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

We decided that the Plan does not have to waive the co-payment for the injection provided on July 29, 2020.

You asked the Plan to waive the co-payment for the injection. You say that you were told there was no cost because this was preoperative service. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 co-payment for Medicare-covered surgery or other services provided to you at an in-network ambulatory surgical center, including but not limited to hospital or other facility charges and physician or surgical charges.

You have been asked to pay a $295 co-payment for the injection. The injection falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. Please note, there is no provision in the contract which indicates a co-payment would be waived for a service performed as a pre-operative service to a surgical procedure.

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 co-payment for the injection provided on July 29, 2020.

Your complaint that the injection was done by mistake 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray provided on October 12, 2020.

You asked the Plan to pay for the first intraoral periapical x-ray. You say that you would like this service to be covered. The Plan denied your request. The Plan says this service exceeds the benefit allowance.

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, intraoral x-rays are limited to once every 36 months. The record shows that you received a first intraoral periapical x-ray on August 29, 2018 and your intraoral x-rays benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray provided on October 12, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for paramedic services (A0432) provided December 9, 2020.

You asked the Plan to pay for the paramedic services. You say that the ambulance should have had a paramedic onboard and you should not be billed separately. The Plan denied your request. The Plan says paramedic services separate from the ambulance transport are not payable.

The Plan must follow Medicare rules. The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the services are furnished under a contract with a qualified basic life support (BLS) ambulance company. In addition, State law must not allow the volunteer ambulance company to bill for the transport or BLS services.

The Plan has confirmed that the company that provided the paramedic service does not have a contract with the volunteer ambulance company that provided the transport services. Therefore, we decided that the Plan does not have to pay for paramedic services (A0432) provided December 9, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from November 14, 2020, to December 13, 2020.

You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says SNF care beyond 100 days per benefit period is not covered by Medicare or the Plan.

The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.

The file shows that the enrollee received 100 days of SNF care during the benefit period from August 24, 2020, to December 30, 2020. The Plan has covered 100 days of SNF care.

Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from November 14, 2020, to December 13, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspirate for lumbar fusion for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this denial is appropriate given the clinical scenario.

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found bone marrow aspirate remains experimental for use in spinal fusion surgery. More research is needed to show safety and efficacy.

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspirate for lumbar fusion for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for family psychotherapy (90847) provided on June 11, 2020.

You asked the Plan to pay for family psychotherapy. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says the CPT code submitted does not appear to be
the most appropriate for the service documented as provided.

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 90847 is family psychotherapy (conjoint psychotherapy)
(with patient present), 50 minutes.

We find that CPT code 90847 is not supported in the record. Specifically, the CPT code billed is for family
therapy with two or more patients. The record indicates that this was a one-on-one service. There is a more
appropriate CPT code to report the services rendered. Based on this information, we decided that Medicare
rules for coverage of family psychotherapy have not been met. Therefore, we decided that the Plan does not
have to pay for family psychotherapy (90847) provided on June 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the semi-electric hospital bed described by current procedural terminology (CPT) code E0260 provided from September 9, 2020 to November 8, 2020.

You asked the Plan to pay for CPT code E0260. 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. Medicare says that suppliers must add a KX modifier to a hospital bed code only if all of the criteria in the "Coverage Indications, Limitations and/or Medical Necessity" section of the related LCD have been met. If all of the coverage criteria have not been met, the GA or GZ modifier must be added to a claim line for a hospital bed and accessories. Claim lines billed without a KX, GA or GZ modifier will be rejected as missing information. The file shows that the claim was not billed with any of these modifiers. Therefore, we decided that the Plan does not have to pay for the semi-electric hospital bed described by current procedural terminology (CPT) code E0260 provided from September 9, 2020 to November 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for pneumatic compression device coded as E0675 provided January 14, 2021.

You asked the Plan to pay for pneumatic compression device. You say that this device was medically necessary. The Plan denied your request. The Plan says this is not a covered service.

The Plan must follow Medicare rules. Medicare rules say that pneumatic compression device coded as E0675 to treat peripheral artery disease is not eligible for reimbursement

We looked at the file and Medicare rules. Based on this information, we decided that Medicare does not provide coverage for the pneumatic compression device coded as E0675. Therefore, we decided that the Plan does not have to pay for pneumatic compression device coded as E0675 provided January 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on January 18, 2021.

You asked the Plan to pay for periodontal maintenance. You say that you feel you should be reimbursed for half the charge for this service, because out-of-network dental care is covered at 50%. The Plan denied your request. The Plan says this service is not covered because the provider has opted out of Medicare and is not part of the Plan's network.

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.

The Plan denied payment for the periodontal maintenance because the provider has opted out of Medicare. If a provider has opted out of Medicare, it is not the same as being an out-of-network provider. Out-of-network providers can accept payment from Medicare plans; however, they may not have agreed to bill or be paid the same rates as in-network providers. Some Plans will cover out-of-network services. Providers who have opted-out of Medicare have decided to not accept payment from Medicare plans and cannot bill Medicare for services rendered. The contract does state that services received out-of-network may be covered at 50% coinsurance. However, the Plan is saying that the provider who rendered services has opted-out of Medicare. According to the contract, services from dentists who have opted-out of Medicare will not be reimbursed.

We requested additional information from the Plan, including the name and information for the provider in question, but the Plan did not forward this information as requested. We do not know what individual provided these services and therefore we cannot verify the opt-out status of this provider. However, periodontal maintenance is not listed as a service that is covered by your supplemental dental benefit. The Plan will only cover standard (prophylaxis) cleanings, which is a different service. This means that periodontal maintenance will not be covered, regardless of who provides the service.

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 periodontal maintenance (D4910) provided on January 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for Medicare Part B drugs and the use of surgical implants and supplies.

You asked the Plan to waive the co-payment for Medicare Part B drugs and the use of surgical implants and supplies. You say that you would like this claim reprocessed and approved for payment since no one told you about the cost share. The Plan denied your request. The Plan says the claim has processed correctly, and no reimbursement is due.

The rules say that a Cost plan must disclose in writing all benefits available under the Plan. The health plan contract says that you must pay a 20% coinsurance for Medicare-covered Part B drugs and prosthetic devices and related supplies.

You have been asked to pay a 20% coinsurance for Medicare Part B drugs and the use of surgical implants and supplies. These services fall within the Medicare-covered Part B drugs and prosthetic devices and related 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 co-payment for Medicare Part B drugs and the use of surgical implants and supplies.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on May 11, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the genetic testing. You say that you were told you would only be responsible for a co-payment. You say the testing was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained, and the provider is non-contract.

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 genetic testing provided on May 11, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on September 3, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the services are not authorized because predictive screening testing is not a covered benefit.

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 the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the eview has determined that the enrollee did not meet the criteria for this request. These services were not authorized because predictive screening testing is not a Medicare benefit.

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 services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on September 3, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90832) provided on October 6, 2020 by an out of network (OON) provider.

You asked the Plan to pay for psychotherapy services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained for the services rendered by an OON 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 for psychotherapy services (90832) provided on October 6, 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 the neuromuscular stimulator (E0745) provided on September 30, 2020.

You asked the Plan to pay for the neuromuscular stimulator. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted documentation does not include an itemized billing/shipping invoice to verify the billed supply.

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 proof of delivery for the supplies provided in this case. The documentation submitted does not include an itemized billing/shipping invoice or proof of delivery to verify the billed items. The record shows that the Plan made several attempts to obtain the necessary documentation without success.

Therefore, we decided that the Plan does not have to pay for the neuromuscular stimulator (E0745) provided on September 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) provided December 15, 2020.

You asked the Plan to pay for the comprehensive oral exam. You say that your previous dentist retired so you needed to have a comprehensive oral exam completed by your new provider and it should be covered. The Plan denied your request. The Plan says this service has been previously covered in the past 3 years and therefore the comprehensive oral exam at issue 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. The Plan covers the comprehensive oral exam once every 36 months. 

We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive oral exam was covered on April 18, 2019. Based on this information, we decided that the Plan's rules for coverage of the comprehensive oral exam have not been met. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) provided December 15, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that all services that would be provided in the LTACH are being provided already in the current acute care setting already approved.

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. You were admitted due to hypoxic respiratory failure due to COVID. You continued to receive acute care services that have not been denied. The medical record does not indicate that you require services that you are currently not receiving but that would be available at the LTACH facility. Our physician reviewer found that your condition does not meet Medicare criteria for LTACH services.

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 long term acute care hospital (LTACH) services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provide on January 10, 2021.
You asked the Plan to pay for the ambulance services. You say that the enrollee was treated in place by the medics then triaged for transport. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on January 10, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on January 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided
on January 19, 2021.

You asked the Plan to pay for the comprehensive periodontal evaluation. You say that your provider said you
needed this evaluation. You also say that you were advised that standard maintenance type work was covered
under your dental insurance. 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 comprehensive periodontal evaluation (D0180) provided on January 19, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on January 14, 2021.
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on January 14, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on January 14, 2021.