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

We decided that the Plan does not have to pay for nurse practitioner services provided on January 16, 2021.

You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.

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Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.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 January 14, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for nurse practitioner services provided on January 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic mammography (77065) and diagnostic digital breast tomosynthesis (G0279) provided on December 28, 2020.

You asked the Plan to pay for the diagnostic mammography and digital breast tomosynthesis. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 77065 exceeds Medicare's MUE limit and CPT code G0279 is an add-on code without an appropriate primary procedure.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. 

In this case, the MUE for CPT code 77065 is 1. You billed 2 units of this code, exceeding the MUE. Because the primary procedure, CPT 77065, remains denied, add-on code CPT G0279, is not eligible for payment. Based on this information, we decided that Medicare rules for coverage of the diagnostic mammography and digital breast tomosynthesis have not been met. Therefore, we decided that the Plan does not have to pay for the diagnostic mammography (77065) and diagnostic digital breast tomosynthesis (G0279) provided on December 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete upper denture (D5110), the partial lower
denture (D5214), the core build up (D2950), the crown (D2740), the scaling and root planing (D4341 x 2), the
gingival irrigation (D4921 x 2), the unspecified periodontal service (D4999 x 2), the oral hygiene instruction
(D1330), and the office visit for observation (D9430 x 2) provided from January 4, 2020, to January 19, 2020.

You asked the Plan to pay for the dental services. You say that according to your Annual Notice of Changes for
2021, some of these services have no copayments and some have 50% copayments. You say that your gums
shrank. You also say that your immediate dentures have no suction and do not stay put. The Plan denied your
request. The Plan says the dental services you received are not listed as covered services.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the 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
complete upper denture (D5110), the partial lower denture (D5214), the core build up (D2950), the crown
(D2740), the scaling and root planing (D4341 x 2), the gingival irrigation (D4921 x 2), the unspecified
periodontal service (D4999 x 2), the oral hygiene instruction (D1330), and the office visit for observation
(D9430 x 2) provided from January 4, 2020, to January 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the specialist services provided on January 21, 2021 by an out of network (OON) provider.

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 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 for the specialist services provided on January 21, 2021 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the negative pressure wound therapy pump
provided on March 12, 2020.

You asked the Plan to waive the cost share for the pump. You say that you were not billed correctly. 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 17%
coinsurance for durable medical equipment.

You have been asked to pay $216.22, which is a 17% coinsurance for the pump. The pump falls within the
durable medical equipment 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 cost share for the negative
pressure wound therapy pump provided on March 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic procedure services coded 97110 provided on
June 23, 2020.

You asked the Plan to pay for the therapeutic procedure 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 97110 is therapeutic procedure, 1 or more areas, each 15
minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility.

We find that CPT code 97110 is not supported in the medical record. Specifically, the documentation shows that these services were performed by an occupational therapist assistant in a home health or hospice setting. There is a more appropriate code to be billed for these rendered services. Based on this information, we decided that Medicare rules for coverage of the therapeutic procedure services have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic procedure services coded 97110 provided on June 23, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for individual psychotherapy session, 60 minutes (90837)
provided on August 17, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the psychotherapy services. You say that the service was provided with no
adequate time frame to obtain authorization for the service. The enclosed medical records clearly reflect the
medical necessity for the services rendered. 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.

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 individual psychotherapy session, 60 minutes
(90837) provided on August 17, 2020 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the oxygen saturation testing rendered on November 18, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. 

In this case, the MUE for CPT code 94761 is 1. You billed 3 units of this code, exceeding the MUE. 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 oxygen saturation testing rendered on November 18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81286, 81404, 81407, 81408, 81479) provided October 1, 2020.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says this service is not covered.

The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular disease. 

We looked at the file and Medicare rules. The testing performed was a cardiovascular risk assessment panel. This is not covered under Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81286, 81404, 81407, 81408, 81479) provided October 1, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for allergy testing (95004) provided on October 12, 2020.

You asked the Plan to pay for allergy testing. You say that this is documented in the records. The Plan denied your request. The Plan says this 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 95004 is percutaneous tests (scratch, puncture, prick) with allergenic extracts, immediate type reaction, including test interpretation and report, specify number of tests.

We find that CPT code 95004 is not supported in the medical record. Specifically, there is conflicting information in the records regarding the date of service. The testing results indicate that the resting took place on October 14 rather than October 12. Based on this information, we decided that Medicare rules for coverage of allergy testing have not been met. Therefore, we decided that the Plan does not have to pay for allergy testing (95004) provided on October 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pain management visits to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve pain management visits to be provided by an OON provider. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The Plan says there are in-network pain management specialist's available to you that can provide the care and treatment you are requesting.

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 pain management visits to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pathology services provided on December 16, 2020 by an
out of network (OON) provider.

You asked the Plan to pay for the OON services. You say that the provider took the specimens and sent them
for analysis. The Plan denied your request. The Plan says authorization was not obtained as required.

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 referring provider is also 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 pathology
services provided on December 16, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81545) provided on March 18, 2020.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the out-of-network services were not pre-approved.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for lab services (81545) provided on March 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), the bone replacement graft for ridge preservation (D7953), and the placement of intra-socket biological dressing to aid in hemostasis or clot stabilization (D7922) provided on January 11, 2021.

You asked the Plan to pay for the dental services. You say that you were advised that you would owe $900 for the services. You say that you were put on a payment plan but needed to pay $500 before the procedure could be started. You say that the oral evaluation is the one thing that should have been covered. You also say that this has been a horrible experience all around. The Plan denied your request. The Plan says 1 limited oral evaluation is covered every 6 months. The Plan says that the frequency limit for this service has been exceeded. The Plan says that bone replacement graft for ridge preservation is not listed as a covered service. The Plan also says that placement of intra-socket biological dressing to aid in hemostasis or clot stabilization is not listed as a covered service either.

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 limited oral evaluation is listed as a covered service, the frequency limit has been exceeded. The record shows that the Plan paid for a limited oral evaluation provided on the same date of service, but to a different provider. Additionally, bone replacement graft and intra-socket biological dressing are among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), the bone replacement graft for ridge preservation (D7953), and the placement of intra-socket biological dressing to aid in hemostasis or clot stabilization (D7922) provided on January 11, 2021.

Your complaint about your overall horrible experience is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for laboratory services provided on November 18, 2020.

You asked the Plan to waive the co-payment for laboratory services. You say that you disagree with the charges because the labs were ordered during an office visit. 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 co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 co-payment for laboratory tests.

You have been asked to pay a $10 co-payment for laboratory services. Laboratory 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 micropayment for laboratory services provided on November 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the inpatient hospital admission provided from August 21, 2020, to September 5, 2020.

You asked the Plan to reduce the copayment for the inpatient hospital admission. You say that this second hospital stay should be considered a continuation of your first hospital stay. The Plan denied your request. The Plan says you have been asked to pay 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 a $340 copayment per day, days 1-5 for each inpatient stay. 

You have been asked to pay a $340 copayment for each day, days 1 to 5 of the inpatient hospital admission. ($340 x 5 = $1,700). The inpatient hospital admission falls within the "Inpatient hospital care" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the copayment for the inpatient hospital admission provided from August 21, 2020, to September 5, 2020.

Your complaint about being released too early from the hospital is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on September 25, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct Place of Service (POS) code.

We looked at the file and Medicare rules. The file shows that the services were incorrectly billed with POS code 15 for a mobile unit. 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 testing services rendered on September 25, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided on December 17, 2020.

You asked the Plan to waive the copayment for a CT scan. You say that you disagree with the charges. 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 CT scans. 

You have been asked to pay a $150 copayment for a CT scan. A CT scan 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 CT scan provided on December 17, 2020.