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

We decided that the Plan does not have to pay for contact lens fitting (92310) and contact lenses (V2510) provided January 29, 2021.

You asked the Plan to pay for the contact lens fitting and contact lenses. You say that this is a therapeutic device not just a vision aid and the cost should be covered. The Plan denied your request. The Plan says contact lenses are not covered under Medicare unless following cataract surgery and are not covered under your supplemental eyewear benefits.

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. 

We looked at the file and the Plan's rules. In this case the contact lenses were not provided following cataract surgery. Contacts are not covered under your supplemental eyewear benefits. Therefore, we decided that the Plan does not have to pay for contact lens fitting (92310) and contact lenses (V2510) provided January 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cup holder.

You asked the Plan to pre-approve a cup holder. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested item is not a covered benefit.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a cup holder.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the HFCWOD to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the HFCWOD. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says you must use network providers for medical care and services when network providers are available.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the HFCWOD to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the seven emergency room visits from October 21, 2020 through November 13, 2020 or inpatient hospital services provided from November 15, 2020 through November 20, 2020.
You asked the Plan to waive the copayments for the emergency room visits and inpatient hospital services. You say that you cannot afford these charges. The Plan denied your request. The Plan says that the claims processed and applied correct cost share in accordance to the Evidence of Coverage.
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 $90 copayment for each Medicare-covered emergency room visit and a $325 copayment per day, days 1-6 for Medicare-covered hospital admission/stays.
You have been asked to pay a $630 copayment for the emergency room visits and a $1,625 copayment for the inpatient hospital services. The emergency room visits fall within the Medicare-covered emergency room visit benefit category and the inpatient hospital services falls within the Medicare-covered hospital admission/stays 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 copayments for the seven emergency room visits from October 21, 2020 through November 13, 2020 and inpatient hospital services provided from November 15, 2020 through November 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 36415, 82565, 84520) provided to the enrollee on January 25, 2021.

You asked the Plan to pay for the laboratory services. You say that the claim should be paid. 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 laboratory services (CPT code(s): 36415, 82565, 84520) provided to the enrollee on January 25, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for DNA gene analysis of 324 genes in solid organ tumor tissue (CPT code 0037U) provided to the enrollee on August 11, 2020.
You asked the Plan to pay for the laboratory services. You say that the services were necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. As Comprehensive Genomic Profile (CGP) testing is not defined as a targeted panel by MolDX; and it is a test not currently
satisfactorily described by any existing CPT code; to report a CGP, service providers should use CPT code 81479 (used for the entire bundled multi-test panel) at this time, in addition to the approved DEX Z-CodeTM entered adjacent in the comment/narrative field for the test; not unbundled to separate codes. Medicare non-coverage applies to both contracted and non-contracted providers and cannot be overridden by plan directed care. Therefore, we decided that the Plan does not have to pay for DNA gene analysis of 324 genes in solid organ tumor tissue (CPT code 0037U) provided to the enrollee on August 11, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to provide the remaining 7 requested occupational therapy visits.

You asked the Plan to provide the remaining 7 requested occupational therapy visits. You say that without additional skilled occupational therapy intervention the enrollee is at risk for loss of effective use of the right limb. The Plan denied your request. The Plan says they will approve 3 of the 10 requested occupational therapy visits for transition to a home exercise program.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.

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 provide the remaining seven requested occupational therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found based on the medical records provided there is no documentation that the requested therapy is generally accepted as specific and effective therapy for the patient's condition. Based on the available records the patient appears to have improved with therapy to the point of being able to manage most activities of daily living with minimal assistance. Further skilled therapy beyond the approved three additional occupational therapy visits at this point does not appear to be likely to achieve any significant improvement in the patient's symptoms or functional status. Further utilization of the home exercise program appears appropriate at this point. Based on the available records the patient appears to have improved with therapy to the point of being able to manage most activities of daily living with minimal assistance.

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 remaining seven requested occupational therapy visits have not been met. Therefore, we decided that the Plan does not have to provide the 7 remaining requested occupational therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation and re-cement or re-bond crown provided on February 24, 2021.

You asked the Plan to pay for the problem focused limited oral evaluation and re-cement or re-bond crown. You say that these services were medically necessary. The Plan denied your request. The Plan says these 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. 

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 problem focused limited oral evaluation and re-cement or re-bond crown provided on February 24, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the infectious agent antigen detection by immunoassay
technique services coded 87338 provided on December 1, 2020.

You asked the Plan to pay for the infectious agent antigen detection by immunoassay technique services. You
say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the
services billed are not supported by the documentation.

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 87338 is infectious agent antigen detection by
immunoassay technique, (e.g., enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA],
immunochemiluminometric assay [IMCA]) qualitative or semiquantitative, multiple-step method; Helicobacter
pylori, stool.

We find that CPT code 87338 is not supported in the medical record. Specifically, the medical records
submitted does not contain a requisition/order or documented request and lab/test result for the service billed.
Based on this information, we decided that Medicare rules for coverage of the infectious agent antigen
detection by immunoassay technique services have not been met. Therefore, we decided that the Plan does not
have to pay for the infectious agent antigen detection by immunoassay technique services coded 87338
provided on December 1, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the positron emission tomography (PET) scan provided to the enrollee on February 9, 2021.

You asked the Plan to pay for the claim as billed. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the Medicare billing criteria are not met, as the diagnosis code used on the claim is not supported by the medical records.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate diagnosis and service codes that report the service billed to the highest degree of specificity. The claim itself was billed with a diagnosis code of "C50.912 defined as Malignant neoplasm of unspecified site of left female breast." However, the medical records provided indicate the left breast was the part of the body that was the area of concern.

In this case, this claim cannot be paid as billed due to a generic diagnosis code and the omission of specific codes or modifiers that identify the exact part of the body requiring the image. If more areas of the body than the right breast required imaging, the claim should have reflected that with the appropriate codes being billed and submission of the appropriate medical record documentation. Based on this information, we decided that Medicare rules for coverage of the claim as billed have not been met. Therefore, we decided that the Plan does not have to pay for the positron emission tomography (PET) scan provided to the enrollee on February 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) and the unspecified preventive service (D1999) provided on December 9, 2020.

You asked the Plan to pay for the dental services. You say that your dentist explained that prophylaxis and periodontal maintenance were the same thing. The Plan denied your request. The Plan says periodontal maintenance is not listed as a covered service. The Plan says that unspecified preventive service is not listed as a covered service either.

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 periodontal maintenance (D4910) and the unspecified preventive service (D1999) provided on December 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 87150 and 87324) provided to the enrollee on July 29, 2020.

You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. CPT code 87150 (11 Units) remains not supported. The place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11. Also, the laboratory results submitted indicate the specimen was collected on July 29, 2020, and received by the lab on July 31, 2020; therefore, the billed code cannot be verified. It is noted multiple attempts were made to obtain additional information from the provider. 

CPT code 87324-XU (1 Unit) remains not supported. The place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11. Also, the laboratory results submitted indicate the specimen was collected on July 29, 2020, and received by the lab on July 31, 2020; therefore, the billed code cannot be verified. It is noted multiple attempts were made to obtain additional information from the provider. Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code(s): 87150 and 87324) provided to the enrollee on July 29, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab tests provided on January 5, 2021, by an OON provider.
You asked the Plan to pay for lab tests. You say that you would like this claim reprocessed and paid. The Plan
denied your request. The Plan says prior authorization was not obtained by the member's primary care
physician. The Plan says that the referring provider is out-of-network.
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 lab tests provided on January 5, 2021, by an OON
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME and related supplies provided on November 3, 2020.

You asked the Plan to waive the coinsurance for DME and related supplies. You say that you have been compliant for over three years and request that the Plan pay for the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for DME and related supplies. 

You received DME and related supplies on November 3, 2020. The total allowed amount is $84.16 and 20% of that is $16.83.

You have been asked to pay the total coinsurance amount of $16.83 for DME and related supplies. DME and related supplies fall within the DME 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 coinsurance for DME and related supplies provided on November 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program (92012) and scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; optic nerve (92133) provided January 28, 2021.

You asked the Plan to waive the copayment for the medical eye exam and computerized scan. You say that it is not fair to have an additional charge for diagnostic services performed during the exam.The Plan denied your request. The Plan says the Plan correctly applied the copayments for the exam and diagnostic scan.

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 $45 copayment for each Medicare-covered specialist office visit. 

You will be responsible for all applicable copayments and/or coinsurances for each service provided at the time of your visit. The Plan contract also says that you must pay a $25 copayment for other Medicare-covered outpatient diagnostic procedures and tests.You have been asked to pay a total of $70 cost-share($45 copayment for the medical eye exam + $25 copayment for the computerized scan = $70 total cost-share) for the medical eye exam and computerized scan. The medical eye exam falls within the Physician/Practitioner services, including doctor's office visits benefit category. The computerized scan falls within the Outpatient diagnostic tests and therapeutic services 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 copayment for the ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program (92012) and scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; optic nerve (92133) provided January 28, 2021.

Your complaint about the policy to charge a separate cost-share for diagnostic services provided during a medical exam 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing (CPT code(s): 81223 and 81425) provided to the enrollee on December 16, 2020.
You asked the Plan to pay for the genetic testing. You say that the claim should be paid. The Plan denied your request. The Plan says the genetic testing was not ordered/approved by ordering provider.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. The genetic testing was not ordered/approved by ordering provider. Therefore, we decided that the Plan does not have to pay for the genetic testing (CPT code(s): 81223 and 81425) provided to the enrollee on December 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a continuous positive airway pressure (CPAP) device (E0601) provided on September 27, 2020, October 25, 2020, November 27, 2020, December 27, 2020, and January 27, 2021.

You asked the Plan to waive the coinsurance for a CPAP device. You say that the device 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 related supplies. 

You have been asked to pay a 20% coinsurance for the CPAP device. This item falls within the durable medical equipment (DME) 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 coinsurance for a continuous positive airway pressure (CPAP) device (E0601) provided on September 27, 2020, October 25, 2020, November 27, 2020, December 27, 2020, and January 27, 2021.