Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on April 24, 2020, by an out-of-network provider.You asked the Plan to pay forthe medical services. You say that the claim should be paid.The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider and the services were 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 forthe medical services provided on April 24, 2020, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services provided on August 18, 2020.You asked the Plan to pay for the outpatient services. The Plan denied your request. The Plan says services with a non-contracted provider requires authorization from 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 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 caseis not a network provider with the Plan. The Plan did not pre-approve the outpatient services.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 outpatient services provided on August 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that these services are medically necessary.The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for congestive heart failure and COPD. Your medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care.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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe hip x-ray rendered on August 9, 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 procedure code 73501is not separately payable.The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.The provider submitted a claimfor procedure codes 73501 and 73502. Code 73501 is a column II code with a modifier indicator of 1 when billed with column I code 73502. Code 73501 was not billed with an appropriate modifier to allow for separate payment.Therefore, we decided that thePlan does not have to pay forthe hip x-ray rendered on August 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Free Style Libre CGM.You asked the Plan to pre-approvethe CGM. You say that the services should be coveredby the plan as the enrollee has type 2 diabetes mellitus.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 therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.We looked at the file and Medicare rules. The clinical information provided does not show that the enrollee takes insulin at least three (3) times per day, or that the enrollee checks their blood sugar at least four (4) times per day as required by the LCD. The request for a continuous glucose monitor system and standard supply allowance for this device has been denied as the LCD criteria have not been met.Therefore, we decided that the Plan does not have to pre-approvea Free Style Libre CGM
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe computedtomography (CT) scan of the thorax (71260) and computed tomography (CT) scan of the abdomen and pelvis (74177) provided on August 12, 2020.You asked the Plan to waive the copayment forthe CT scan of the thorax and CT scan of the abdomen and pelvis. You say that you believe you only received one CT scan and would like the copayment waived to reflect this.The Plan denied your request. The Plan says the copayment has processed correctly in this case.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 $275 copayment for advanced imaging services. You have been asked to pay a totalcost share of $550 for the CT scan of the thorax and CT scan of the abdomen and pelvis ($275 copayment + $275 copayment). The services provided fall within the advanced imaging services 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 forthe computed tomography (CT) scan of the thorax (71260) and computed tomography (CT) scan of the abdomen and pelvis (74177) provided on August 12, 2020.Your complaint about a potential coding error for an additional CT scan 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for durable medical equipment provided by a participating provider on July 31, 2020.You asked the Plan to waive the coinsurance for a walker. You say that youwere told that you were allowed one free piece of equipment. The Plan denied your request. The Plan says the correct coinsurance 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 an 18% coinsurance for durable medical equipment/in-network. You have been asked to pay an 18% coinsurance of the allowed amount for a walker. The total allowed amount is $85.69. The total amount you are being asked to pay is $15.42 ($85.69 x 18% = $15.42). A walker falls within the durable medical equipment/in-network 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 durable medical equipment provided by a participating provider on July 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visits(99205, 99215), massage therapy (97124), vasopneumatic device therapy (97016), infrared therapy (97026), manual therapy (97140), neomuscular reeducation (97112), physical medicine procedure (97139), and the therapeutic exercises (97110)provided from September 23, 2020 through October 5, 2020.You asked the Plan to pay forthese services. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says these services are not a covered benefit under your contractual policyor by Medicare.The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. 
We looked at the file and Medicare rules. Basedon this information, we decided that the Medicare rules for coverage of these services have not been met. Specifically, acupuncturists are not eligibleto enroll in Medicare.The limited acupuncture benefit indicated by the Medicare rule only allows coverage for the actual acupuncture procedures to be performedby the acupuncturist. The other billed services do not meet criteria for coverage under Medicare. Therefore, we decided that the Plan does not have to pay forthe office visits(99205, 99215), massage therapy (97124), vasopneumatic device therapy (97016), infrared therapy (97026), manual therapy (97140), neomuscular reeducation (97112), physical medicine procedure (97139), and the therapeutic exercises (97110)provided from September 23, 2020 through October 5, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forhearing aids (V5298) received on August 27, 2020.You asked the Plan to pay forhearing aids. You say that you weremisled by a Plan representative who did not advise you to seek an in-network vendor.The Plan denied your request. The Plan says rules for payment have not been met.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 when obtained fromthe Plan's network hearing service provider. We looked at the case file and the Plan's rules. The items or services in question in this case were not obtained from the Plan's network hearing service provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met.Therefore, we decided that the Plan does not have to pay forhearing aids (V5298) received on August 27, 2020.Your complaint about receiving erroneous or misleading information about your supplemental benefit from a representative of the Planis 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe 2 root canals that you received from February 6, 2020, to May 6, 2020.You asked the Plan to pay forthe dental services. You say that you understand that the services you received are not covered per your 2020 benefits. You say that they are covered under your 2021 benefits. You say that the plan must have determined that those services should be added on. You also say that an exception should be made to approve covering these services to the extent allowed in the 2021 plan.The Plan denied your request. The Plan says root canals are not listed as covered services. The Plan also says that any services not listed are not covered.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 Evidence of Coverage clearly states that any services not listed are not covered.Therefore, we decided that the Plan does not have to pay forthe 2 root canals that you received from February 6, 2020, to May 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on September 18, 2020, by an OON provider.You asked the Plan to pay forinfluenza vaccine and its administration. You say that your doctor ordered these services for infection control.The Plan denied your request. The Plan says rules for payment have not been met.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 anetwork 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. There is no documentation in the case record to support that an in-network provider referred you to the OON provider. 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 September 18, 2020, by an OON provider
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe transportation of portable x-ray equipment coded R0070 and the set-up portable x-ray equipment coded Q0092 provided on June 25, 2020.You asked the Plan to pay forthe transportation of portable x-ray equipment and the set-up portable x-ray equipment. 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 payable.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 codes R0070 and Q0092 are not supported in the medical record. Specifically, these codes have a PC/TC indicator of three, for a technical component only. These codes should only be reported in a hospital setting. In addition, there was no inpatient skilled nursing facility claim to support the place of service billed. Based on this information, we decided that Medicare rules for coverage of the transportation of portable x-ray equipment and the set-up portable x-ray equipment have not been met.Therefore, we decided that the Plan does not have to pay forthe transportation of portable x-ray equipment coded R0070 and the set-up portable x-ray equipment coded Q0092 provided on June 25, 2020
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forduplex scan of lower extremity arteries or arterial bypass grafts (93925) provided on August 26, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe diagnostic services. You say that all the claims attached are for members of the nursing facilities that called in the exams for same day service because you do not need authorization for in-network providers.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 forduplex scan of lower extremity arteries or arterial bypass grafts (93925) provided on August 26, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay fora mammogram provided on September 16, 2020 by an out of network (OON) provider.You asked the Plan to pay fora mammogram. You say that you did not know that the provider needed to be in-network.The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that there are in-network providers available for these services.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 fora mammogram provided on September 16, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe office visits to be provided by an out-of-network provider.You asked the Plan to pre-approvethe office visits. You say that you are in extreme pain and need to see the provider before your condition gets worse.The Plan denied your request. The Plan says this provider is out-of-network and there are in-network providers who can render the requested chiropractor services.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 carethat 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-approvethe office visits to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on August 10, 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 August 10, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe complete series x-ray (D0210) provided on October 6, 2020.You asked the Plan to pay forthe dental service. You say that you went in for an exam, cleaning, and an x-ray. You say that you were informed by the insurance that you were totally covered for it. You say that you received a bill for $119 for the services that you received. You also say that had you known about this fee, you would have declined the service.The Plan denied your request. The Plan says the complete series x-ray is not listed as a covered service.The Plan also says that a pay agreement was signed verifying that you agreed to be responsible for all services rendered on your behalf.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 dentalbenefit 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 forthe complete series x-ray (D0210) provided on October 6, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forlaboratory tests provided on February 12, 2020.You asked the Plan to waive the copayment forlaboratory tests. You say that you disagree with the charges.The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $15 copayment for lab services provided in an outpatient hospital facility. The enrollee has been asked to pay a $15 copayment for laboratory tests. Laboratory tests fall within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This meansthat 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 forlaboratory tests provided on February 12, 2020.