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

We decided that the Plan does not have to pay for the outpatient office visits, anesthesia for diagnostic arteriography/venography, non-emergency transport ambulance services, and ground mileage.
The enrollee asked the Plan to pay for the outpatient office visits, anesthesia for diagnostic arteriography/venography, non-emergency transport ambulance services, and ground mileage. The enrollee says that they fell behind on their bills because they were too preoccupied with their husband's needs. The Plan denied the enrollee's request. The Plan says charges for enrollees electing hospice are considered by Medicare. The Plan also says that they have asked the enrollee's provider to send these claims to Original Medicare.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. Medicare hospice also 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 ended Medicare Hospice benefits on September 10, 2019. The services in question were provided before the end of that month. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the outpatient office visits, anesthesia for diagnostic arteriography/venography, non-emergency transport ambulance services, and ground mileage.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
You asked the Plan to pre-approve the CGM. You say that the CGM is medically necessary. The Plan denied your request. The Plan says rules for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor. 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 CGM. Our reviewer says that coverage criteria has not been met. Our physician reviewer found the enrollee does not use insulin so coverage criteria is not met. 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 CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a stress test.
You asked the Plan to waive the copayment for a stress test. You say that you cannot afford the charges and the test as a waste. 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 $150 copayment for stress tests. You have been asked to pay the allowed amount of $69.18, which is less than the $150 copayment for a stress test. A stress test 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 a stress test.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the MPI Biomarker Testing rendered.
You asked the Plan to pay for these services. You say that you were not aware prior authorization was needed. The Plan denied your request. The Plan says that the testing is not covered.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. You were referred for these services by a contract provider. The file does not show that the Plan provided notice that these services would not be covered. Under Medicare rules, this means these services is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the MPI Biomarker Testing rendered.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services 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 10061 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 10061 is incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or multiple. We find that CPT code 10061 is not supported in the medical record. Specifically, there is no documentation of incision and drainage of complicated or multiple abscesses. There is more appropriate code for the rendered services. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services rendered.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 has network providers available who can provide 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 medical services provided to the enrollee by an out-of-network provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care provided.
You asked the Plan to pay for the physician services. You say that the charges were for services that the enrollee received while inpatient. You say that the enrollee cannot be on hospice and receive inpatient care. You also say that the enrollee was discharged from hospice on November 11, 2019 and was not re-enrolled until December 5, 2019. 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.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on November 11, 2019. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the reline complete maxillary denture and reline complete
mandibular denture.
You asked the Plan to pay for the reline complete maxillary denture and reline complete mandibular denture.
You say that the enrollee's previous reline of her dentures had started to break off in October, and she was
unable to use them. You also say that the enrollee found a different dentist who was able to do a soft reline on
her old set of dentures. The Plan denied your request. The Plan says these services exceed the maximum
allowed per period.
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, denture reline procedures are limited to
one procedure every two years. The record shows that the enrollee received a reline complete maxillary denture
and reline complete mandibular denture on January 23, 2019 and the enrollee's denture reline procedures
benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the reline complete
maxillary denture and reline complete mandibular denture.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gingival irrigations (D4921), periodontal medicament carriers with peripheral seals (D5994), periodontal maintenance (D4910), and localized deliveries of antimicrobial agents (D4381).
You asked the Plan to pay for the gingival irrigations, periodontal medicament carriers, periodontal maintenance, and localized deliveries of antimicrobial agents. The Plan denied your request. The Plan says gingival irrigation and periodontal medicament carrier are not covered benefits. The Plan also says that you were correctly charged for the periodontal maintenance and localized deliveries of antimicrobial agents.
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 gingival irrigations and periodontal medicament carriers are not among those covered under this benefit. The Plan contract says that you are responsible for a $40 copayment for periodontal maintenance (D4910) and a $35 copayment for each localized delivery of antimicrobial agents (D4381). Therefore, we decided that the Plan does not have to pay for the gingival irrigations (D4921), periodontal medicament carriers with peripheral seals (D5994), periodontal maintenance (D4910), and localized deliveries of antimicrobial agents (D4381).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services.
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 separately payable.
The Plan must follow Medicare rules. Medicare rules say that the PC of codes with a PC/TC indicator of 8 is
only separately payable when billed as hospital inpatient.
We looked at the file and Medicare rules. The file shows that procedure code 85060 was billed with place of
service code 22 for outpatient hospital. This code has a PC/TC indicator of 8 and the PC is only separately
payable when the services are billed with an inpatient hospital code. 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 laboratory services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the breast reconstruction with other technique services coded 19366 provided.
You asked the Plan to pay for the breast reconstruction with other technique services. 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 19366 is breast reconstruction with other technique. 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 breast reconstruction with other technique services. Our reviewer says that the documentation does not support the billing of code 19366. Our physician reviewer found following a segmental mastectomy, the enrollee underwent bilateral mastoplexies. While both procedures are considered reconstructive, not cosmetic, as they are being performed in the setting of breast cancer, the procedures should be billed as mastoplexies, not as an unspecified breast reconstruction on the left and a mastoplexy on the right. The surgery on the left did not involve the creation of a flap or insertion of tissue to reconstruct the breast. Rather, tissue was removed and rearranged, with conservation of the nipple. While the left breast used a large medial pedicle and the right breast used a superomedial pedicle, the surgeries were nearly identical mastoplexies and should be billed as such. The billing of CPT 19366 LT is not supported. 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 breast reconstruction with other technique services have not been met. Therefore, we decided that the Plan does not have to pay for the breast reconstruction with other technique services coded 19366 provided.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the arthrocentesis.
You asked the Plan to waive the copayment for the arthrocentesis. You say that the copayment for outpatient surgery is incorrect. You say that Part B coinsurance should have applied. 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 $290 copayment per visit for Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient facility. You have been asked to pay a $290 copayment for the arthrocentesis. The arthrocentesis falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The arthrocentesis is considered a surgical injection. 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 arthrocentesis.
Appeal type: ER
Decision: Partially Favorable

We decided that the Plan has to reduce the cost for the CT scan provided. We decided that the Plan does not have to waive the cost for the remaining observation services.
You asked the Plan to waive the copayment for observation services. You say that you did not have 3 CT scans. You say that some services are not shown on the statement. The Plan says that the copayments applied correctly.
We decided that the Plan has to reduce the cost for the CT scan provided.
The records show that the CT scan provided was performed prior to being admitted to observation. This means that only the emergency room copayment applies. Therefore, we decided that the Plan has to reduce the cost for the CT scan provided from $121.64 to $80.
We also decided that the Plan does not have to waive the cost for the remaining observation services.
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 $210 for each Medicare-covered outpatient hospital observation stay at a hospital facility and $200 for each type of Medicare-covered diagnostic radiology service including MRI, CT Scans, Nuclear Scans and PET scans, per date of service. Therefore, we decided that the Plan does not have to waive the cost for the remaining observation services.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to issue reimbursement in the amount of $100 for the progressive lenses (v2781) and the polarization of each lens (V5762) purchased.
You asked the Plan to issue reimbursement in the amount of $100 for the lenses. You say that you have been trying to resolve an issue with the vendor of the Plan supplemental vision benefit. The Plan denied your request. The Plan says that the claim was processed through the vendor at the contracted rate.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers frames and lenses up to a benefit limit of $100 per year. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the lenses at a $100 benefit have been met. Specifically, the record shows that you were issued reimbursement of $60, $40 less than the allowed benefit of $100. There was no information to show that you previously exhausted the benefit limit for frames and lenses.
There is also no Plan benefit limitation listed in the EOC which would exclude payment for the items at issue. Therefore, we decided that the Plan has to issue reimbursement in the amount of $100 for the progressive lenses (v2781) and the polarization of each lens (V5762) purchased.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the cystoscopy provided.
You asked the Plan to waive the copayment for the cystoscopy. You say that you were only seen in the doctor's office. You say that you already paid the office visit 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $50 copayment per visit for in-network outpatient surgery. The enrollee has been asked to pay a $50 copayment for the cystoscopy. The cystoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that the physician and the hospital charged separately for the cystoscopy. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the cystoscopy provided.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the mammogram coded 77065.
You asked the Plan to pay for the mammogram. 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 77065 is diagnostic mammography, including computer-aided detection (CAD) when performed; unilateral. We find that CPT code 77065 is not supported in the medical record. Specifically, the documentation supports one unit of this service (code 77065) for this date of service, which was previously approved/paid. There is no additional documentation supporting additional studies. Based on this information, we decided that Medicare rules for coverage of the mammogram have not been met. Therefore, we decided that the Plan does not have to pay for the mammogram coded 77065.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health care provided by a provider that does not participate in Medicare from September 6, 2019 to November 24, 2019.
You asked the Plan to pay for home health care. You say that these services were medically necessary and not available from participating providers. The Plan denied your request. The Plan says these services cannot be covered when received from a provider that is not enrolled in Medicare.
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program. We looked at the file and Medicare rules. The provider that the enrollee received these services from is not enrolled in Medicare. Based on this information, we decided that Medicare rules for coverage of home health care have not been met. Therefore, we decided that the Plan does not have to pay for home health care provided by a provider that does not participate in Medicare from September 6, 2019 to November 24, 2019.