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

We decided that the Plan does not have to pay for the blood glucose strips provided by a retail pharmacy from September 8, 2020, through December 27, 2020.
You asked the Plan to pay for the blood glucose strips. You say that you have been able to keep tighter controls on your levels with these sensors. You say that Medicare covers the sensors, and this should be covered. The Plan denied your request. The Plan says diabetic supplies obtained at a retail pharmacy are limited to One Touch, Breeze and Contour. The Plan also says that in-network durable medical equipment providers can provide FreeStyle Libre supplies.
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 blood glucose strips provided by a retail pharmacy from September 8, 2020, through December 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on October 28, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was billed incorrectly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on October 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the periodic oral evaluation (D0120), bitewing x-rays (D0274), and prophylaxis (D1110) provided on February 22, 2021 by an OON provider.
You asked the Plan to pay more for the periodic oral evaluation, bitewing x-rays, and prophylaxis. You say that you believe these services should be covered in full. The Plan denied your request. The Plan says the total $178 amount applied correctly as enrollee liability. The Plan also says that cost sharing is a contractual obligation under the Plan and cannot be waived.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for the difference
between the billed amount and allowed amount. Therefore, we decided that the Plan does not have to pay more for the periodic oral evaluation (D0120), bitewing x-rays (D0274), and prophylaxis (D1110) provided on February 22, 2021 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) and knee braces (L1851) with suspension sleeves (L2397) provided on October 21, 2020.
You asked the Plan to pay for a lumbar-sacral orthosis and knee braces with suspension sleeves. You say that the requested items are a necessity for the enrollee's care. The Plan denied your request. The Plan says the requested items are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for a lumbar-sacral orthosis and knee braces with suspension sleeves. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the available documentation in the case file does not support that the requested lumbar-sacral orthosis was medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by Medicare. A physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for an LSO have been met. The documentation does not support that the lumbar-sacral orthosis is being prescribed for one or more of the covered indications in this case, as there is insufficient documentation of a credible physical examination of the back. Our physician reviewer also found that the documentation in the case file does not support that the requested knee orthoses with sleeves were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by Medicare. There is no documentation of recent injury to, or recent surgical procedure on, either of the enrollee's knees, and there is insufficient credible objective documentation of joint laxity. The items coded L2397 (sleeves) are not separately payable when the base item is not covered. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a lumbar-sacral orthosis and knee braces with suspension sleeves have not been met. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) and knee braces (L1851) with suspension sleeves (L2397) provided on October 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on February 22, 2021 by an out of network provider.
You asked the Plan to pay for the office visit. You say that you did not know you needed authorization. The Plan denied your request. The Plan says you did not request prior authorization for the out of network, non-urgent services.
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 service 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 this service. Therefore, we decided that the Plan does not have to pay for the office visit provided on February 22, 2021 by an out of network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on September 17, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure codes 75625 and 76937 are not supported.
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 75625 is aortography, abdominal, by serialography, radiological supervision and interpretation. The definition of code 76937 is ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle entry, with permanent recording and reporting
(List separately in addition to code for primary procedure). We find that CPT codes 75625 and 76937 are not supported in the medical record. Specifically, there is no documentation of radiological supervision and interpretation of an abdominal aortography by serialography to support code 75625. There is no documentation of ultrasound guidance for vascular access procedures to support code 76937. 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 surgical services rendered on September 17, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound of the breast provided on February 19, 2019.
You asked the Plan to waive the copayment for an ultrasound of the breast. You say that you disagree with the charges because you feel that the services should be considered preventative. 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 $50 copayment for diagnostic radiology. You received an ultrasound of the breast on February 19, 2019. An ultrasound of the breast is not considered a preventative procedure. Therefore, you are responsible to pay the $50 copayment. You have been asked to pay a $50 copayment for diagnostic radiology for an ultrasound of the breast. An ultrasound of the breast 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 an ultrasound of the breast provided on February 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on November 4, 2020 by an out of network (OON) provider.
You asked the Plan to pay for skilled nursing services. You say that these services were provided at a skilled nursing facility. 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.
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 skilled nursing services provided on November 4, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services rendered from January 18, 2021 to January 21, 2021.
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 claim was billed with an incorrect type of bill code.
The Plan must follow Medicare rules. The rules say that claims must be billed with the correct Type of Bill code. We looked at the file and Medicare rules. The file shows that the provider did not submit the claim with the correct Type of Bill code. Based on this information, we decided that Medicare rules for coverage of these services have not been met. The Plan may reprocess the claim once a corrected claim is received from the provider. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services rendered from January 18, 2021 to January 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for podiatry services provided on June 12, 2020, to June 15, 2020 by an out of network (OON) provider.
You asked the Plan to pay for podiatry services. 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 a participating provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for podiatry services provided on June 12, 2020, to June 15, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81479, 81286, 81407, 81408) provided August 14, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says these services are not covered.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular risk assessment testing / panels, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular disease. We looked at the file and Medicare rules. Medicare does not cover cardiovascular risk assessment panels. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81479, 81286, 81407, 81408) provided August 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on December 1, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 provided on December 1, 2020 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 November 28, 2020, to January 28, 2021 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this reprocessed and paid. You say that doctor was already at the facility and checked on the member. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that prior authorization is required for these services.
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 physician services provided on November 28, 2020, to January 28, 2021 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the alginate or other fiber gelling dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in. coded A6197 provided on January 21, 2021.
You asked the Plan to pay for the alginate or other fiber gelling dressing, wound cover, sterile, pad. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the items are not payable as billed.
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 A6197 is alginate or other fiber gelling dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., each dressing.
We find that CPT code A6197 is not supported in the medical record. Specifically, this is considered as part of the global surgical package of the initial procedure (code 11043-Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq cm or less)) billed on the same claim. Based on this information, we decided that Medicare rules for coverage of the alginate or other fiber gelling dressing, wound cover, sterile, pad have not been met. Therefore, we decided that the Plan does not have to pay for the alginate or other fiber gelling dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in. coded A6197 provided on January 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services (D7140, D0140, D0220) received October 6, 2020 from the out-of-network provider.
You asked the Plan to pay for the dental services (D7140, D0140, D0220). You say that the enrollee was in a great amount of pain and needed the requested services. The Plan denied your request. The Plan says there is no coverage for services received out-of-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. 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. These services were received out-of-network. The Plan contract clearly states that if the enrollee receives services out-of-network then they must pay 100% of the cost.
Therefore, we decided that the Plan does not have to pay for the dental services (D7140, D0140, D0220) received October 6, 2020 from the out-of-network provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee from June 1, 2020, and June 11,2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare database shows the member was enrolled in hospice from May 26, 2020, to June 25, 2020.
In accordance with Medicare guidelines, the provider needs to bill Original Medicare, using the proper modifiers, for services rendered on June 01, 2020 and June 11, 2020. Per the regulations above, the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. It is the provider's responsibility to verify the member's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice
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 medical services provided to the enrollee from June 1, 2020, and June 11,2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for inpatient psychiatric hospital service provided on November 24, 2020 through December 29, 2020, by an out of network provider.
You asked the Plan to waive the coinsurance for inpatient psychiatric hospital services. You say that the services 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 50% out of network coinsurance for inpatient mental health care. You have been asked to pay a 50% out of network coinsurance for inpatient psychiatric hospital services. These services fall within the inpatient mental health 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 coinsurance for inpatient psychiatric hospital service provided on November 24, 2020 through December 29, 2020, by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the 20% coinsurance charged for a walker provided from May 1, 2020 to January 28, 2021.
You asked the Plan to waive this coinsurance. You say that you thought this cost was waived during Covid-19. The Plan denied your request. The Plan says this coinsurance was charged based on services provided and the Plan contract agreement.
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 durable medical equipment. Medicare did not waive coinsurance requirements during the pandemic for any circumstance. 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 20% coinsurance charged for a walker provided from May 1, 2020 to January 28, 2021.