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

We decided that the Plan does not have to pay for the x-ray and emergency room services provided on June 26,
2020.
You asked the Plan to pay for the hospital services. You say that you would like reconsideration because the
right to recover for services provided to eligible beneficiaries is not extinguished by specific Plan requirements.
The Plan denied your request. The Plan says these services have not been billed correctly.
The Plan must follow Medicare rules. Medicare rules say that all charges, except for therapies, telehealth
originating site facility fee, PPV, influenza virus vaccine, hepatitis B vaccine and hospital-based ambulance
services are combined and reported under revenue code 0510.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the hospital services have not been met. Specifically, these services have not been billed with
revenue code 0510. Therefore, we decided that the Plan does not have to pay for the x-ray and emergency room
services provided on June 26, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the nerve conduction studies (95911) and the needle electromyography (95886) rendered by the out of network (OON) provider on October 13, 2020.
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 nerve conduction studies (95911) and the needle electromyography (95886) rendered by the out of network (OON) provider on October 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the replacement CPAP supplies provided
on September 16, 2020.
You asked the Plan to waive the coinsurance for the CPAP supplies. You say that you should be reimbursed
80% of what you paid out-of-pocket for the replacement CPAP supplies. The Plan denied your request. The
Plan says you have been charged the correct cost sharing 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 20%
of the total cost for Medicare-covered durable medical equipment and related supplies when using your pointof-
service (POS) benefit.
You have been asked to pay $164.59 which is 20% of the allowed amount for the CPAP supplies. The allowed
amount is $822.97. ($822.97 x 20% = $164.59). The CPAP supplies falls within the "Durable medical
equipment (DME) and related 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 the replacement CPAP supplies provided on September 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the extraction, erupted tooth (D7210).
You asked the Plan to pre-approve the extraction, erupted tooth. You say that these services are necessary for
your condition. The Plan denied your request. The Plan says the service is not medically necessary.
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. The Plan covers the extraction,
erupted tooth when the services are medically necessary and reasonable.
We looked at the file and Medicare rules. Medical records including relevant X-rays were not provided by the
dentist. We sent an additional request for these records, but the dentist did not respond. Based on this
information, we decided that the Plan's rules for coverage of the extraction, erupted tooth have not been met.
Therefore, we decided that the Plan does not have to pre-approve the extraction, erupted tooth (D7210).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical laparoscopy with lysis of adhesions (58660) provided on May 26, 2020.
You asked the Plan to pay for the surgical laparoscopy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 58660 is a column II to column I code 58571 and 58662.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the 58571 and 58662 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the surgical laparoscopy with lysis of adhesions (58660) provided on May 26, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRFadmission and services.You asked the Plan to pre-approveIRF care. You say that the stay is medically necessary.The Plan denied your request. The Plan says the stay 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 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 complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does not currently require intensive physician and nursing oversight only in an IRF. You were stable for discharge and has improved pancytopenia and liver and kidney function. You have controlled blood pressure and will follow up outpatient for your multiple sclerosis. You may benefit from multiple therapies such as physical and occupational therapy but the documentation does not support that your functional status requires an intensive rehabilitation therapy program provided 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-approveacute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on March 13, 2020 by an out of network (OON) provider.You asked the Plan to pay forthese services. You say that you disagree with the denial.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 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 forthe medical services provided on March 13, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 12, 2020, by an out-of-network provider.
You asked the Plan to pay for the medical services. You say that the claim should be paid. The Plan denied your request. The Plan says this provider is not a network provider, the services were not referred by a network provider and 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 the medical services provided on October 12, 2020, by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the outpatient services provided on September 17, 2020.
You asked the Plan to waive the copay for the services provided. You say that your normal out-of-pocket cost is $35. The Plan denied your request. The Plan says the claim processed 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 $200 copay for each Medicare-covered visit to an ambulatory surgical center You have been asked to pay a $200 copay for the services provided. The services fall within the outpatient surgery 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 copay for the outpatient services provided on September 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network gastroenterologist.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your
request. The Plan says out-of-network services are not a covered benefit when the services are available within
the plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
a referral to an out-of-network gastroenterologist.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on November 22, 2019 by an out of
network (OON) provider.
You asked the Plan to pay for the OON services. You say that the test was ordered to determine the optimal
treatment options for the enrollee. The Plan denied your request. The Plan says prior authorization was not
obtained prior to the services being offered.
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 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 lab services provided on November 22, 2019 by an out of network (OON)
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the home oxygen concentrator and portable oxygen system rental provided from February 19, 2020, to April 19, 2020 by an out of network provider.
You asked the Plan to pay for the home oxygen concentrator and portable oxygen system rental. You say that the Plan should pay this claim. The Plan denied your request. The Plan says you did not request 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 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 at issue in this appeal. The Plan did not pre-approve the items 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 home oxygen concentrator and portable oxygen system rental provided from February 19, 2020, to April 19, 2020 by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature (CPT Code E2300).
You asked the Plan to pre-approve a power seat elevation feature. You say that you are requesting review of
denial of services. The Plan denied your request. The Plan says this item is not primarily medical in nature.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The rules say that a power seat elevation feature (E2300) and power standing feature (E2301) are non-covered
because they are not primarily medical in nature. This item is available to the general public and would be
helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to preapprove
a power seat elevation feature (CPT Code E2300).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the unspecified endodontic service (D3999).

You asked the Plan to pre-approve the dental service. You say that you need the service to be approved so that you can have work done on your teeth.The Plan denied your request. The Plan says the unspecified endodontic service is not listed as a covered service.

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 pre-approve the unspecified endodontic service (D3999).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered on July 23, 2020.You asked the Plan to pay forthese 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 forthe drug testing rendered on July 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids purchased on August 7, 2020.
You asked the Plan to pay for the hearing aids. You say that you feel that this denial is incorrect. The Plan
denied your request. The Plan says there is no coverage for hearing aids when received from a non-plan
vendor.
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 pays for
hearing aids only from the plan-approved vendor.
The provider in this case is not plan approved. Based on this information, we decided that the Plan's rules for
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for
hearing aids purchased on August 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (S9328) provided from March 25, 2020, to
August 12, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not
payable.
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee
Schedule indicates that the code in question is not valid for Medicare purposes.
We looked at the file and Medicare rules. Code S9328 is assigned a status indicator of "I" under the Physician
Fee Schedule, which means that this code is not valid for Medicare purposes. Medicare uses another code for
reporting of, and payment for, these services. Based on this information, we decided that Medicare rules for
coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the
services (S9328) provided from March 25, 2020, to August 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for an ultrasound of extracranial arteries
(93880), of the aorta (93979), of the leg arteries (93926), and of the extremities (93922) performed on July 14,
2020.
You asked the Plan to waive the copayments for an ultrasound of extracranial arteries, of the aorta, of the leg
arteries, and of the extremities. You say that the benefit book for 2020 shows a $30 copayment. The Plan
denied your request. The Plan says the correct copayments were 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 $160
copayment for each Medicare-covered radiological diagnostic service, not including X-rays.
You have been asked to pay $420.91, or less than or equal to a $160 copayment for each of 4 ultrasounds.
Ultrasounds of extracranial arteries, of the aorta, of the leg arteries, and of the extremities fall within the
"Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. This means that you
have been asked to pay less than or equal to 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 an ultrasound of extracranial arteries (93880), of the aorta
(93979), of the leg arteries (93926), and of the extremities (93922) performed on July 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), the periapical x-ray (D0220), and the panoramic x-ray (D0330) provided.

You asked the Plan to pay for the dental services. You say that you had to drive 45 minutes to the dentist that you were told was in network. You say that you cannot tell the dentist which x-ray to use. You say that your policy covers 2 fillings per year and cleanings. You also say that you should not have to fight with your plan or dentist office as to what they say they would cover.The Plan denied your request. The Plan says the limited oral evaluation is not listed as a covered service. The Plan says that periapical x-ray is not listed as a covered service. The Plan also says that panoramic x-ray is not listed as a covered service.

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 the limited oral evaluation (D0140), the periapical x-ray (D0220), and the panoramic x-ray (D0330) provided.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forhome infusion services (S9328) provided June 10, 2020 to September 2, 2020.You asked the Plan to pay forhome infusion services. You say that the services were medically necessary.The Plan denied your request. The Plan says this CPT code is not eligible for Medicare payment.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 S9328 is not supported in the medical record. Specifically, the National Physician Fee Schedule shows this CPT code has a status of "I" which means it is invalid for Medicare payment. Based on this information, we decided that Medicare rules for coverage of home infusion services have not been met.Therefore, we decided that the Plan does not have to pay forhome infusion services (S9328) provided June 10, 2020 to September 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvehyperbaric oxygen therapy (HBO therapy).You asked the Plan to pre-approveHBO therapy. You say that hyperbaric oxygen is the only therapy which the enrollee has not attempted and would be beneficial according to studies.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because HBO therapy is excluded from coverage for theenrollee's condition.The Plan must follow Medicare rules. Medicare rules say that Medicare does not cover HBO therapy for chronic venous stasis ulcers from chronic peripheral vascular disease. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of HBO therapy have not been met.Therefore, we decided that the Plan does not have to pre-approvehyperbaric oxygen therapy (HBO therapy).