you did not receive the dental services by a licensed dentist within the United States and its territories; therefore, the Plan is unable to issue reimbursement for these services.  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 this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of these services have not been met. Specifically, the record indicates that you received services in Nuevo Progreso, Tamaulipas, a town in Mexico. In order to receive reimbursement for dentals services, the plan contract states that the services must be provided by a licensed dentist within the United States and its territories. Therefore, we decided that the Plan does not have to issue reimbursement for the dental cleaning (D1110), the intraoral-periapical first radiographic image (D0220), and the extraction of an erupted tooth or exposed root (D7140) provided on April 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a tertiary level of care for oncology services.  You asked the Plan to pre-approve advanced services. The Plan denied your request. The Plan says the enrollee does not need a tertiary level of care.  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 advanced services. Our physician reviewer found that you have a cystic renal mass and paraaortic and gastrohepatic adenopathy. At this point, with an uncertain nature of planned surgery, care from a community level network provider would be recommended. If surgery is suggested, care can be provided by an experienced community-level network provider. Therefore, the requested tertiary level of care is not medically reasonable or necessary 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 advanced services have not been met. Therefore, we decided that the Plan does not have to pre-approve a tertiary level of care for oncology services.