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

We decided that the Plan does not have to pay for home infusion therapy services (HCPCS S9374 and HCPCS S9375) provided to the enrollee from January 2, 2020 to January 5, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says these codes are not valid for Medicare purposes.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. We find that HCPCS S9374 and HCPCS S9375 are not supported in the medical record. Specifically, these codes have a status indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the codes are not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy services (HCPCS S9374 and HCPCS S9375) provided to the enrollee from January 2, 2020 to January 5, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the subsequent nursing facility care (99233) provided on December 29, 2019.You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment as the enrollee was seen by multiple physicians on the same date of service.The Plan denied your request. The Plan says that procedure code 99233 is not covered because it is a column II procedure to the column 1 procedure, 99222, per the policy, based upon the CMS Correct Coding Initiative (CCI).The Plan must follow Medicare rules. Medicare rules say that physicians in the same group practice but who are in different specialties may bill and be paid without regard to their membership in the same group.We find that the record supports payment of CPT code99233. Specifically, the services on this date were provided by two physicians of different specialties. Medicare rules say that physicians in the same group practice but who are in different specialties may bill and be paid without regard to their membership in the same group. Based on this information, we decided that Medicare rules for coverage of these services have been met.Therefore, we decided that the Plan has to pay for the subsequent nursing facility care (99233) provided on December 29, 2019.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 foroutpatient services provided on December 19, 2019 by an out of network (OON) provider.You asked the Plan to pay foroutpatient services. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the 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 foroutpatient services provided on December 19, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the transitional care management (TCM) services provided on January 4, 2020.You asked the Plan to pay for the TCM services. The Plan denied your request. The Plan says the place of service 31 was not the most appropriate place of service.The Plan must follow Medicare rules. Medicare rules say that TCM services can be provided only in accordance with the above policy. We looked at the file and Medicare rules. The POS in this case indicates that the enrollee was in a SNF stay when this TCM visit was provided. The POS in question is not a location in which TCM services can be provided. Based on this information, we decided that Medicare rules for coverage of the TCM services have not been met.Therefore, we decided that the Plan does not have to pay for the transitional care management (TCM) services provided on January 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on January 3, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on January 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe comprehensive periodontal evaluation (D0180), the complete series of periapical x-rays (D0210), and the scaling of generalized moderate to severe gingival inflammation (D4346) provided on February 20, 2020.You asked the Plan to pay forthe dental services. You say that you got your teeth cleaned. You say that the services should be covered. You also say that the dentist talked you into getting x-rays and probably knew that they would not be covered.The Plan denied your request. The Plan says the comprehensive periodontal evaluation, complete series of x-rays, and scaling of gingival inflammation 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 forthe comprehensive periodontal evaluation (D0180), the complete series of periapical x-rays (D0210), and the scaling of generalized moderate to severe gingival inflammation (D4346) provided on February 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam CT capture and interpretation, preventive resin restoration, endodontic therapy, pulp vitality tests, and problem focused limited oral evaluation provided on January 23, 2020.You asked the Plan to pay for the cone beam CT capture and interpretation, preventive resin restoration, endodontic therapy, and pulp vitality tests. You say that you would have had the tooth extracted, but your dentist advised you that saving the tooth would be better for your overall health.The Plan denied your request. The Plan says these services are not covered benefits.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 cone beam CT capture and interpretation, preventive resin restoration, endodontic therapy, pulp vitality tests, and problem focused limited oral evaluation provided on January 23, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe x-ray services coded 73564 provided on October 31, 2019.You asked the Plan to pay forthe x-ray services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services were billed incorrectly.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 73564 is radiologic examination, knee; complete, 4 or more views.We find that CPT code 73564 is not supported in the medical record. Specifically, this code must be billed with the correct anatomic-specific modifier (LT for left side, RT for right side, or 50 for bilateral. This claim was not billed with the correct modifier. Based on this information, we decided that Medicare rules for coverage of the x-ray services have not been met.Therefore, we decided that the Plan does not have to pay forthe x-ray services coded 73564 provided on October 31, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an office visit and injection provided on February 10, 2020.You asked the Plan to waive the deductible for office visit and injection. You say that you thought your copayment was $5 for this visit.The Plan denied your request. The Plan says the deductible amount you are being charged is correct.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $750 deductible for out-of-network office visit and injection. At the time this claim was processed, $0 of the $750 deductible amount had been met. The allowed amount of these services is $111.36, resulting in a deductible obligation of $111.36. The items or services you asked the Plan to waive the deductible for fall within the benefit categories "Physician/Practitioner Services, Including Doctor's Office Visits" and "Medicare Part B Prescription Drugs". The Plan has followed Medicare rules by clearly disclosing in the contract that there is $750 deductible for out-of-network office visit and injection. This cost sharing is a contractual obligation that had not been met at the time office visit and injection was received on February 10, 2020.Therefore, we decided that the Plan does not have to waive the deductible for an office visit and injection provided on February 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on January 6,2020 to January 13, 2020 by an out of network (OON) provider.You asked the Plan to pay forlaboratory tests. You say that the enrollee receives bloodwork regularly due to a medication he is on.The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network and the services were not urgent or emergent in nature.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. You say that the enrollee regularly receives these lab services, therefore the services would not be urgent or emergent in nature and the need for testing would have been foreseeable prior to the enrollee leaving the Plan's service area. 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 January 6, 2020 to January 13, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora shoulder-hand-wrist orthosis (L3960) provided to the enrollee on December 23, 2019.You asked the Plan to payforthe orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items orderedand for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified.Therefore, we decided that the Plan does not have topay fora shoulder-hand-wrist orthosis (L3960) provided to the enrollee on December 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

e decided that the Plan does not have to pre-approvesix visits and treatment with an OON provider.You asked the Plan to pre-approvethe visits and treatment. You say that the provider you have requested to see is OON, but his office is close to your home.The Plan denied your request. The Plan says Medicare does not cover dental appliances. The Plan also says that Medicare would not cover any procedure done as preparation for a non-covered service.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 items or services are not covered when they are received OON.Therefore, we decided that the Plan does not have to pre-approvesix visits and treatment with an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate forthe periapical x-ray (D0220) provided on August 19, 2019 by an outof network provider.You asked the Plan to pay the in network rate forthe dental services. You say that the appointment you had when you received these services was an emergency. You also say that you did not have time to get approval for the services.The Plan denied your request. The Plan says the periapical x-ray is not a covered service.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, periapical x-rays are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay the in network rate forthe periapical x-ray (D0220) provided on August 19, 2019 by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe hearing aids provided on November 12, 2019 by an out-of-network provider.You asked the Plan to pay forthe hearing aids. You say that you do not see why it was denied because you received one before through the same company.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 hearing aids have not been met. The provider is not in-network with your supplemental hearing plan and your EOC clearly states, coverage for hearing aids is limited to your network supplemental hearing provider.Therefore, we decided that the Plan does not have to pay forthe hearing aids provided on November 12, 2019 by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an oxygen concentrator (E1390) purchased from October 17, 2019.
You asked the Plan to pay for the DME. You say that the advertisement by the provider states that insurance will pay for the device. The Plan denied your request. The Plan says purchased oxygen equipment is statutorily non-covered.
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 DME have not been met. Review of the file show that you purchased an oxygen concentrator (E1390) on October 17, 2019. The Medicare rules state that oxygen equipment is eligible for coverage. Purchased oxygen equipment is statutorily non-covered. Therefore, we decided that the Plan does not have to pay for an oxygen concentrator (E1390) purchased from October 17, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lidocaine (J3490).
You asked the Plan to pre-approve Lidocaine. You say that this is the best option for the enrollee to avoid addiction. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Lidocaine (J3490).
Benefits for Lidocaine may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible forthe outpatient radiology services provided on December 11, 2019.You asked the Plan to waive the deductible forthe outpatient radiology services. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request.The Plan denied your request.The Plan says you received outpatient radiology services on the date of service at issue in this appeal. The Plan says that the correct amount has applied towards your deductible per your contract with the Plan.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $1000 deductible that must be paid before the Plan will pay their share for Outpatient diagnostic tests. The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient diagnostic tests. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $1000 deductible that must be paid before the Plan will pay their share for Outpatient diagnostic tests when provided by an out-of-network provider. This cost sharing is a contractual obligation that had not been met at the time the outpatient radiology services were received on December 11, 2019.Therefore, we decided that the Plan does not have to waive the deductible forthe outpatient radiology services provided on December 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the enhanced eyeglass lenses provided on December 19, 2019.
You asked the Plan to pay for the Hi-Index Lenses, Progressive Lenses, and Anti-Reflective Coating. You say that the Plan should pay more. The Plan denied your request. The Plan says these are not covered services under your routine vision benefit.
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 up to $105 copayment for premium progressive lenses, and savings of 20-25% on lens enhancements for Prescription Glasses. You have been asked to pay $105 copayment for premium progressive lenses, $64 for Hi-Index Lenses and $85 for Anti-Reflective Coating. The Hi-Index Lenses, Progressive Lenses, and Anti-Reflective Coating fall within the Supplemental Prescription Glasses 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 pay for the enhanced eyeglass lenses provided on December 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the surgical extraction (D7210) and general anesthesia (D9223 x 2) provided November 14, 2019 by an oral surgeon.
You asked the Plan to reimburse you for the dental service. You say that the extraction was more of a surgery. You say that the anesthesia should be reimbursed at least. You also say that the anesthesia was medically necessary. The Plan denied your request. The Plan says the services that you received are dental in nature. The Plan also says that you are not enrolled in the dental option rider and therefore are not covered.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to reimburse you for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to reimburse you for the surgical extraction (D7210) and general anesthesia (D9223 x 2) provided November 14, 2019 by an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the incision and drainage of an abscess provided on December 30, 2019.
You asked the Plan to pay for the incision and drainage of an abscess. You say that according to your 2019 plan, you pay a $0 copayment, 20% or 50% coinsurance for comprehensive dental services. You also say that you are covered for up to $500 per year. The Plan denied your request. The Plan says this service is not covered under your contract under any normal circumstances.
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 incision and drainage of an abscess provided on December 30, 2019.