Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for contact lenses (V2521) received on December 16, 2020.

You asked the Plan to pay for contact lenses. You say that you did not understand that the benefit allowance had been exhausted and it would not be covered. The Plan denied your request. The Plan says the services at issue are covered benefits, however the benefit maximum had already been met before this date.

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 these services up to a $175 allowance 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 contact lenses have not been met. Specifically, the record shows that you had exhausted your eyewear benefit maximum on December 28, 2019. Therefore, we decided that the Plan does not have to pay for contact lenses (V2521) received on December 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation and surgical extraction provided on December 16, 2020, and December 17, 2020.

You asked the Plan to pay for the problem focused limited oral evaluation and surgical extraction. You say that you would like these services to be covered. The Plan denied your request. The Plan says problem focused limited oral evaluation is not a covered benefit. The Plan also says that you were charged the correct amount for the surgical extraction.

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, problem focused limited oral evaluation is not among those covered under this benefit. The contract also says that you are responsible for a 50% coinsurance for surgical extractions. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation and surgical extraction provided on December 16, 2020, and December 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam, cleaning, and bitewing x-rays provided on February 2, 2021.

You asked the Plan to pay for the dental services. You say that you received information from your health plan that did not state that you could not see providers that have opted out of Medicare. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan also says that dental services performed by a provider who has opted out of Medicare are not payable.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage and the services could be covered, dental services performed by a provider who has opted out of Medicare are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the oral exam, cleaning, and bitewing x-rays provided on February 2, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement services provided on January 17, 2020.

You asked the Plan to pay for the debridement services. You say that the services that were rendered are not related to the enrollee's hospice diagnosis. 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. The Plan also says it is the provider's responsibility to verify the member's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice 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 was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the debridement services provided on January 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (LSO, a back brace) billed for date of service December 7, 2020.

You asked the Plan to pay for back brace. You say that you received a call about a free brace which you accepted, but never received the brace in the mail. The Plan denied your request. The Plan says the denial of payment for this item is correct, because this item was never provided to you.

The Plan must follow Medicare rules. Medicare rules say that a supplier of DME may not contact an individual regarding the furnishing of an item to the individual except under specific circumstances. 

We looked at the file and Medicare rules. You say that you received a phone call offering you a brace. The record does not show that the provider had prior written permission to contact you about this by telephone. Based on this information, we decided that Medicare rules for coverage of back brace have not been met. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (LSO, a back brace) billed for date of service December 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on November 12, 2020.

You asked the Plan to pay for the office visit. You say that the medical records support the medical necessity for the services provided. You say that the claim should be reconsidered for payment. The Plan denied your request. The Plan says out-of-network visits require 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 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 office visit provided by an out-of-network provider on November 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive procedure provided on January 28, 2021.

You asked the Plan to pay for the preventive procedure. You say that you should not be held responsible for this charge. The Plan denied your request. The Plan says this service is not covered. The Plan also says that you did not contact the Plan prior to the date of service to verify benefits and provider eligibility.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, 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 preventive procedure provided on January 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for domiciliary or rest home visit (99336) rendered by an out of network (OON) provider on September 2, 2020.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for domiciliary or rest home visit (99336) rendered by an out of network (OON) provider on September 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab work provided by a participating hospital on January 25, 2021.

You asked the Plan to waive the copayment for lab work. You say that you do not agree with this copayment. The Plan denied your request. The Plan says the correct copayment has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 copayment for outpatient diagnostic tests/labs/outpatient hospital. 

You have been asked to pay a $15 copayment for lab work. The correct copayment has been applied to the services that were provided. Lab work falls within the outpatient diagnostic tests/labs/outpatient hospital benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for lab work provided by a participating hospital on January 25, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the TdaP vaccine provided on December 31, 2020.

You asked the Plan to pay for the TdaP vaccine. You say that the nurse told you the booster would probably be covered by your insurance. The Plan denied your request. The Plan says that a TdaP vaccine is not covered under your Medicare Part B Immunization benefit.

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 the TdaP vaccine by a contract provider. The file does not show that the Plan provided notice that the TdaP vaccine would not be covered. Under Medicare rules, this means the TdaP vaccine is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the TdaP vaccine provided on December 31, 2020.

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 nursing facility care services provided on June 13, 2020.

You asked the Plan to pay for the services provided. You say that the billed code is compatible with the place of service. The Plan denied your request. The Plan says the claim processed correctly.

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 99309 is subsequent nursing facility care, per day, for the evaluation and management of a patient. We find that CPT code 99309 is not supported. Specifically, the claim shows the services were provided in an inpatient rehab facility, not a nursing facility. 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 the nursing facility care services provided on June 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213, 81003) provided to the enrollee on June 30, 2020.

You asked the Plan to pay this claim. You say that this service should be covered by the Plan. The Plan denied your request. The Plan says Medicare billing criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that this claim denied because the provider is not eligible for payment of this type of service.

The Plan states the NPI Registry website shows this provider is registered with a taxonomy for a nurse practitioner. However, the provider billed the service as a registered nurse taxonomy. A General Practice Registered Nurse taxonomy is not eligible to receive Medicare Advantage reimbursement.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate and eligible taxonomy code. In this case, the taxonomy code submitted under Registered Nurse is not payable under Medicare. Therefore, we decided that the Plan does not have to pay for the office visit (99213, 81003) provided to the enrollee on June 30, 2020 and billed Claim A.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the positron emission tomography (PET) with computed tomography (CT) (78815) provided on December 21, 2020.

You asked the Plan to pay for the PET with CT. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this claim was not billed with an appropriate diagnosis code.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

We find that CPT code 78815-26 PI is not supported in the record. Specifically, the claim submitted was not billed with one of the appropriate diagnosis codes listed in the Medicare Claims Processing Manual. Based on this information, we decided that Medicare rules for coverage of the PET with CT have not been met. Therefore, we decided that the Plan does not have to pay for the positron emission tomography (PET) with computed tomography (CT) (78815) provided on December 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit provided by an out-of-network provider on December 15, 2020.

You asked the Plan to pay for the home visit. You say that the physician depends on the hospital staff to verify eligibility and obtain proper authorization. You say that the physician provided medically necessary services and the claim should be processed for payment. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not approved in advance.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 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 home visit provided by an out-of-network provider on December 15, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial nursing facility care provided on December 22, 2020.

You asked the Plan to pay for the evaluation and management service. You say that the service should be covered. 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. The Plan also says it is the provider's responsibility to verify the member's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.

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 December 21, 2020. 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 initial nursing facility care provided on December 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for Sphere, bifocal (V2200), Vision frames purchases (V2020), and Progressive lens per lens (V2781) received December 11, 2020.

You asked the Plan to pay for the vision care services. You say that you were not told that you needed to wait two more days before the requested services could be covered. The Plan denied your request. The Plan says the vision services were rendered prior to 365 days from the last date of your vision care.

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 these services when received once annually, based on a rolling calendar year, when received through your Vision Care.

We looked at the file and the Plan's rules. You last received vision care December 9, 2019. The Plan's benefit is based on a rolling calendar year. You were not eligible for the vision care on this date of service. Based on this information, we decided that the Plan's rules for coverage of the vision care services have not been met. Therefore, we decided that the Plan does not have to pay for Sphere, bifocal (V2200), Vision frames purchases (V2020), and Progressive lens per lens (V2781) received December 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services you received from October 26, 2020, to December 29, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not covered.

Medicare rules say the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The contract with the Plan says that up to 4 routine chiropractic visits are covered per calendar year. 

The records show that some of the services at issue (99213, 97035, 97530) are not manual manipulation of the spine. These services are not covered by Medicare or the Plan when provided by a chiropractor. While CPT code 98941 is a covered benefit, the records show that the Plan has paid for 4 visits for the 2020 Calendar year. The requested additional visits exceed the benefit limit. Therefore, we decided that the Plan does not have to pay for the chiropractic services you received from October 26, 2020, to December 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) provided on January 21, 2021.

You asked the Plan to pay for the office visit. You say that you would like reconsideration because you would like the claim to be submitted with modifier 24. The Plan denied your request. The Plan says a corrected claim is needed in order to process this claim.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

We find that CPT code 99214 is not supported in the medical record. Specifically, this service was rendered within the global surgery period of a major surgery. The rendering provider is in the same group as the surgeon, therefore; modifier 24 is required. Based on this information, we decided that Medicare rules for coverage of the office visit have not been met. Therefore, we decided that the Plan does not have to pay for the office visit (99214) provided on January 21, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the services (99223) provided on October 25, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says that this procedure has
been billed and allowed the maximum number of times.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan says that this service has been billed and allowed the maximum
number of times. However, the Plan has not provided evidence supporting its denial. The Plan has not
referenced a Medicare rule regarding its denial. Without supporting documentation, the Plan's denial cannot be
substantiated. Therefore, we decided that the Plan has to pay for the services (99223) provided on October 25,
2020.

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.