Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee on April 10,
2019, by an out-of-network provider.
You asked the Plan to pay for the medical 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 medical services provided to the enrollee on
April 10, 2019, by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment forthe arthrocentesis on February 28, 2020.You asked the Plan to reduce the copayment forthe arthrocentesis. You say that you received a shot in the doctor's office and did not expect to receive such a high bill. You say you had already paid a $40 copayment. 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 $300 copayment for each Medicare-covered outpatient surgical procedure at an in-network outpatient hospital. You have been asked to pay a $300 copayment for the arthrocentesis. The arthrocentesis falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows the arthrocentesis is considered a surgical procedure and you were billed by the outpatient hospital.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 reduce the copayment forthe arthrocentesis provided on February 28, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe core buildup, including any pins when required (D2950) provided on October 8, 2020.You asked the Plan to pay forthe core buildup. You say that you would like this claim covered.The Plan denied your request. The Plan says your annual benefit had been exhausted.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 Plan offers an annual maximum benefit of $1,000 every year. The contract says that after your annual maximum benefit maximum has been met, you are responsible for the full charges of any additional dental services. The record shows that you met the annual maximum benefit on October 8, 2020,and your annual maximum benefit has been exhausted.Therefore, we decided that the Plan does not have to pay forthe core buildup, including any pins when required (D2950) provided on October 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe genetic testing provided on September 1, 2020.You asked the Plan to pay forthe genetic testing. 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.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The genetic testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. In addition, laboratory assays are non-covered when they have two or more genes in a patient in parallel. Those two or more genes will be considered part of the same panel.Therefore, we decided that the Plan does not have to pay forthe genetic testing provided on September 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora pneumatic compression device (E0675, E0673).

You asked the Plan to pay for a pneumatic compression device. You say that the device is necessary to prevent deep vein thrombosis.The Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.

The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism is a preventive service. PCDs billed by E0675 are not covered.

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage.Therefore, we decided that the Plan does not have to pay fora pneumatic compression device (E0675, E0673)
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency department visit (99285)
provided August 17, 2020.
You asked the Plan to waive the copayment for the emergency visit. You say that you were feeling dizzy and
since you had a triple bypass in the past year you went to your primary doctor. Since your doctor insisted you
go to emergency, you should not be liable for the $85. The Plan denied your request. The Plan says the claim
was processed and the correct copayment was applied per 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 $85 for
each visit to an emergency room for Emergency care.
You have been asked to pay $85 for each visit to an emergency room for the emergency visit. The emergency
visit falls within the Emergency 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 emergency department visit (99285) provided August 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean ultra-lightweightwheelchair and accessories.You asked the Plan to pre-approvean ultra-lightweightwheelchair and accessories. You say that the enrollee needs an ultra-lightweightwheelchair and accessories.The Plan denied your request. The Plan says durable medical equipment is not separately covered in a skilled nursing facility.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF to be a home. Records show that an ultra-lightweightwheelchair and accessories is being requested for use in a SNF. Therefore, we decided that the Plan does not have to pre-approvean ultra-lightweight wheelchair and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fornerve conduction studies (95912) and needle electromyography (95886) provided on August 7, 2020.You asked the Plan to pay fornerve conduction studies and needle electromyography. You say that you would like reconsideration based on the records submitted.The Plandenied your request. The Plan says the documentation does not support the services 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 95912 is nerve conduction studies; 11-12 studies.The CPT Code Manual definition of CPT code 95886 is needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List separately in addition to code for primary procedure).We asked our coder 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 nerve conduction studies and needle electromyography. Our reviewer says that CPT codes 95912 and 95886 do not meet criteria for billing or reimbursement consideration. Our reviewer found medical records does not include sufficient documentation to validate that a Nerve conduction studies; 11-12 studies was performed on August 7, 2020, therefore, this service cannot be verified.CPT 95886 is an add-on code and requires that the primary code be eligible for reimbursement. In this case, CPT 95912, the primary code did not meet criteria for reimbursement, therefore, add-on code 95886 is not eligible for reimbursement.We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of nerve conduction studies and needle electromyography have not been met.Therefore, we decided that the Plan does not have to pay fornerve conduction studies (95912) and needle electromyography (95886) provided on August 7, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe topical application of fluoride varnish (D1206) and the full mouth debridement (D4355) provided on September 2, 2020.You asked the Plan to pay forthe fluoride varnish and full mouth debridement. You say that you contacted the provider who told you they were in network and covered the treatment. You also say that you saw the provider on the website that they were in network.The Plan denied your request. The Plan says fluoride varnish is not listed as a covered service. The Plan says that full mouth debridement 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 forthe topical application of fluoride varnish (D1206) and the full mouth debridement (D4355) provided on September 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe surgical services provided on August 10, 2020.You asked the Plan to waive the copayment forthe surgical services. You say that the services were medically necessary,and the Plan should have paid more.The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received the surgical services on August 10, 2020. The Medicare-allowed amount for the surgery services are less than the set $250 copayment; therefore, you have been asked to pay the lesser amount of $248.59 for the services. This means that you have been asked to pay the correct amount based on your contract with thePlan. 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 forthe surgical services provided on August 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Group 3 power wheelchair power seat elevation feature.You asked the Plan to pre-approvea power seat elevation feature (E2300). You say that the enrollee needs a Group 3 power wheelchair, accessories and a power seat elevation feature.The Plan denied your request. The Plan saysa power seat elevation feature is not covered by Medicare or the Plan.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  A power seat elevation feature does not serve a purpose that is primarily medical in nature. This feature is not covered by Medicare.Therefore, we decided that the Plan does not have to pre-approvea Group 3 power wheelchair power seat elevation feature.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe replacement of a gastro-jejunostomy tube and a gastric emptying imaging study provided from February 7, 2020, and March 11, 2020.You asked the Plan to waive the copayments forthe replacement of a gastro-jejunostomy tube and a gastric emptying imaging study. You say that you disagree with the chargesbecause the member is deceased.The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $225 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. The enrollee's contract with the Plan also clearly says that enrollees must pay a $20 copayment for X-rays and ultrasounds and a $250 copayment for all other outpatient diagnostic tests.The enrollee received the replacement of a gastro-jejunostomy tube on February 7, 2020. This is considered an outpatient surgical procedure.  Therefore, the enrollee is responsible to pay the $225 copayment. The enrollee received a gastric imaging study on March 11, 2020. Therefore, the enrollee is responsible to pay the allowed amountof $118.42, which is less than the $250 copayment. The total amount the enrollee owes is: $343.42.
The enrollee has been asked to pay the total copayment amount of $343.42 for the replacement of a gastro-jejunostomy tube and a gastric emptying imaging study. The replacement of a gastro-jejunostomy tube falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. Agastric emptying imaging study falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.Therefore, we decided that the Plan does not have to waive the copayments forthe replacement of a gastro-jejunostomy tube and a gastric emptying imaging study provided from February 7, 2020, and March 11, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forhospital care (99222) provided on September 15, 2019.You asked the Plan to pay forhospital care. You say that you should not be penalized for delays in the receipt of information from the providing facility.The Plan denied your request. The Plan says rules for payment have not been met.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.The record shows that a claim for hospital care was not filed until September 24, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay forhospital care (99222) provided on September 15, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlab services (G0483) provided August 6, 2020.You asked the Plan to pay forthe lab services. You say that the testing was medically necessary.The Plan denied your request. The Plan says insufficient information was provided to determine if the services at issue were medically necessary.The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.We looked at the file and Medicare rules. No medical records were provided from the ordering provider to determine if these lab services were medically necessary. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met.Therefore, we decided thatthe Plan does not have to pay forlab services (G0483) provided August 6, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay forhospital day care provided on June 21, 2020.You asked the Plan to pay forhospital day care. You say that the Plan should pay this claim.The Plan denied your request. The Plan says Original Medicare is responsible for payment of this claim.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 forhospital day care provided on June 21, 2020
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvepositron emission tomography (PET) scan.You asked the Plan to pre-approvea PET scan. You say that providing the wrong medical management to an enrollee suffering from Alzheimer's disease or bipolar disease can have detrimental effects.The Plan denied your request. The Plan says the enrollee does not have a condition whereMedicare covers PT scan of the brain.The Plan follows Medicare rules. Medicare rules say that PET scans are only covered under certain medical indications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a PET scan. Our physician reviewer found that inthis case,the medical records provided indicate that the enrollee'sdifferential diagnoses at this time include AD versus bi-polar disorder vs. age related cognitive changes. The enrollee'sneuropsychological testing was said to suggest features of AD. However, nowhere in the records is there mention of a differential diagnosis of FTD. The enrollee'spresentation is not otherwise readily consistent with that seen in FTD.In as much the requested service would not meet the Medicare criteria for coverage.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 PET scan have not been met.Therefore, we decided that the Plan does not have to pre-approvepositron emission tomography (PET) scan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an eye exam (92014) and computerized ophthalmic diagnostic imaging (92134) performed on August 20, 2019.
You asked the Plan to waive the copayment for an eye exam and computerized ophthalmic diagnostic imaging. You say that the enrollee had exceeded the $2,750 yearly out-of-pocket maximum by the date of service. The Plan denied your request. The Plan says the correct copayment was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $25 copayment for Medicare-covered vision services provided at a specialist's office. The enrollee has been asked to pay a $25 copayment for an eye exam and computerized ophthalmic diagnostic imaging. The case record documents that the enrollee's annual out-of-pocket maximum had not been met by the date of service. An eye exam and computerized ophthalmic diagnostic imaging fall within the "Vision care" benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an eye exam (92014) and computerized ophthalmic diagnostic imaging (92134) performed on August 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an out-of-network provider.

You asked the Plan to pay for the medical services. You say that the services were rendered under the impression that this was a participating provider.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 medical services provided  by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve6 applications of desensitizing medicament (D9910 x6).You asked the Plan to pre-approvethe applications of desensitizing medicament. You say that desensitizing is needed with the composite restoration to treat the hypersensitivity of the dentin to avoid the painful response in the exposed dentin to stimuli that are thermal, evaporative, tactile, osmotic or chemical.The Plan denied your request. The Plan says this service is not covered under the enrollee's 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 pre-approve6 applications of desensitizing medicament (D9910 x6).