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

We decided that the Plan does not have to pay for the catheters rendered on May 28, 2019.
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 there is no valid physician order.
The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating physician before dispensing any DMEPOS item to a beneficiary. We looked at the file and Medicare rules. There is no valid physician order for the DME. 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 catheters rendered on May 28, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), the periapical x-ray
(D0220), and the 2 surgical extractions (D7210) provided on January 5, 2021.

You asked the Plan to pay for the dental services. You say that you contacted the dental office before your
appointment. You say that you were advised that they would accept your insurance. You say that you paid your
copayment. You also say that you do not have the means to pay more. The Plan denied your request. The Plan
says the provider in this case is out of network. The Plan says that dental services performed out of network are
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, dental services performed out of
network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to
pay for the limited oral evaluation (D0140), the periapical x-ray (D0220), and the 2 surgical extractions
(D7210) provided on January 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extractions (D7140 x 2), the periapical x-ray (D0220), and the placement of intra-socket biological dressing to aid in hemostasis or clot stabilization, per site, (D7922) provided on March 3, 2021.
You asked the Plan to pay for the dental services. You say that your right jaw bone was split. You say that you were advised it would take a long time to heal. You also say that you were in a lot of pain. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that dental services performed out of network are not covered. The Plan also says placement of intra-socket biological dressing to aid in hemostasis 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 and extractions and periapical x-ray are listed as covered, dental services performed out of network are not covered. Additionally, placement of intra-socket biological dressing to aid in hemostasis is not among those covered under this benefit regardless of the provider's network status. Therefore, we decided that the Plan does not have to pay for the extractions (D7140 x 2), the periapical x-ray (D0220), and the placement of intra-socket biological dressing to aid in hemostasis or clot stabilization, per site, (D7922) provided on March 3, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the inpatient evaluation and management (EM) services provided on
February 22, 2021.
You asked the Plan to pay for the EM services. You say that these services were provided during an emergency
admission. They are payable as billed and do not require authorization. The Plan denied your request. The Plan
says that this claim is only payable if submitted with modifier -77 because another physician also billed the
same services on this date. Since a corrected claim was not submitted, no payment can be made.
The Plan must follow Medicare rules. Medicare rules say that while payment cannot be made for two inpatient
physician EM services on the same date of services if one physician is covering for another, payment can be
made when both physicians are responsible for a different aspect of the enrollee's care, when the physicians are
of different specialties and different diagnosis code are billed.
In this case, the provider at issue has a specialty of Internal Medicine, while the other provider who billed for
the same services has a specialty of Internal Medicine Infectious Disease. The records show that the provider at
issue is a hospitalist while the other provider was providing an infectious disease consultation. The claims were
billed with different principal diagnoses. Although the Plan states modifier -77 is needed for payment, its use in
this situation is not appropriate. The rules do not indicate that this or any other modifier is required in this
situation. Therefore, we decided that the Plan has to pay for the inpatient evaluation and management (EM)
services provided on February 22, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397) provided March 18, 2021.
You asked the Plan to pay for the orthoses. You say that this enrollee requested services utilizing access to telemedicine from the physician of their choice in an effort to address Coronavirus concerns. The Plan denied your request. The Plan says the ordering physician and the provider is not a Medicare certified DME supplier, there is no evidence of an established relationship between the enrollee and the ordering physician.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397) provided March 18, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services rendered from November 29, 2020 to November 30, 2020.
You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the 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 $250 copayment per day for days 1-6 for Medicare-covered hospital care.
Review of the file shows that you received one day of inpatient hospital care from November 29, 2020 to November 30, 2020. You have been asked to pay a $250 copayment for these services. These services fall within the Medicare-covered hospital 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 inpatient hospital services rendered from November 29, 2020 to November 30, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for self-administered medication provided during a hospital stay from March 3, 2021, to March 4, 2021.
You asked the Plan to pay for self-administered medication. You say that you were not able to administer medication from your own supply. The Plan denied your request. The Plan says self-administered medication is not covered even while provided in a hospital.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered medication
provided during a hospital stay from March 3, 2021, to March 4, 2021.
Benefits for self-administered medication may be available under Medicare Part D. Contact the Plan that
administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from
January 6, 2021 to January 12, 2021.
You asked the Plan to pay for home health 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. The rules say that certain data elements on the RAP and the claim must
be completed for home health care services to be covered.
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that
Medicare rules for completing the claim for home health services have not been met. Specifically, a corrected
claim will need to be billed with a valid Health Insurance Prospective Payment System (HIPPS) code. Therefore,
we decided that the Plan does not have to pay for the home health services provided to the enrollee from
January 6, 2021 to January 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the echocardiogram rendered on February 27, 2021.
You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the 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 $110 copayment for Medicare-covered diagnostic radiology services.
Review of the file shows that you received an echocardiogram on February 27, 2021. You have been asked to pay a $110 copayment for these services. These services fall within the Medicare-covered diagnostic radiology services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the echocardiogram rendered on February 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services rendered on March 14, 2021 to March 22, 2021.
You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the 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 $200 copayment for each inpatient admission per benefit period.
Review of the file shows that you received inpatient hospital services from March 14, 2021 to March 22, 2021. You have been asked to pay a $200 copayment for these services. These services fall within the inpatient admission 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 inpatient hospital
services rendered on March 14, 2021 to March 22, 2021
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the ambulance response and treatment, no transport (A0998) provided
on January 7, 2021.
You asked the Plan to pay for the ambulance response and treatment, no transport. You say that you would like
the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are
not covered.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. Effective for dates of service 3/1/20 FORWARD, The Center for Medicare and
Medicaid Services (CMS) is waiving the requirement that in order for ambulance services to be covered that
there must be actual transport. CMS will pay for treatment in place under this waiver in cases where the
individual that would have been transported would have met the Medicare criteria for a medically necessary
ground ambulance transport to the nearest appropriate facility that could have treated the patient's condition,
but such transport did not occur as a result of community-wide EMS protocols due to the COVID-19 PHE. In
this case, the Plan made no attempts at obtaining medical records to establish if medical necessity criteria per
Medicare guidelines had been met. Therefore, we decided that the Plan has to pay for the ambulance response
and treatment, no transport (A0998) provided on January 7, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory services (36415, 80061, 83036, 85027, G0103) provided on April 9, 2021.
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 was applied correctly to the services 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 $10 copayment for laboratory services. You have been asked to pay a $9.47 copayment for the laboratory services provided. This amount is less than the applicable copayment for this service.
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 laboratory services (36415, 80061, 83036, 85027, G0103) provided on April 9, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on July 27, 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 27, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the oxygen and oxygen supplies (A0422), ground mileage (A0425), emergency ambulance transport (A0427), and BLS emergency transport (A0429) provided on January 25, 2018.
You asked the Plan to pay for the oxygen and oxygen supplies, ground mileage, emergency ambulance transport, and BLS emergency transport. You say that it is unlawful for the Plan to recoup the money for the transport is payment is more than 18 months prior. The Plan denied your request. The Plan says Original
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the oxygen and oxygen supplies (A0422), ground mileage (A0425), emergency ambulance transport (A0427), and BLS emergency transport (A0429) provided on January 25, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee brace (L1833, L2397) provided on December 19, 2020.
You asked the Plan to pay for a knee brace. You say that this was medically necessary. The Plan denied your request. The Plan says this was provided following an unsolicited phone call.
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 a knee brace have not been met. Therefore, we decided that the Plan does not have to pay for a knee brace (L1833, L2397) provided on December 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the maxillary immediate denture (D5130), mandibular immediate denture (D5140), and thirteen simple extractions (D7140 x13) provided from October 23, 2020, to November 9, 2020.
You asked the Plan to pay for the maxillary immediate denture, mandibular immediate denture, and simple extractions. You say that these services were provided in order to get rid of the infection in your jaws. The Plan denied your request. The Plan says these services are purely dental in nature and are unrelated to the limited clinical indications. The Plan also says that these services are not eligible for coverage under the medical benefit.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the maxillary immediate denture
(D5130), mandibular immediate denture (D5140), and thirteen simple extractions (D7140 x13) provided from October 23, 2020, to November 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a medical eye exam (92004, 92083) and an eye exam with photos (92250) provided on January 27, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for a medical eye exam and photos. You say that you had surgery in both eyes years ago and the surgery did not go well. You also say you would like reconsideration of the denied charges. 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 a medical eye exam (92004, 92083) and an eye exam with photos (92250) provided on January 27, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120), intraoral - periapical first radiographic image (D0220), prophylaxis - adult (D1110), and bitewings - four radiographic images (D0274) provided March 8, 2021.
You asked the Plan to pay for the periodic oral exam, intraoral x-rays, dental cleaning and bitewing x-rays. You say that your agent did not tell you that your dentist had to be enrolled in Medicare. The Plan denied your request. The Plan says the provider who rendered the services has opted out of Medicare and therefore the services are 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 periodic oral exam, intraoral x-rays, dental cleaning and bitewing x-rays when you see any licensed dental provider who accepts Medicare patients in the United States and has not opted out of Original Medicare. You can find this information on pages 66-67 of the Plan's 2021 Evidence of Coverage (EOC). We looked at the file and Medicare rules. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Based on this information, we decided that the Plan's rules for coverage of the periodic oral exam, intraoral x-rays, dental cleaning and bitewing x-rays have not been met. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120), intraoral - periapical first radiographic image (D0220), prophylaxis - adult (D1110), and bitewings - four radiographic images (D0274) provided March 8, 2021.