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

We decided that the Plan does not have to provide an exception to the 50-mile one-way limit for routine transportation.
You asked the Plan to provide an exception an exception to the 50-mile limit. You say that it is medically necessary for you to see the requested provider and you need transportation to that provider. The Plan denied your request. The Plan says the Plan contract is clear that routine transportation has a 50-mile limit one way. The Plan states the destination you are requesting is 95.1 miles one way.
Medicare does not cover routine transportation. While plans may offer supplemental transportation benefits, they are not required to do so. Medicare does not provide exceptions to supplemental benefits or the benefit rules and limitations. Therefore, we decided that the Plan does not have to provide an exception to the 50-mile one-way limit for routine transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan has to pay for 2 units of the behavioral assessment (96127). We decided that the Plan does not have to pay for 1 unit of the behavioral assessment. 

You asked the Plan to pay for 3 units of the behavioral assessment (96127x3). You say that 3 units of this service were medically necessary due to the scope of pain management medicine. The Plan says that the units billed exceed the allowed amount of only 2 units per day for this service.

We decided that the Plan has to pay for 2 units of the behavioral assessment (96127). 

The Plan follows Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for that HCPCS/CPT code will be denied.
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 3 units of the behavioral assessment (96127x3). Our reviewer says that Medicare limits the billable for behavioral assessment to 2 units per session. Our physician reviewer found there was no extra-ordinary additional or disorder specific testing performed.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 2 units of the behavioral assessment (96127x2) have been met. Therefore, we decided that the Plan has to pay for 2 units of the behavioral assessment (96127x2). 

We also decided that the Plan does not have to pay for 1 unit of the behavioral assessment.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 1 unit of the behavioral assessment have not been met. Therefore, we decided that the Plan does not have to pay for 1 unit of the behavioral assessment.

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: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation and prophylaxis provided on October 3, 2019.
You asked the Plan to pay for the comprehensive oral evaluation and prophylaxis. You say that the provider's office confirmed that you were covered for the cleaning. The Plan denied your request. The Plan says the services were rendered by an out-of-network provider. The Plan also says that these services are not covered benefits when rendered by a dentist who does not participate in the Plan's program.
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 covered when they are received out-of-network. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation and prophylaxis provided on October 3, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray provided on November 15, 2019.
You asked the Plan to pay for the limited oral evaluation and intraoral periapical x-ray. You say that you were not aware of your maximum benefits. You also say that you were in pain and needed to see a doctor. The Plan denied your request. The Plan says you had exceeded your annual maximum benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan offers a $2,000 annual dental benefit maximum. The contract says that after your annual deductible benefit maximum has been met, you are responsible for the full charges of any additional dental services. The record shows that you met the annual deductible benefit on October 29, 2019 and your annual deductible benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray provided on November 15, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from August 1, 2019 through September 10, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you were told to return to the hospital because your condition was too severe to be helped by rehab services. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received inpatient hospital care from August 1, 2019 through September 10, 2019. You are asked to pay a $300 copayment for the inpatient hospital care. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital care from August 1, 2019 through September 10, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive oral evaluation - new or established patient
(D0150) provided on October 15, 2019.
You asked the Plan to pay for the dental services. You say that the service is medically necessary. The Plan
denied your request. The Plan says you exhausted your benefit frequency limit.
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 exhausted your benefit frequency
limit, because you had a comprehensive oral evaluation on January 11, 2018. Your EOC clearly states, one
comprehensive evaluation per 36 months. Therefore, we decided that the Plan does not have to pay for
comprehensive oral evaluation - new or established patient (D0150) provided on October 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for crutch substitute, lower leg platform, with or without wheels
(a knee walker/scooter) (CPT Code E0118) provided from July 25, 2019 through August 25, 2019, by an out-of-
network provider.
You asked the Plan to pay for the crutch substitute. You say that the durable medical equipment is medically
necessary. The Plan denied your request. The Plan says this item is not covered under Medicare or the Health
Plan.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the crutch substitute have not been met. Your medical records
show that you obtained this item to help you with mobility following your foot surgery. The Centers for
Medicare & Medicaid Services National Correct Coding Initiative Coding Policy Manual for Medicare
Services says that E0118 is not covered by Medicare in any payment system. Payment cannot be made for this
item because it is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for crutch
substitute, lower leg platform, with or without wheels (a knee walker/scooter) (CPT Code E0118) provided
from July 25, 2019 through August 25, 2019, by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for automatic external defibrillator (K0606) provided to the enrollee from May 24, 2019 through July 24, 2019.
You asked the Plan to waive the coinsurance for the DME. You say that the member is being charged the full amount for the final month when he only wore the device for the eleventh day. The Plan denied your request. The Plan says the claim was processed accordingly with the member's 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that the enrollee received an automatic external defibrillator (K0606) provided to the enrollee from May 24, 2019 through July 24, 2019. The enrollee is asked to pay 20% coinsurance per date of service for the DME. 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 coinsurance for automatic external defibrillator (K0606) provided to the enrollee from May 24, 2019 through July 24, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on October 2, 2019 by an outof-
network provider.
You asked the Plan to pay for the dental services. You say that you believed the provider was in-network. The
Plan denied your request. The Plan says they reviewed the call you made to the customer service department
and confirmed that you were given details for four in-network dentists.
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 provider is not in-network and your EOC clearly states, services
performed by an out-of-network dentist if your plan does not have out-of-network coverage. Therefore, we
decided that the Plan does not have to pay for the dental services provided on October 2, 2019 by an out-ofnetwork
provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on April 2, 2019 and billed under codes 80307 and G0483.
You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your request. The Plan says codes 80307 and G0483 remain not supported. 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, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11. Also, the laboratory results submitted indicate the specimen was collected on April 2, 2019 and received by the lab on April 3, 2019; therefore, the billed code cannot be verified. The Plan states the documentation submitted did not include a valid physician order/lab requisition or medical records (signed by the ordering physician) stating exactly what tests are to be performed. Per the submitted toxicology profile, "My custom profile is effective for 1 year as of the date signed; however, I may make changes at any time." The signature date of the Toxicology Profile is March 8, 2018; however, the billed date of service is April 2, 2019; therefore, the billed codes cannot be verified. The Plan says that multiple attempts were made to obtain additional information from the provider. The Plan must follow Medicare rules. Medicare has specific documentation requirements for this type of testing. Medicare requires the claim to reflect the appropriate POS code. The physicians order and the medical records must specifically show how this testing will be used to treat illness or disease present in the enrollee at the time of service as opposed to this testing being done for screening purposes. Based on the records provided, the required Medicare criteria are not met. The claim submitted lacks the appropriate POS code and physician documentation required for payment. Therefore, we decided that the Plan does not have to pay for drug testing services provided to the enrollee on April 2, 2019 and billed under codes 80307 and G0483.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for bilateral knee orthoses (L1833) and suspension sleeves (L2397) provided to the enrollee on October 15, 2019.
You asked the Plan to pay for V. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The billed service, L1833, POSITIONAL ORTHOSIS, RIGID SUPPORT, PREFABRICATED, OFF-THE SHELF), was denied because two or more diagnosis codes associated to it are mismatched per the ICD-10-CM Official Guidelines for Coding and Reporting. The billed service, L2397, was denied because two or more diagnosis codes associated to it are mismatched per the ICD-10-CM Official Guidelines for Coding and Reporting. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for bilateral knee orthoses (L1833) and suspension sleeves (L2397) provided to the enrollee on October 15, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on November 8, 2019 by a non-participating provider.
You asked the Plan to pay for the services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says you do not have out-of-network benefits.
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. 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 services have not been met. Review of the file shows that you received services by a non-participating provider. Your EOC clearly states, any fees for any services rendered by a non-network hearing aid provider. In-network hearing aid providers reserve the right to only service devices purchased from in-network providers. Therefore, we decided that the Plan does not have to pay for the services provided on November 8, 2019 by a non-participating provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sinus endoscopy with balloon dilation (30140, 31295, and 31298).
You asked the Plan to pre-approve a sinus endoscopy with balloon dilation. You say that this is the best treatment for the enrollee. The Plan denied your request. The Plan says this is experimental.
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 a sinus endoscopy with balloon dilation. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found high quality data regarding the efficacy of balloon dilation are limited. While there may be a role for balloon dilation in patients with recurrent acute sinusitis, a Clinical Consensus Statement regarding Balloon Dilation of the Sinuses states that strong consensus was met that a computed tomography scan of the sinuses is necessary before performing sinus dilation, in order to confirm the diagnosis. There is no documentation of imaging in the case file. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a sinus endoscopy with balloon dilation have not been met. Therefore, we decided that the Plan does not have to pre-approve a sinus endoscopy with balloon dilation (30140, 31295, and 31298).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for outpatient services provided from August 7, 2019 through August 20, 2019.
You asked the Plan to waive the coinsurance for outpatient services. You say that you were informed the procedure would be fully covered. You were not informed of a copayment or deductible. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for all other outpatient services including observation and outpatient surgical services not provided in an in-network ambulatory surgical center. You have been asked to pay $807.20, which is 20% of the allowed amount for outpatient services.
The outpatient services fall within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that you were only charged for the prostatectomy provided from August 19, 2019 to August 20, 2019. 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 outpatient services provided from August 7, 2019 through August 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for wheelchair and accessories provided from October 15, 2019 through November 15, 2019 by an in-network provider.
You asked the Plan to waive the coinsurance for the DME. You say that the cost is too expensive as you are on disability and do not have much money. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received a wheelchair and accessories provided from October 15, 2019 through November 15, 2019 by an in-network provider. You are asked to pay 15% coinsurance per date of service for DME. 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 wheelchair and accessories provided from October 15, 2019 through November 15, 2019 by an in-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for massage therapy services provided on September 16, 2019.
You asked the Plan to pay for the massage therapy services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says an itemized bill is needed in order for the claims to be reprocessed.
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the massage therapy services have not been met. Specifically, the documentation submitted does not include sufficient information to determine whether payment is due and the amount of payment. Therefore, we decided that the Plan does not have to pay for massage therapy services provided on September 16, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says that your clinical condition does not require skilled nursing care as an inpatient.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.