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

We decided that the Plan does not have to pay for the 2D oral/facial photographic images (code D0350 x4) provided on September 10, 2019.
You asked the Plan to pay for the 2D oral/facial photographic images. You say that you do not understand why these services were denied. You also say that you were told these services would be covered. The Plan denied your request. The Plan says these services are not covered by your dental plan.
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 2D oral/facial photographic images (code D0350 x4) provided on September 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a hearing test provided on August 21, 2019.
You asked the Plan to waive the copayment for a hearing test. You say that you disagree with the additional $50 copayment. 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 $50 copayment for hearing services provided by a specialist. You have been asked to pay a $50 copayment for hearing services provided by a specialist. A hearing test falls within the hearing 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 for a hearing test provided on August 21, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the parathyroidectomy services coded 60500 and the total thyroid lobectomy services coded 60220 provided on May 22, 2019.
You asked the Plan to pay for the parathyroidectomy services coded 60500 and the total thyroid lobectomy 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 60500 is parathyroidectomy or exploration of parathyroid(s). The CPT Code Manual definition of code 60220 is total thyroid lobectomy, unilateral; with or without isthmusectomy. We find that CPT codes 60500 and 60220 are not supported in the medical record. Specifically, the medical records did not include documentation of a parathyroidectomy or exploration of parathyroid(s), therefore, code 60500 cannot be verified. Also, the medical records did not include documentation of a unilateral total thyroid lobectomy with or without isthmusectomy; therefore, code 60220 cannot be verified. Based on this information, we decided that Medicare rules for coverage of the parathyroidectomy services coded 60500 and the total thyroid lobectomy services have not been met. Therefore, we decided that the Plan does not have to pay for the parathyroidectomy services coded 60500 and the total thyroid lobectomy services coded 60220 provided on May 22, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued use of the CPAP device.
You asked the Plan to pre-approve continued use of the CPAP device. You say that right now you have a disorder and will use the CPAP device as soon as you are able. The Plan denied your request. The Plan says you have not demonstrated consistent use of the device.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.
We looked at the file and Medicare rules. The record shows you are not compliant. Based on this information, we decided that Medicare rules for coverage of continued use of the CPAP device have not been met. Therefore, we decided that the Plan does not have to pre-approve continued use of the CPAP device.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyalgan injections for the enrollee.
You asked the Plan to pre-approve Hyalgan. The Plan denied your request. The Plan says that they did not
receive documentation or medical records supporting the medical necessity for a step therapy exception.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
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 Hyalgan. Our reviewer says that
Hyalgan is not medically reasonable and necessary for the enrollee in this case. The documentation does not
support that the enrollee has tried and failed Orthovisc and Monovisc or that they would likely be less effective,
and/or would likely have adverse effects for the enrollee in this case. Our physician reviewer found that the
enrollee's condition does not meet criteria for coverage of Hyalgan.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Hyalgan have not been met. Therefore, we decided that the Plan does not have
to pre-approve Hyalgan injections for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the colonoscopy services provided to the enrollee on
September 10, 2019 by out of network provider.
You asked the Plan to pay for the out-of-network services. The Plan denied your request. The Plan says there is
no network deficiency for the services, and alternate network providers were found.
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 for the colonoscopy services provided to the enrollee on
September 10, 2019 by out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a refraction provided on September 10, 2019.
You asked the Plan to pay for the refraction. The Plan denied your request. The Plan says eye refraction's for a medical condition of the eye are not covered.
The Plan must follow Medicare rules. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury.
We looked at the file and Medicare rules. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Therefore, we decided that the Plan does not have to pay for an eye refraction provided on September 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for tape, non-waterproof, per 18 square inches (CPT Code A4450) provided to the enrollee on January 30, 2019.
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported.
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. Medicare guidance says the following modifiers were added to the HCPCS to identify supplies and equipment that may be covered under more than one DMEPOS benefit category: - AU Item furnished in conjunction with a urological, ostomy, or tracheostomy supply; - AV Item furnished in conjunction with a prosthetic device, prosthetic or orthotic; and - AW Item furnished in conjunction with a surgical dressing. Codes A4450 and A4452 are the only codes that have been identified at this time that would require use of all three of the above listed modifiers. Providers must report these modifiers on claims for items identified by codes A4450 and A4452 that are furnished on or after January 1, 2005. You can find this guidance in the
Medicare Claims Processing Manual Chapter 20 - Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), Section 30.9 - Payment of DMEPOS Items Based on Modifiers. As the HCPCS code A4450 was not billed with the required durable medical equipment modifier; we find that Medicare rule for payment of this claim has not been met. If the provider determines that a billing error occurred during the initial submission of the denied claim, the plan would accept a submission of a corrected claim to consider services for payment. You can find the above guidelines on the Medicare website at https://www.cms.gov. Therefore, we decided that the Plan does not have to pay for tape, non-waterproof, per 18 square inches (CPT Code A4450) provided to the enrollee on January 30, 2019.
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 August 6, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says non-emergent services rendered by non-participating providers in non-participating facilities require prior authorization as outlined in the enrollee's EOC.
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 August 6, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services coded S9328 provided from September 6, 2019 to September 13, 2019.
You asked the Plan to pay for the home infusion therapy 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 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. In this case, the CPT Code Manual definition of code S9328 is home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem. We find that CPT code S9328 is not supported in the medical record. Specifically, code S9328 has a status code of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy services coded S9328 provided from September 6, 2019 to September 13, 2019.
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 September 11, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says non-emergent services rendered by non-participating providers in non-participating facilities require prior authorization as outlined in the enrollee's EOC.
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 by an out-of-network provider on September 11, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transport to hospice care provided on July 24, 2019.
You asked the Plan to pay for the ambulance transport to hospice care. You say that the enrollee was not enrolled in hospice until 1:50 p.m. You say that payment should be made. The Plan denied your request. The Plan says Original Medicare is responsible for payment.
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 dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the ambulance transport to hospice care provided on July 24, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy (HIT) services provided from July 18, 2019 to July 25, 2019.
You asked the Plan to pay for the HIT services. You say that you are not given consistent information on why you are never paid for the services you provide. CMS website says this is a valid code and you feel you should be told what the valid code is since these keep getting denied. The Plan denied your request. The Plan says Medicare does not recognize S-codes for payment.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. CPT code S9328 has a status indicator of "I" which means it is invalid for Medicare billing purposes. Based on this information, we decided that Medicare rules for coverage of the HIT services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy (HIT) services provided from July 18, 2019 to July 25, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a computed tomography angiogram (CTA).
You asked the Plan to pre-approve the CTA. The Plan denied your request. The Plan says that this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. 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 the CTA. Our reviewer says that the requested CTA is medically reasonable and necessary. Our physician reviewer found that the enrollee is noted to have symptoms of claudication. Ultrasound imaging has identified a decreased ABI. While the provider wants to be cautious in treating the enrollee given the enrollee's diabetes, her diabetes does not preclude treatment and the provider wants to evaluate possible treatment options. Higher level imaging is warranted. The requested CT scan is medically necessary and reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CTA have been met. Therefore, we decided that the Plan has to pre-approve a computed tomography angiogram (CTA).
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation provided on
October 10, 2019.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you were sent to this
provider by your dentist because they could not read your x-ray. You also say that you were told this provider
was in network and the service would be completely covered. The Plan denied your request. The Plan says this
service is allowed two times per calendar year. The Plan also says that you have reached this limit for this
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, you are limited to two routine
preventive periodic oral dental exams and cleanings per calendar year. The record shows that you received
exams on February 21, 2019 and August 29, 2019 and your preventive periodic oral dental exams and
cleanings benefit was then exhausted. The Plan also says that they contacted this provider's office and spoke
with the practice manager. The Plan says that the office has written off the amount for the exam and you will
not be charged. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral
evaluation provided on October 10, 2019.
Your complaint about the dental provider not cleaning your teeth without a panoramic x-ray 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on July 15, 2019.
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says non-urgent, non-emergent services require prior authorization. The Plan requires utilization of network providers when possible and available.
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 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 subsequent nursing facility care provided on July 15, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for adjacent tissue transfer or rearrangements provided on July 31, 2019 and August 9, 2019.
You asked the Plan to waive the coinsurance for adjacent tissue transfer or rearrangements. You say that you disagree with the charge because you would pay 20% coinsurance with Medicare alone. 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 20% coinsurance for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You received adjacent tissue transfer or rearrangement on July 31, 2019. The allowed amount is $730.19 and 20% of that is $146.04. You received adjacent tissue transfer or rearrangement on August 9, 2019. The allowed amount is $227.64 and 20% of that is $45.53. The total amount you owe is: $191.57. You have been asked to pay the total coinsurance amount of $191.57 for adjacent tissue transfer or rearrangements. Adjacent tissue transfer or rearrangements fall within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 adjacent tissue transfer or rearrangements provided on July 31, 2019 and August 9, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an EGD provided by the hospital on August 27, 2019.
You asked the Plan to waive the copayment for an EGD. You say that you were told that you would not owe a copayment. 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 $200 copayment for each outpatient hospital facility visit. You have been asked to pay a $200 copayment for an EGD. An EGD falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 an EGD provided by the hospital on August 27, 2019.
We note your complaint that the provider told you that you would not owe a copayment. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.