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

We decided that the Plan does not have to pay for CxBladder testing provided on October 26, 2020.
You asked the Plan to pay for CxBladder test. You say that this test is eligible for payment as long as the service meets medical necessity guidelines. The Plan denied your request. The Plan says this test is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that CxBladder testing is not covered by Medicare for date of service October 26, 2020. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CxBladder test have not been met. Therefore, we decided that the Plan does not have to pay for CxBladder testing provided on October 26, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for emergency care provided on June 8, 2020, and June 18, 2020.
You asked the Plan to waive the copayments for emergency care. You say that you disagree with the charges because you feel that your primary care physician should have seen you. 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 $120 copayment for emergency care. The medical records show that you received emergency care on June 8, 2020, and June 18, 2020. Therefore, you are responsible to pay a $120 copayment for each ER visit. The total amount you owe is: $240. You have been asked to pay the total copayment amount of $240 for emergency care. Emergency care falls within the emergency 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 copayments for emergency care provided on June 8, 2020, and June 18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on August 5, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on August 5, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound provided on July 29, 2020.
You asked the Plan to waive the copayment for the ultrasound. You say that the wires of the machine were broken or not properly connected to the computer. You say that the test was done at the request of the Plan not your doctor, so you should not be responsible for the copayment. The Plan denied your request. The Plan says the copayment 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 $160 copayment for each Medicare-covered radiological diagnostic service from an in-network provider. You have been asked to pay $141.69, which is less than the standard $160 copayment for the ultrasound. The ultrasound 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 copayment for the ultrasound provided on July 29, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on May 5, 2020.
You asked the Plan to pay for the ambulance transport (A0428, A0425) from residence to physician's office. You say that the Plan should pay this claim. The Plan denied your request. The Plan says a van transport or other vehicle may have been an option.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 ambulance transport from residence to physician's office. Our reviewer says that the ambulance service was not medically necessary. Our physician reviewer found the patient was hemodynamically stable and calm with no acute findings on physical examination or complications during transport. The documentation does not support that other means of transport, such as a stretcher van, would have been contraindicated for this patient. The documentation does not support that the patient needed expertise or special equipment during transport. The documentation does not support that the ambulance transport on May 5,2020 was medically necessary or reasonable for the patient. A stretcher van would have been more appropriate. We looked at this physician's review, the file, and Medicare rules. During the Public Health Emergency, for dates of service Mary 31, 2020 and forward, Medicare covers ambulance transportation to physician offices. While Medicare allows ground ambulance transports to physician offices, on this date of service there was no treatment or medical services needed during the transportation to justify the ambulance services. Based on this information, we decided that Medicare rules for coverage of the ambulance transport from residence to physician's office have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on May 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation (D9310) for tooth trauma provided on October 20, 2020 by an out-of-network provider.
You asked the Plan to pay for the consultation. You say that you had an incident a few weeks prior that resulted in the need to see a maxillofacial surgeon to remove or save your teeth. You were told by the hospital that your insurance would cover the dental services because it was caused by a medical problem. The Plan denied your request. The Plan says Medicare does not cover general dental care, but the Plan does provide limited dental benefits. You only elected to enroll in the mandatory benefit that comes with your Plan, which requires that services must be provided by in-network dentists, except in an emergency. Dental emergency services require immediate attention. Dental care provided more than a day after the initial symptoms are not considered a dental emergency. In addition, the consultation is not a covered service under the mandatory supplemental benefit regardless of whether it is provided in or out of network.
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. The Plan has indicated that you are enrolled with the mandatory dental option only, which does not cover the requested service or provide out-of-network benefits. Therefore, we decided that the Plan does not have to pay for the consultation (D9310) for tooth trauma provided on October 20, 2020 by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered on September 1, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered on September 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder elbow wrist hand orthosis (L3962) provided on September 30, 2020.
You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the documentation provided does not support the billed item in this case.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. All services that do not have an appropriate proof of delivery will be denied. Additionally, the patient's medical record must contain sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use or replacement. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this item have not been met. Specifically, the record does not contain sufficient information of the patient's medical condition, as there was no documentation provided by the ordering physician. Additionally, the record does not contain valid proof of delivery as the delivery ticket did not indicate the enrollee's name and address, or information about the item billed in this case.
Therefore, we decided that the Plan does not have to pay for the shoulder elbow wrist hand orthosis (L3962) provided on September 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided October 8, 2020.
You asked the Plan to pay for the lumbar-sacral orthosis. You say that the item provided was medically necessary. The Plan denied your request. The Plan says the patient did not receive a video or telephonic visit by the ordering physician in order to warrant the code billed.
The Plan follows Medicare rules. Medicare rules say that the lumbar-sacral orthosis is subject to the criteria listed 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 pay for the lumbar-sacral orthosis. Our reviewer says that the requested orthosis was not medically necessary and reasonable. Our physician reviewer found the enrollee is a 78 year old female with a diagnosis of lower back pain. Based on the medical records provided, there is no evidence of an established relationship between the provider and the enrollee. Therefore, without evidence of an established relationship for medical necessity of the orthosis, the requested orthosis does not satisfy the criteria listed in the Local Coverage Determination for Spinal Orthoses. 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 lumbar-sacral orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided October 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance provided on December 9, 2020.
You asked the Plan to pay for the periodontal maintenance. You say that you have been advised by several
dentists and periodontal specialists that you need to have exams and periodontal cleanings every three months.
The Plan denied your request. The Plan says this cleaning exceeds the number of dental cleanings offered in a
calendar year.
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, you are limited to two cleanings
(regular or periodontal maintenance) per year. The record shows that you received periodontal maintenance
services on January 9, 2020, and June 11, 2020, and your cleanings benefit had been exhausted. Therefore, we
decided that the Plan does not have to pay for the periodontal maintenance provided on December 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the blood glucose strips provided by an out-of-network
provider on May 27, 2020.
You asked the Plan to pay for the blood glucose strips. You say that purchasing online is half the cost of the
pharmacy prices. You say that you want to be reimbursed for what you spent. The Plan denied your request.
The Plan says care and supplies must be received from in-network providers.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the blood glucose strips provided by an out-ofnetwork
provider on May 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the complete series x-ray (D0210), core build up
(D2950), the crown (D2740), and the fillings (D2332 x 3) provided from November 17, 2020, to November 30,
2020.
You asked the Plan to reimburse you for the complete series x-ray, core build up, crown, and fillings. You say
that you had 3 cavities filled. You say that you paid out of pocket for these services. You also say that you
should be reimbursed. The Plan denied your request. The Plan says complete series x-ray is not listed as a
covered service. The Plan says that core build up is not listed as a covered service. The Plan says that crown is
not listed as a covered service. The Plan also says that fillings are not listed as covered 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.
Though the Plan offers a dental benefit in excess of Medicare coverage, the complete series x-ray, core build
up, crown, and fillings are not among those covered under this benefit. Therefore, we decided that the Plan
does not have to reimburse you for the complete series x-ray (D0210), core build up (D2950), the crown
(D2740), and the fillings (D2332 x 3) provided from November 17, 2020, to November 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on November 24, 2020 by an out of network (OON) provider.
You asked the Plan to pay for lab work. You say that these services were referred to you. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained for 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 lab work provided on November 24, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (99100) provided August 26, 2020.
You asked the Plan to pay for anesthesia services. You say that the services were medically necessary. The Plan denied your request. The Plan says payment for these services is bundled in payment for another service. This code is 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 99100 has a bundled relationship with code 00731 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 anesthesia services (99100) provided August 26, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Urine PCR testing rendered on January 23, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the testing is not covered.
The Plan must follow Medicare rules. The rules say that urinalysis is covered when a patient has clinical signs and symptoms indicative of a possible urinary tract infection (UTI). We looked at the file and Medicare rules. The services at issue are urine PCR testing. This testing is not the standard of care over urinalysis for urinary tract infections. 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 Urine PCR testing rendered on January 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aid repair or modification (V5014) and binaural dispensing fee (V5160) provided on November 17, 2020.

You asked the Plan to pay for the hearing aid services. You say that you received a bill for $400 and the Plan should cover this. The Plan denied your request. The Plan says that they have paid the allowed $500 maximum for the services provided. However, the provider billed a total cost of $900 for these services. You are responsible for these charges beyond the Plan's $500 limit.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan will pay up to $500 for a hearing aid once every three years. 

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's benefit for this service was paid correctly and exhausted on the date in question. Per your contract, you are responsible for the costs of hearing aid services that exceed the Plan's allowed amount. Therefore, we decided that the Plan does not have to pay for the hearing aid repair or modification (V5014) and binaural dispensing fee (V5160) provided on November 17, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for extracorporeal photopheresis (35622) provided November 2, 2020.

You asked the Plan to pay for extracorporeal photopheresis. You say that the records provided should support the necessity of the service in dispute. The Plan denied your request. The Plan says this service is not covered per the Medicare NCD.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of extracorporeal photopheresis have not been met. Therefore, we decided that the Plan does not have to pay for extracorporeal photopheresis (35622) provided November 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental consultation (D9310) and tooth extractions (D7210) provided on September 23, 2020.

You asked the Plan to pay for the dental services. You say that the requirements for dental coverage were misleading and confusing. The Plan denied your request. The Plan says the contract clearly states that dental services must be provided by a licensed provider who participates in Medicare. The provider in question does not participate in or accept Medicare insurance.

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, no items or services are covered when they are received from a provider who has opted out of Medicare. Therefore, we decided that the Plan does not have to pay for the dental consultation (D9310) and tooth extractions (D7210) provided on September 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing provided on September 25, 2020.

You asked the Plan to pay for genetic testing. You say that the enrollee's treating physician ordered this testing to determine if there was a more effective therapy to treat the enrollee's condition. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this testing was not billed with the appropriate coding.

The Plan must follow Medicare rules. Medicare rules say that CGP testing must be billed with CPT code 81479 for date of service September 25, 2020. 

We looked at the file and Medicare rules. This testing was not billed with the appropriate coding. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing provided on September 25, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (G0482) provided September 15, 2020.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim did not include a valid place of 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. 

We find that CPT code G0482 is not supported in the medical record. Specifically, the claim was submitted with a place of service 81- Laboratory, however, the record shows the sample was obtained in the office setting (place of service 11). 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 lab services (G0482) provided September 15, 2020.