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

We decided that the Plan does not have to waive the cost share for the podiatry services received in an outpatient hospital facility provided December 22, 2020.
You asked the Plan to waive the cost share for the podiatry services received in an outpatient hospital facility. You say that you are used to this service being processed with a $45 copayment. The Plan denied your request. The Plan says the claim has processed correctly in this case.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $400 copayment for podiatry services rendered in an outpatient hospital facility. You have been asked to pay a total cost share of $127.93 for the podiatry services received in an outpatient hospital facility. These services fall within the podiatry services rendered in an outpatient hospital facility benefit category. The cost share charged is less than the required $400 copayment. Although you previously might have paid the copayment for specialty physician's office, the claim was billed as 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 cost share for the podiatry services received in an outpatient hospital facility provided December 22, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay fora drug test provided on December 2, 2020 by an out of network (OON) provider.You asked the Plan to pay fora drug test. You say that you would like this claim reprocessed and paid. You say that your lab performed all the tests that were ordered by the referring physicianThe Plan denied your request. The Plan says prior authorization was not obtained by a participating provider.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay fora drug test provided on December 2, 2020 by anout of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on September 23, 2020.

You asked the Plan to pay for the testing services. You say that you have no knowledge of the enrollee's coverage prior to the specimen's arrival at the lab. The Plan denied your request. The Plan says the billed codes cannot be verified.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.

We looked at the file and the rules. The claim shows a place of service as an independent lab. The records do not indicate the specimen was taken at an independent lab. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on September 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary for
the enrollee's condition. The Plan denied your request. The Plan says rules for LTACH care have not been met.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee is an 82-year-old female who admitted to the acute hospital on March 31,
2021, with upper gastrointestinal bleeding and acute respiratory failure requiring mechanical ventilation. There
is no documentation provided necessitating admission to an LTACH. The enrollee is receiving appropriate care
at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at
the acute care hospital where she is currently receiving care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation and complete series of intraoral x-rays provided on January 12, 2021 by an OON provider.
You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral x-rays. You say that you contacted the Plan and confirmed this treating provider was in-network. The Plan denied your request. The Plan says there is no coverage for when services are rendered by an OON provider. The Plan also says that you did not contact the Plan until after this date of service, and did not verify if the provider was participating.
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 responsible for 100% of the cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation and complete series of intraoral x-rays provided on January 12, 2021 by an OON provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for an emergency room visit (99285, 31500, 92950, 32551) provided on February 10, 2021.
You asked the Plan to pay for an emergency room visit. You say that the medical records support the billing of this claim. The Plan denied your request. The Plan says this was not billed with an appropriate primary diagnosis.
The Plan must follow Medicare rules. Medicare rules say that certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the ICD-
10-CM has a coding convention that requires the underlying condition be sequenced first, if applicable, followed by the manifestation. We looked at the file and Medicare rules. The services at issue were billed with a primary diagnosis of I46.8, cardiac arrest due to other underlying condition. This is a manifestation code, meaning the underlying condition should be coded first and this is not an appropriate primary diagnosis. Based on this information, we decided that Medicare rules for coverage of an emergency room visit have not been met. Therefore, we decided that the Plan does not have to pay for an emergency room visit (99285, 31500, 92950, 32551) provided on February 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the molded socket sach foot (L5100), test socket (L5620), acrylic sock (L5629), below knee total contact (L5637), flex inner socket external flame (L5645), suction socket (L5647), socket insert (L5679), alignable system (L5910), ultra-light material (L5940), and flex walk system (L5981), provided on December 17, 2021.

You asked the Plan to waive the coinsurance for the foot orthotics. You say that the items should be covered. The Plan denied your request. The Plan says the cost share 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 20% coinsurance for durable medical equipment (DME) and supplies. 

You have been asked to pay a 20% coinsurance for the foot orthotics. the foot orthotics falls within the durable medical equipment (DME) and supplies 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 the molded socket sach foot (L5100), test socket (L5620), acrylic sock (L5629), below knee total contact (L5637), flex inner socket external flame (L5645), suction socket (L5647), socket insert (L5679), alignable system (L5910), ultra-light material (L5940), and flex walk system (L5981), provided on December 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the dermatology services provided from January 6, 2021, to February 15, 2021.
You asked the Plan to pay for the services provided. You say that the services were medically necessary, not cosmetic. The Plan denied your request. The Plan says the primary insurance is responsible for payment.
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. As the secondary insurer, the Plan cannot be held responsible for the services provided until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the dermatology services provided from January 6, 2021, to February 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), and crown (D2740) provided on January 26, 2021 by an OON provider.
You asked the Plan to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, and crown. You say that these services were rendered for prevention before your teeth broke off. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that you did not contact the Plan's customer service department prior to receiving these services to verify the provider's network status or confirm your 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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), and crown (D2740) provided on January 26, 2021 by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation (A0428, A0425) received January 6, 2021.
You asked the Plan to waive the copayment for the ambulance transportation. You say that without assistance from a trained, medical personnel, it would not have been possible for the enrollee to return to the assisted living facility. The Plan denied your request. The Plan says the correct cost share applied to the claim.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $290 copayment for Ambulance Services. The enrollee has been asked to pay a $277.92 copayment for the ambulance transportation. The ambulance transportation falls within the Ambulance Services benefit category.
This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This amount is less than the required copayment of $290. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance transportation (A0428, A0425) received January 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the Knee orthosis, adjustable knee joints (L1833) and suspension sleeve (L2397) provided on September 2, 2020.
You asked the Plan to pay for the knee orthosis and suspension sleeve. You say that the item should be covered. The Plan denied your request. The Plan says the reasonableness of the provided durable medical equipment was not established.
The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances. We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item.
The record does not show that contact was initiated regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the past 15 months. Based on this information, we decided that Medicare rules for coverage of the knee orthosis and suspension sleeve have not been met. Therefore, we decided that the Plan does not have to pay for the Knee orthosis, adjustable knee joints (L1833) and suspension sleeve (L2397) provided on September 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the office visit provided on January 27, 2021.
You asked the Plan to waive the copay for the services provided. You say that the provider had a lack of expertise in the specialty. The Plan denied your request. The Plan says you are responsible for paying your share of the cost.
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 copay for services obtained from a Tier 1 specialist. The file shows that you received urology services on the date of service at issue. You have been asked to pay a $25 copay for the services provided. The services fall within the physician 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 copay for the office visit provided on January 27, 2021.
Your complaint about the quality of care 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 injection services rendered on July 21, 2020.
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 the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. In this case, the MUE for CPT code 64416 is 1. You billed 2 units of this code, exceeding the MUE. 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 injection services rendered on July 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound care (CPT code 99309-25, 11043-59, 11047, 11044) provided to the enrollee on March 3, 2021, by an out-of-network provider.
You asked the Plan to pay for the wound care. You say that the services were medically necessary. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the wound care (CPT code 99309-25, 11043-59, 11047, 11044) provided to the enrollee on March 3, 2021, by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies (K0553), provided on January 10, 2021.
You asked the Plan to pay for the CGM supplies. You say that the items should be covered. The Plan denied your request. The Plan says If the supplier uses a delivery/shipping service, the supplier may use the shipping date as the date of service on the claim. The shipping date may be defined as the date the delivery/shipping service label is created or the date the item is retrieved for delivery; however, such dates should not demonstrate significant variation.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid date of service for the supplies provided in this case. The date of service should match either the date on the shipment ticket or the date the package was delivered. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies (K0553), provided on January 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora back brace (L0650), provided on February 23, 2021.You asked the Plan to pay fora back brace. You say that the item was medically necessary.The Plan denied your request. The Plan says the item is not medically necessary because your records show you do not have an appropriate face-to-face encounter documented in the records to substantiate the need for this item or the intent of your provider to prescribe it.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 pay for a back brace. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the clinical documentation does not support the need for a lumbar sacral orthosis.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a back brace have not been met. Specifically, there is no documentation indicating the medical necessity of the item.Therefore, we decided that the Plan does not have to pay fora back brace (L0650), provided on February 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit provided on January 8, 2021 by an out of network (OON) provider.You asked the Plan to pay forthe services provided. You say that the medical records prove medical necessity.The Plan denied your request. The Plan says prior authorization was not 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 records show the enrollee was seen for medication refills. 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 servicesat 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 forthe office visit provided on January 8, 2021 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.
You asked the Plan to pre-approve additional routine transportation. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says you are only covered for 20 one-way trips per year under the Plan's transportation benefit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 20 one-way transportation trips per year. We looked at your request, the records in the case file, and the rules. The file shows that you have used 16 one-
way trips and have 4 one-way trips remaining for the 2021 benefit year. The Plan's contract clearly covers 20 one-way trips per year. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation.