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

We decided that the Plan does not have to pay for esophagogastroduodenoscopy procedures provided on January 30, 2020.
You asked the Plan to pay for the esophagogastroduodenoscopy procedures. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider such as an urgent or an emergent situation that has been documented.
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 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 esophagogastroduodenoscopy procedures provided on
January 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the group 2 power wheelchair including power tilt and power recline.
You asked the Plan to pre-approve the group 2 power wheelchair including power tilt and power recline. You say that you would like reconsideration as you are offering a free upgrade because the member requires power tilt/recline. The Plan denied your request. The Plan says the requested equipment is not medically necessary.
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 group 2 power wheelchair including power tilt and power recline. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the records from the physician do not include documentation of a need for the tilt/recline function such as a need for urinary bladder catherization, presence of muscle spasticity or a high risk of skin breakdown.
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 group 2 power wheelchair including power tilt and power recline have not been met. Therefore, we decided that the Plan does not have to pre-approve the group 2 power wheelchair including power tilt and power recline.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0482 provided on July 29, 2020.
You asked the Plan to pay for the drug testing. 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 G0482 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed. We find that CPT code G0482 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0482 provided on July 29, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (80307, G0483) provided on June 29, 2020.
You asked the Plan to pay for drug testing. You say that this was medically necessary. The Plan denied your request. The Plan says this was not billed with the correct place of service.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The services at issue were billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (80307, G0483) provided on June 29, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the imaging services provided on May 1, 2020.
You asked the Plan to pay for the imaging services. The Plan denied your request. The Plan says this is not a payable service.
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay for any service furnished by a student. We looked at the file and Medicare rules. The imaging services in question were provided by student. Medicare does not pay services provided by a student. Based on this information, we decided that Medicare rules for coverage of the imaging services have not been met. Therefore, we decided that the Plan does not have to pay for the imaging services provided on May 1, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab work provided by a participating
provider on November 6, 2019.
You asked the Plan to waive the copayment for lab work. You say that you do not agree with this copayment.
You say that you already paid this. The Plan denied your request. The Plan says the correct copayment has
been 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 $40
copayment for outpatient diagnostic tests/lab services/outpatient hospital.
You have been asked to pay a $40 copayment for lab work. Lab work falls within the outpatient diagnostic
tests/lab services/outpatient hospital 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
lab work provided by a participating provider on November 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay from May 26, 2020, through May 28, 2020 and the observation stay from May 28, 2020, through May 29, 2020.
You asked the Plan to waive the copayment for the inpatient stay and observation stay. You say that this was a planned surgery, but you are being charged a copayment twice. You say that only one copayment should apply for surgery. 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 $250 copayment for each in-network, Medicare-covered inpatient hospital stay and a $250 copayment per observation stay for each in-network, Medicare-covered service. You have been asked to pay a $250 copayment for the inpatient stay and a $250 copayment for the observation stay. The total amount you owe is $500 ($250/stay x 2 stays = $500). The inpatient stay falls within the "Inpatient hospital care" benefit category and the observation stay falls within the "Outpatient Hospital Observation" benefit category. The records show that you were admitted to outpatient observation after being discharged from your inpatient stay.
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 inpatient stay from May 26, 2020, through May 28, 2020 and the observation stay from May 28, 2020, through May 29, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for comprehensive eye exam (92014) scanning computerized ophthalmic diagnostic imaging (92133) optical coherence biometry (92136) provided November 18, 2019.
You asked the Plan to waive the copayment for the vision services. You say that you have never had diagnostic testing performed unless you had a problem, talked with the doctor, gave your consent for testing and definitely ask about the cost. The Plan denied your request. The Plan says the claim processed, and the correct copayment was applied per the Evidence of Coverage.
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 20% coinsurance for diagnostic tests and procedures. You have been asked to pay $369.75 the diagnostic services. The diagnostic services fall 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 comprehensive eye exam (92014) scanning computerized ophthalmic diagnostic imaging (92133) optical coherence biometry (92136) provided November 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous therapeutic glucose monitor provided September 30, 2020.
You asked the Plan to pay for the continuous therapeutic glucose monitor. You say that this item is medically necessary for the enrollee. The Plan denied your request. The Plan says medical necessity criteria have not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the continuous therapeutic glucose monitor have not been met. Therefore, we decided that the Plan does not have to pay for the continuous therapeutic glucose monitor provided September 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care rendered.

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 99231 is not separately payable.

The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. 

The provider submitted a claim for procedure codes 99231 and 01480. Code 99231 is a column II code with a modifier indicator of 1 when billed with column I code 01480. Code 99231 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care rendered.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for Esophagogastroduodenoscopy provided on November 4, 2020 by an out of network provider.
You asked the Plan to pay for Esophagogastroduodenoscopy (43239,43251). You say that the services were medically necessary. The Plan denied your request. The Plan says prior authorization was denied.
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 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 Esophagogastroduodenoscopy provided on November 4, 2020 by an out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that you would benefit from and need inpatient rehabilitation. The Plan denied your request. The Plan says this request is not medically necessary.
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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that your current medical condition does not require intensive physician or nursing supervision in an IRF. Our physician reviewer also found that you may benefit from additional physical and occupational therapy, but the documentation does not reveal that this therapy must be only on an intensive level in an IRF. 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 the acute IRF admission and services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for audiology services provided on January 19, 2021.
You asked the Plan to pay for the audiology services. The Plan denied your request. 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 Plan says that 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 did not pre-approve the
audiology services. 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 audiology services provided on January 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a foot insert (L3000) provided on November 5, 2020.
You asked the Plan to pay for foot orthotics. You say that the requested item helps you with post-surgical foot pain and should be a covered medical expense. The Plan denied your request. The Plan says the requested item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pay for a foot insert (L3000) provided on November 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided by a
participating provider.

You asked the Plan to waive the copayment for ambulance services. You say that you would like this claim
reprocessed and paid. The Plan denied your request. The Plan says the correct copayment has been 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 $310
copayment for ambulance services.

You have been asked to pay a $310 copayment for ambulance services. Ambulance services fall within the
ambulance services benefit category. This means that you have been asked to pay the correct amount based on
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services
provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse the full amount for the comprehensive oral evaluation (D0150), the cleaning (D1110), and the panoramic x-ray (D0330) provided on September 30, 2020.
You asked the Plan to reimburse the full amount for the dental services. You say that you contacted the plan prior to the appointment to verify that it would be covered. You say that a plan representative advised that you were covered for preventive and comprehensive dental up to $1,000. You say that the total cost was $778 out of pocket. You say that you were only reimbursed $273. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that out of network providers may bill you for any amount over the MAC.
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 services are listed as covered, dental services that you receive out of network may cost more. Out of network providers may bill you for any amount over the MAC. Therefore, we decided that the Plan does not have to reimburse the full amount for the comprehensive oral evaluation (D0150), the cleaning (D1110), and the panoramic x-ray (D0330) provided on September 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), the periapical
x-ray (D0220), the additional periapical x-ray (D0230), and bitewing x-rays (D0274) provided on November 9,
2020.
You asked the Plan to pay for the dental services. You say that you called the dentist several times and were
told they accept your plan. You say that after your appointment you were told that the plan threw the provider's
office out of the plan. You say that you cannot afford to pay this bill. You also say that you are on disability.
The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that
dental services that you receive out of network are not covered. The Plan also says that you did not contact the
plan prior to the date of service to verify benefits and 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 and the services you received are listed
as covered, the requested items or services are not among those covered under this benefit when you receive
them from an out of network provider. Therefore, we decided that the Plan does not have to pay for the oral
exam (D0120), prophylaxis (D1110), the periapical x-ray (D0220), the additional periapical x-ray (D0230), and
bitewing x-rays (D0274) provided on November 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for removal of intrauterine device (58301) insertion of intrauterine device (58300) Levonorgestrel-releasing intrauterine contraceptive system (J7298) provided by an out of network (OON) provider.

You asked the Plan to pay for removal and insertion of IUD. You say that please kindly review closely per your contract. 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 item is 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. This service also is not covered as the service is intended to prevent pregnancy and not to treat an illness or injury. 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 removal of intrauterine device (58301) insertion of intrauterine device (58300) Levonorgestrel-releasing intrauterine contraceptive system (J7298) provided by an out of network (OON) provider.