Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the nebulizer with compression rental (E0570) provided on December 3, 2020.
You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says this item is not payable as the billing of durable medical equipment is only allowed once within a 28 day period.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that you had a nebulizer with compression at the time this item was received. The nebulizer with compression serves the same purpose as this item. Additionally, there is no explicit medical documentation provided that supports that a separate nebulizer is needed for each drug in the treatment regimen. Therefore, we decided that the Plan does not have to pay for the nebulizer with compression rental (E0570) provided on December 3, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency care services provided from March 2, 2020 to March 3, 2020.
You asked the Plan to waive the copayment for the emergency care 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 emergency care services on the dates of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.
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 $120 copayment for Emergency care. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received emergency care services from March 2, 2020 to March 3, 2020. You have been asked to pay a $120 copayment for the emergency care services. The emergency care services fall within the Emergency care 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 the emergency care services provided from March 2, 2020 to March 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction (92015) provided on October 13, 2020.

You asked the Plan to pay for the eye refraction. You say that this service should be covered, either by the supplemental vision benefit or by Medicare. The Plan denied your request. The Plan says this service cannot be covered because it was billed with a medical diagnosis and is therefore not routine. The supplemental benefit only covers routine refractions. In addition, this service was not provided in the Plan's supplemental vision network. 

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers eye refractions when they are provided as part of a routine eye exam by a provider in the Plan's supplemental vision network.

We looked at the file and the Plan's rules. This service was billed with a medical diagnosis and therefore is not considered a routine service. The provider in this case is not part of the Plan's routine vision network, and Medicare does not cover eye refractions. Based on this information, we decided that the Plan's rules for coverage of the eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for an eye refraction (92015) provided on October 13, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for X-Ray examinations provided by a chiropractor on October 2, 2020.

You asked the Plan to pay for X-Rays. You say that the provider needed to do these X-Rays to determine the cause and needed treatment, and you could not find any evidence in your Evidence of Coverage that would indicate X-Rays would not be covered. The Plan denied your request. The Plan says the denial of payment for these services is correct, because X-Rays are not covered by Medicare or the Plan when performed by a chiropractor.

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 Plan also has a supplemental routine chiropractic benefit; however, X-Rays are excluded from this benefit. 

The records show that the service at issue is not manual manipulation of the spine. X-Rays are excluded from the Plan's chiropractic benefits. Therefore, we decided that the Plan does not have to pay for X-Ray examinations provided by a chiropractor on October 2, 2020.

Your complaint regarding feeling discriminated against is considered to be a grievance. The Qualified Independent Contractor (QIC) does not have the jurisdiction to address grievances. Please contact the Plan for more information about your grievance.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomographic angiography of
the abdomen and pelvis, with contrast material (74174) provided on November 17, 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 $275
copayment for each advanced imaging service.
You have been asked to pay a $275 copayment for the advanced imaging service provided. 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 computed tomographic angiography of the abdomen and pelvis,
with contrast material (74174) provided on November 17, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF services.
You asked the Plan to pre-approve the SNF services. The Plan denied your request. The Plan says you do not meet Medicare guidelines for services in a SNF.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found from a nursing perspective, you received oral and inhaled medications. You had stable vital signs. You were treated for chronic pain. Regarding rehabilitation services, you received physical therapy in the SNF. By the dates in question, you were at a standby assist to contact guard assist level with functional mobility including gait to short distances (10 feet) with a rolling walker. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. As a practical matter, you do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on July 2, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on July 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of an impacted tooth (D7240) for tooth # 5 provided on December 14, 2020.

You asked the Plan to pay for the dental service. You say that a plan representative advised you were eligible for $3,500 a year for dental services. You say that you will need other services. You say that you need to know if they will be covered. You also say that you want to know why your plan was changed. The Plan denied your request. The Plan says removal of an impacted tooth is not listed as 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, 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 removal of an impacted tooth (D7240) for tooth # 5 provided on December 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Esophagogastroduodenoscopy (43239) provided on
March 30, 2020.
You asked the Plan to pay for the Esophagogastroduodenoscopy. You say that you would like the Plan to
reconsider their denial of payment. The Plan denied your request. The Plan says the medical records do not
support the billing of 43239.
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment
for any item or service, the information submitted by the supplier or provider must confirm that Medicare
coverage criteria have been met.
We looked at the file and Medicare rules. In this case, there were no medical records provided confirming that
an Esophagogastroduodenoscopy (43239) was provided on March 30, 2020. The medical records submitted do
not include a detailed procedure report to verify the billed code is correct. Therefore, we decided that the Plan
does not have to pay for the Esophagogastroduodenoscopy (43239) provided on March 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for initial observation care provided on December 27, 2020.

You asked the Plan to pay for initial observation care. You say that the Plan should pay this claim. The Plan denied your request. The Plan says a claim was paid for the emergency department visit 99285 for the same provider.

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, we have confirmed that code 99220 initial observation care has a bundled relationship with code 99285 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for initial observation care provided on December 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the services provided by a specialist from October 23, 2020 to December 7, 2020.
You asked the Plan to waive the copayments for the specialist 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 specialist services on the dates of service at issue in this appeal. The Plan says that the correct copayments have applied per your contract with the Plan.
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 $25 copayment for services obtained from a specialist, or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's office. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received services provided by a specialist from October 23, 2020 to December 7, 2020. You have been asked to pay a $25 copayment for each of the specialist services. The specialist services fall within the Physician/Practitioner services benefit category. This means that you have been asked to pay the correct amounts 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 copayments for the services provided by a specialist from October 23, 2020 to December 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the addition of tooth to existing partial denture (D5650) provided on December 14, 2020.

You asked the Plan to pay for the addition of tooth to existing partial denture. You say that you would like this service to be covered. The Plan denied your request. The Plan says this service is not a covered benefit under 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 addition of tooth to existing partial denture (D5650) provided on December 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on April 10, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.
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 for the physician services provided on April 10, 2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on
September 7, 2020.
You asked the Plan to waive the copayment for the ambulance transport. The Plan denied your request. The
Plan says that cost sharing is a contractual obligation of the plan and cannot be waived.
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 $220
copayment for each one-way Medicare-covered ground trip.
You have been asked to pay a $220 copayment for the ambulance transport. The ambulance transport falls
within the one-way Medicare-covered ground trip 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 the ambulance transport provided on September 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for domiciliary or rest home visit (99327, 99335) rendered by the out of network (OON) provider on October 13, 2020 and October 20, 2020.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 domiciliary or rest home visit (99327, 99335) rendered by the out of network (OON) provider on October 13, 2020 and October 20, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram described by code 93010 provided on August 28, 2020.
You asked the Plan to pay for code 93010. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says code 93010 is not separately 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, we have confirmed that code 93010 has a bundled relationship with code 31500 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the electrocardiogram described by code 93010 provided on August 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the unspecified preventive procedure (D1999) and the unspecified oral surgery procedure (D7999) received November 11, 2020.
You asked the Plan to pay for the dental services (D1999, D7999). You say that you should only be required to pay $60 for the procedure. The Plan denied your request. The Plan says the requested services are not covered under your supplemental benefit.
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. You have been asked to pay $1,066.00 for services D1999 ($10.00) and D7999 ($1056.00). You have no liability for D7210. Based on this information, you have been asked to pay the correct amount for services D1999 and D7999. Therefore, we decided that the Plan does not have to pay for the unspecified preventive procedure (D1999) and the unspecified oral surgery procedure (D7999).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services for an eye exam and YAG laser surgery provided on October 12, 2020 and November 2, 2020.
You asked the Plan to pay for the physician's services for an eye exam and YAG laser surgery. You say that you went to the physician for a retinal examination because you could not see, and it was determined that you needed laser cataract surgery. The Plan denied your request. The Plan says that the services were rendered by a provider who is not under contract with the Plan, and the services were not approved in compliance with the Plan's authorization procedures.
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 physician's services for an eye exam and YAG laser surgery provided on October 12, 2020 and November 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the amalgam-three surfaces, primary or permanent (D2160) and the amalgam-two surfaces, primary or permanent (D2150) provided on November 11, 2020.
You asked the Plan to pay for these 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 policy.
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 services provided are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the amalgam-three surfaces, primary or permanent (D2160) and the amalgam-two surfaces, primary or permanent (D2150) provided on November 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an echocardiography provided on August 20, 2020.
You asked the Plan to pay for the echocardiography. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for an echocardiography provided on August 20, 2020.