Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for post-stabilization inpatient care provided August 17 to August 19, 2018. 
 
You asked the Plan to pay for the inpatient care. You say that the services were medically necessary. The Plan denied your request. The Plan says rules for coverage were not met. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 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 inpatient care. Our reviewer says that coverage criteria has not been met. Our physician reviewer found the enrollee was stable for a plan facility after the initial emergency room services. The attending physician did not document that the enrollee was unstable at any time. 
 
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 inpatient care have not been met. Therefore, we decided that the Plan does not have to pay for post-stabilization inpatient care provided August 17 to August 19, 2018.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for finger x-rays (73140) provided on January 21, 2020. 
 
You asked the Plan to pay for the x-rays. You say that you would like reconsideration because this member received multiple services on the same date of service. The Plan denied your request. The Plan says this claim was submitted without an appropriate modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that generally, A/B MACs (B) must pay for only one interpretation of an EKG or x-ray procedure furnished to an emergency room patient. 
 
We find that CPT code 73140 is not supported in the record. Specifically, this claim has been submitted without the appropriate modifier to validate a second interpretation. Based on this information, we decided that Medicare rules for coverage of the x-rays have not been met. Therefore, we decided that the Plan does not have to pay for finger x-rays (73140) provided on January 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation, oral hygiene instructions, prophylaxis, complete series of intraoral x-rays, office visit for observation, and gingival irrigations provided by an OON dentist on May 22, 2019 and February 6, 2020. 
 
You asked the Plan to pay for the dental services. You say that you were told by the provider that they were innetwork with your dental plan. You also say that you are not able to afford these bills. The Plan denied your request. The Plan says these services were performed by an OON dentist. The Plan also says that there is no benefit for dental services performed by OON providers. 
 
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 comprehensive oral evaluation, oral hygiene instructions, prophylaxis, complete series of intraoral x-rays, office visit for observation, and gingival irrigations provided by an OON dentist on May 22, 2019 and February 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrical stimulation rendered on August 9, 2019 to August 14, 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 the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. The file shows that the chiropractor submitted a claim for electrical stimulation billed with code G0283. Therefore, we decided that the Plan does not have to pay for the electrical stimulation rendered on August 9, 2019 to August 14, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services coded S9328 provided from December 6, 2019 to December 13, 2019. 
 
You asked the Plan to pay for the home infusion therapy 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 a covered benefit. 
 
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 S9328 is home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem. 
 
We find that CPT code S9328 is not supported in the medical record. Specifically, code S9328 has a status code of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy services coded S9328 provided from December 6, 2019 to December 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for ear wax removal provided on December 16, 2019 by an out
of network (OON) provider.
You asked the Plan to pay for ear wax removal. You say that you were referring to see this provider. The Plan
denied your request. The Plan says no referral was submitted for these services by the member's primary care
physician.
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 has network providers
available who can provide 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 ear wax removal provided on December 16, 2019
by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on September 9, 2019 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that the information that was given from the patient was misleading. You say that prior authorization was impossible due to that. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that these services were self-referred.
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 has network providers available who can provide 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 physician services provided on September 9, 2019 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 endodontic therapy (D3320) provided on June 19, 2018. 
 
You asked the Plan to pay for the endodontic therapy. You say that services billed to the insurance company have not been completed as promised. You also say that you have seen this provider multiple times for the seating of the permanent crown, but it has not been done. 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 endodontic therapy (D3320) provided on June 19, 2018.  
 
Your complaint about being misled by the provider 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) perfusion analysis rendered on August 8, 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 procedure code 0042T is not covered. 
 
The Plan must follow Medicare rules. The rules say that procedure code 0042T is noncovered. 
 
We looked at the file and Medicare rules. The services at issue are CT perfusion analysis billed with code 0042T. This code is noncovered by Medicare. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) perfusion analysis rendered on August 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on January 31, 2019, February
1, 2019 and February 5, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says there is not
a valid referral on file for this service.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for physician's services provided on January 31, 2019, February 1,
2019 and February 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on December 30, 2019. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you were told that you would only owe a $10 copayment and only saw a nurse practitioner. 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 a $40 copayment a specialist visit.  
 
The record shows that you received services from a specialist on December 30, 2019. Therefore, you are responsible to pay the $40 copayment.  
 
You have been asked to pay a $40 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services including doctor's office visits 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 a specialist visit provided on December 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the ear wax removal services provided on December 16, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for these OON services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit when provided 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 has network providers available who can provide 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 ear wax removal services provided on December 16, 2019 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 wrist hand orthosis provided on October 21, 2019. 
 You asked the Plan to pay for the wrist hand orthosis (L3916). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the documentation submitted did not indicate the provider discussed the need for the billed supply codes, therefore the billed supply codes cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.  
 
We looked at the file and Medicare rules. No medical records were received to support the diagnosis on the submitted order, therefore the billed codes cannot be supported. Based on this information, we decided that Medicare rules for coverage of the wrist hand orthosis (L3916) have not been met. Therefore, we decided that the Plan does not have to pay for the wrist hand orthosis provided on October 21, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0483 provided on November 8,
2019.
You asked the Plan to pay for the drug testing. 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 G0483 is drug test(s), definitive, utilizing (1) drug
identification methods able to identify individual drugs and distinguish between structural isomers (but not
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type,
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g.,
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drugspecific
calibration and matrix-matched quality control material (e.g., to control for instrument variations and
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or
more drug class(es), including metabolite(s) if performed.
We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation
submitted did not include a valid physician order/lab requisition for the billed test. Based on this information,
we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that
the Plan does not have to pay for the drug testing coded G0483 provided on November 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on December 5, 2019. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you should not be charged for the visit. You say they took you back, checked your pacemaker, and you were done. The Plan denied your request. The Plan says you have been charged 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 copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 copayment for a specialty physician.  
 
You have been asked to pay a $30 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" category. The record shows you received services during your office visit. 
 
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 specialist office visit provided on December 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that the orthotics were requested to assist with your healing process. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 15, 2019 by a non-participating provider.
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 were rendered by a non-participating 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 has network providers available who can provide 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 medical services provided on August 15, 2019 by a non-participating provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for shingles vaccines and preventative immunizations provided from September 16, 2019 to December 3, 2019 under Medicare Part B.  
 
You asked the Plan to pay for preventative vaccines under Medicare Part B. You say that these vaccines should be covered by the Plan. The Plan denied your request. The Plan says preventative vaccines are not covered under Medicare Part B. The Plan says that you do not have Medicare Part D coverage with the Plan.  
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide vaccines under Medicare Part B. The Plan follows the same rules. The records do not show that you were injured or directly exposed to any illness related to the vaccines given. Medicare coverage criteria were not met as these vaccines were preventative in nature. Therefore, we decided that the Plan does not have to pay for shingles vaccines and preventative immunizations provided from September 16, 2019 to December 3, 2019 under Medicare Part B.  
 
Benefits for preventative vaccines may be available under your Medicare Part D carrier. Please contact the administrator of your Medicare Part D coverage for further information.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic exercises provided on December 11, 2019. 
 
You asked the Plan to pay for the therapeutic exercises. You say that this claim is not related to the enrollee's time in hospice. 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 therapeutic exercises provided on December 11, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the 3D imaging rendering (76376) provided on November 27, 2019.You asked the Plan to pay for the imaging services. You say that the services were medically necessary.The Plan denied your request. The Plan says the services were not emergent or pre authorized. There were network providers 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 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 has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay for the 3D imaging rendering (76376) provided on November 27, 2019.