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

We decided that the Plan does not have to pay for the surgical extraction (D7210) provided on March 25, 2021. 
 
You asked the Plan to pay for the surgical extraction. You say that the tooth needed to be removed and you feel 
the Plan should reimburse you up to the amount allowed for a simple extraction. The Plan denied your request. 
The Plan says this service is 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 only type of extraction that is covered by the Plan is simple 
extractions. Therefore, we decided that the Plan does not have to pay for the surgical extraction (D7210) 
provided on March 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the infusion services rendered on March 29, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 96413 is not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

In this case, the CPT Code Manual definition of code 96413 is chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug. 

We find that CPT code 96413 is not supported in the medical record. Specifically, the records show that the enrollee had an intravenous infusion of Reclast and there is a more appropriate code for these services. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the infusion services rendered on March 29, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency ambulance transportation services (A0425, A0429) provided on April 28, 2021.

You asked the Plan to waive the copayment for the ambulance services. You say that you cannot afford this cost. The Plan denied your request. The Plan says this claim was processed correctly. Ambulance services require a $290 copayment.

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 $290 copayment for ambulance services. 

You have been asked to pay a $290 copayment for the ambulance services. 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 the emergency ambulance transportation services (A0425, A0429) provided on April 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an NPlate (romiplostim) injection.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found you have a diagnosis of pancytopenia (low white and red blood cells). There is no history of recent bleeding in the records. The clinic note does not state that your condition cannot be managed by your current medication regimen. The requested NPlate is not FDA-approved for your diagnosis. The records do not support that the NPlate is safe and effective and reasonable and medically necessary at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve an NPlate (romiplostim) injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for durable medical equipment (walker and orthosis) provided to the enrollee on April 17, 2021.

You asked the Plan to pay for this claim. You say that this equipment should be covered by the Plan. The Plan denied your request. The Plan says the enrollee's primary insurance carrier must address this claim first. The Plan has contacted the primary insurance carrier and requested an Explanation of Benefits for review.

The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has been in contact with the primary insurer and requested their review information. As the secondary insurer, the Plan cannot be held responsible for this claim until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for durable medical equipment (walker and orthosis) provided to the enrollee on April 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and
services provided from March 18, 2021, to March 23, 2021.

You asked the Plan to waive the copayment for the inpatient care. You say that you do not understand why this
bill was not paid in full. The Plan denied your request. The Plan says the inpatient care is covered, and your
copayment was applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $175
copayment for each of the first four days of an inpatient hospital stay at an in-network facility. There is a $0
copayment for additional days.

You have been asked to pay a $700 copayment for the inpatient care provided from March 18, 2021 to March
23, 2021. ($175 copayment x 4 days = $700). 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 the inpatient
hospital admission and services provided from March 18, 2021, to March 23, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a pharmacogenetic panel (81225, 81226, 81227, 81230, 81231, 81328, 81335) provided on December 9, 2020.

You asked the Plan to pay for a pharmacogenetic panel. You say that this is supported by the records. The Plan denied your request. The Plan says this was not billed 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. If a laboratory assays 2 or more genes in a patient in parallel, then those 2 or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so 1 code must be submitted for the panel. 

We find that CPT codes 81225, 81226, 81227, 81230, 81231, 81328, and 81335 are not supported in the medical record. Specifically, these codes were billed for testing that was performed as a panel, which should be reported with a single code. Based on this information, we decided that Medicare rules for coverage of a pharmacogenetic panel have not been met. Therefore, we decided that the Plan does not have to pay for a pharmacogenetic panel (81225, 81226, 81227, 81230, 81231, 81328, 81335) provided on December 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a CPAP device (E0601) provided on March 30, 2021.
You asked the Plan to pay for a CPAP device. You say that the enrollee no longer has the CPAP provided by a prior durable medical equipment provider. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. Medicare rules say that, in the absence of program instructions, the reasonable useful lifetime of equipment in no case can be less than 5 years. Computation of the useful lifetime is based on when the equipment is delivered to the enrollee, not the age of the equipment.
We looked at the file and Medicare rules. In this case, you are requesting a replacement for a CPAP received by the enrollee in April 2017. The requested replacement is for an item that has not outlasted its reasonable useful lifetime. Based on this information, we decided that Medicare rules for coverage of a CPAP have not been met. Therefore, we decided that the Plan does not have to pay for a CPAP device (E0601) provided on March 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (CPT code 99212) provided on April 8, 2021.
You asked the Plan to pay for the office visit. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says Medicare does not cover non-manipulative services provided by chiropractors.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the office visit (CPT code 99212) provided on April 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for intravenous (IV) drugs you received on December 2, 2020, to December 24, 2020.
You asked the Plan to waive the coinsurance for the IV drugs. You say that you were not provided with monthly invoices, so you could not appropriately plan for these expenses. You say that you sought this treatment only because you were offered financial assistance through The Assistance Fund. You said that because you did not receive the invoices from the Plan in a timely manner, you could not meet the deadline for filing with The Assistance Fund. The Plan denied your request. The Plan says you were charged this coinsurance correctly. The Plan also shows that it issued you an invoice for these services on January 22, 2021.
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 Medicare Part B-covered drugs.
You have been asked to pay 20% coinsurance for the IV drugs. The IV drugs fall within the Medicare Part Bcovered
drugs 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 intravenous (IV) drugs
you received on December 2, 2020, to December 24, 2020.
Your complaint about the frequency of the Plan's invoices 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 the office visit provided on December 22, 2020 by an out-of-network
provider.

You asked the Plan to pay for the office visit. You say that due to the short time of period you were unable to
get the authorization before the service was done. The Plan denied your request. The Plan says prior
authorization was not obtained as required.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.

The requested 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 the service. Therefore, we decided that
the Plan does not have to pay for the office visit provided on December 22, 2020 by an out-of-network
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit with a specialist (99214) provided on September 9, 2020, to October 14, 2020, by an out-of-network (OON) provider.

You asked the Plan to pay for an office visit. You say that other claims in the past were paid and you would like these claims paid with this provider. The Plan denied your request. The Plan says services were provided 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. The records provided for review do not show that the services at issue were urgent or emergent. 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 an office visit with a specialist (99214) provided on September 9, 2020, to October 14, 2020, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the debridement of subcutaneous tissue (11042) provided on August 26, 2020.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.

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 $295 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges.

You have been asked to pay a $250 copayment for the Medicare-covered surgery provided at an outpatient hospital. 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 the debridement of subcutaneous tissue (11042) provided on August 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on May 11, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit. You say that your practice was one of the only offices in the area at the time of service. 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 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 on May 11, 2020 by an out-of-network (OON) provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for supply allowance for therapeutic CGM (CPT code K0553) provided to the enrollee on January 14, 2021.

You asked the Plan to pay for the supplies. You say that the supplies are medically necessary. 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 and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. 

We looked at the file and Medicare rules. Medical records from the attending physician does not document three (3) or more insulin injections per day. Based on this information, we decided that Medicare rules for coverage of the supplies have not been met. Therefore, we decided that the Plan does not have to pay for supply allowance for therapeutic CGM (CPT code K0553) provided to the enrollee on January 14, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the platelet rich plasma injection.
You asked the Plan to pre-approve the platelet rich plasma injection. You say that you would like reconsideration because the requested service is medically reasonable and necessary. The Plan denied your request. The Plan says there is not enough evidence to support this type of treatment.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 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 platelet rich plasma injection. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the use of platelet-rich plasma is considered experimental or investigational for the treatment of acute or chronic wounds, including surgical wounds and nonhealing ulcers. The evidence is insufficient to determine the effects of the technology on health outcomes.Use of platelet-rich plasma is considered experimental or investigational for all orthopedic indications. 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 platelet rich plasma injection have not been met. Therefore, we decided that the Plan does not have to pre-approve the platelet rich plasma injection.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services provided on October 22, 2020.

You asked the Plan to pay for surgical services. You say that the Plan is your primary insurance. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the Plan is your secondary payer and is not responsible for payment of this claim until after your primary insurance carrier has processed this claim.

The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.

The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has instructed your primary insurance carrier to submit details about their payment of this claim. As the secondary insurer, the Plan cannot be held responsible for surgical services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for surgical services provided on October 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable


The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that therapeutic continuous glucose monitors (CGMs) and related supplies are covered by 
Medicare when all of the following coverage criteria are met: 
  1. The beneficiary has diabetes mellitus, 
  2. The beneficiary has been using a blood glucose monitor (BGM) and performing frequent (four or more 
times a day) testing, 
  3. The beneficiary is insulin-treated with multiple (three or more) daily injections of insulin or a Medicare-
covered continuous subcutaneous insulin infusion (CSII) pump, 
  4. The beneficiary's insulin treatment regimen requires frequent adjustment by the beneficiary on the basis of 
BGM or CGM testing results. 
  5. Every six (6) months following the initial prescription of the CGM, the treating practitioner has an in-
person visit with the beneficiary to assess adherence to their CGM regimen and diabetes treatment plan. 
 
You can find this information in the Local Coverage Determination (LCD): Glucose Monitors (L33822). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your 
request. The Plan says you do not use insulin. 
 
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 and have had an in-person visit with their treating physician to assesses 
adherence to their CGM regimen and diabetes treatment plan. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of the monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose 
monitor.