Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy provided on November 25, 2020.
You asked the Plan to waive the copayment for the colonoscopy. You say that there is no charge for a colonoscopy, and it does not say anything about removing polyps. The Plan denied your request. The Plan says you have been asked to pay 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 $250 copayment for ambulatory surgical center and outpatient hospital visits. You have been asked to pay a $250 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows four existing polyps were removed which changes the colonoscopy from a screening to outpatient surgery. 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 colonoscopy provided on November 25, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on February 20, 2020.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider such as an urgent or an emergent situation that has been documented.
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 laboratory services. 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 laboratory services provided on February 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the parathyroid planar imaging provided on September 4, 2020.
You asked the Plan to waive the copayment for the parathyroid planar imaging. You say that the copayment cost is very high. The Plan denied your request. The Plan says you have been asked to pay 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 Medicare-covered advanced imaging or nuclear medicine services in a physician office or outpatient facility setting, in addition to any applicable office visit or facility copayment. You have been asked to pay a $300 copayment for the parathyroid planar imaging. The parathyroid planar imaging 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 parathyroid planar imaging provided on September 4, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on September 15, 2020 by an out of network (OON) provider.
You asked the Plan to pay for skilled nursing 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 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 September 15, 2020 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 sensitive skin wash provided on September 13, 2020.
You asked the Plan to pay for the skin wash. You say that the items are necessary for your age and disabilities. The Plan denied your request. The Plan says the item is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the skin wash is an OTC item. Although the plan offers a benefit for some OTC items, the sensitive skin wash is not among those covered. Therefore, we decided that the Plan does not have to pay for the sensitive skin wash provided on September 13, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from May 4, 2017 to July 2, 2017.
You asked the Plan to pay for home health services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not payable as billed.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the services were billed without a valid Health Insurance Prospective Payment System (HIPPS) code. This code is required for processing. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from May 4, 2017 to July 2, 2017.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on July 16, 2020.
You asked the Plan to pay for the physician's services. You say that The Plan denied your request. The Plan says generally you must receive care from a network provider. In most cases, care you receive from an out-of-network provider (a provider who is not part of our Plan's network) will not be covered.
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 physician's services. 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 July 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation, prophylaxis, bitewing x-rays, and panoramic x-ray provided on December 10, 2020.

You asked the Plan to pay for the comprehensive oral evaluation, prophylaxis, bitewing x-rays, and panoramic x-ray. You say that you feel that you were misled when you contacted the Plan to discuss your dental benefits. The Plan denied your request. The Plan says these services were provided during the 2020 plan year, and were correctly processed under your $500 annual maximum for 2020. The Plan also says that you were advised multiple times when you contacted the Plan that if you saw a dentist in the 2020 plan year, your exam would still count towards your annual $500.00 maximum for 2020.

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 a combined benefit maximum of $500 per calendar year for the non-Medicare-covered preventive services listed in the EOC. This means that the Plan will pay up to $500 for covered supplemental dental services. The record shows that on this date of service you had not yet met the $500 annual benefit, and these services were covered and correctly applied toward your $500 maximum. The records do not show that you were provided with any misinformation when you contacted the Plan. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation, prophylaxis, bitewing x-rays, and panoramic x-ray provided on December 10, 2020. 

Your complaint about possibly being misled by the Plan 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on April 17, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says generally must you receive care from a network provider. In most cases, care you receive from an out-of-network provider (a provider who is not part of our Plan's network) will not be covered.
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 physician's services. 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 April 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the occlusal guard - hard appliance, full arch (D9944) provided December 17, 2020.
You asked the Plan to pay for the mouth guard. You say that you need the mouth guard and would like the Plan to cover it. The Plan denied your request. The Plan says your $500 allowance is met therefore no further payment is due.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the mouth guard up until the $500 allowance is met. We looked at the file and Medicare rules. The Plan provided documentation showing that when the claim for the mouth guard was processed you had $183 remaining in your $500 allowance. The Plan covered this amount and the remaining $440 is your responsibility. Therefore, we decided that the Plan does not have to pay for the occlusal guard - hard appliance, full arch (D9944) provided December 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81403, 81404, 81405) provided July 11, 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 rules for coverage were not met.
The Plan must follow Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary. We looked at the file and Medicare rules. In this case, plan documentation shows no history of the ordering physician providing any physician service to the enrollee prior to the lab services being ordered. 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 (81403, 81404, 81405) provided July 11, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services provided by an opted-out physician on October 14, 2020.
You asked the Plan to pay for surgical services. You say that if the primary surgeon was paid, then this provider should get 20% of the primary surgeon's payment. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider has opted out of Medicare coverage and is not payable.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for surgical services provided by an opted-out physician on October 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two semi-precision attachment abutments (D6052 x2).
You asked the Plan to pre-approve the semi-precision attachment abutments. 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-approve two semi-precision attachment abutments (D6052 x2).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 9, 2020.
You asked the Plan to pay for the services provided. You say that you do the things necessary to minimize medical expenses. The Plan denied your request.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $1300 deductible.
The file shows that anesthesia services were provided by an out-of-network provider. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1300 deductible. This cost sharing is a contractual obligation that had not been met at the time the services were received October 9, 2020. Therefore, we decided that the Plan does not have to pay for the medical services provided on October 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for blood glucose test strips (A4254), calibrator solution (A4256), lancets (A4259), and home blood glucose monitor (E0607) provided January 7, 2020, to April 6, 2020.
You asked the Plan to pay for blood glucose test strips, calibrator solution, lancets, and home blood glucose monitor. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the documentation submitted did not include an itemized shipping/billing invoice to indicate the specific supplies, or proof of delivery.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid proof of delivery. In this case, the record does not contain a proof of delivery to indicate the items were delivered to the enrollee. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for blood glucose test strips (A4254), calibrator solution (A4256), lancets (A4259), and home blood glucose monitor (E0607) provided January 7, 2020, to April 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the polycarbonate lenses (V2784) and frames (V2020) provided October 14, 2020.

You asked the Plan to provide additional payment for the polycarbonate lenses and frames. You say that your frames and lenses should be covered. The Plan denied your request. The Plan says a $100 allowance for the eyewear has already been issued and therefore no additional payment is due.

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. The Plan covers these services up to a $100 maximum benefit every year.

We looked at the file and the Plan's rules. The Plan has a $100 allowance for eyewear every year. The Plan provided documentation showing that a check for $100 was issued to you on November 20, 2020 for the eyewear. Based on this information, we decided that the Plan does not have to provide additional payment for the polycarbonate lenses (V2784) and frames (V2020) provided October 14, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for assistant surgery services (52000) provided February 17, 2020.
You asked the Plan to pay for the assistant surgery services. You say that the services were medically necessary. The Plan denied your request. The Plan says this service is not eligible for payment for assistant-at-surgery services.
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current Procedural Terminology (CPT) code 52000. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the assistant surgery services have not been met. Therefore, we decided that the Plan does not have to pay for assistant surgery services (52000) provided February 17, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Hepatitis A and Hepatitis B vaccine provided on November 19, 2020.
You asked the Plan to pay for the Hepatitis A and Hepatitis B vaccine. You say that the vaccine is medically necessary because you work in a medical office. The Plan denied your request. The Plan says this is a Part D prescription drug.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Hepatitis A and Hepatitis B vaccine. The Plan follows the same rules. Hepatitis A is not covered under your Medicare Part B drug benefit. Therefore, we decided that the Plan does not have to pay for the Hepatitis A and Hepatitis B vaccine provided on November 19, 2020.
Benefits for the Hepatitis A and Hepatitis B vaccine may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (87186, 87482, 87640, 87653, 87798) provided December 10, 2020.
You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan denied your request. The Plan says the genetic testing was performed as a screening service and is non-covered.
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 test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for genetic testing (87186, 87482, 87640, 87653, 87798) provided December 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for current procedural terminology (CPT) code J0280 provided on October 2, 2020.
You asked the Plan to pay for CPT code J0280. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the medical records do not support the billing of CPT code J0280.
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 J0280 is Injection, aminophyllin, up to 250 mg. We find that CPT code J0280 is not supported in the medical record. Specifically, the documentation provided did not include documentation to indicate that aminophyllin up to 250 mg was provided. Based on this information, we decided that Medicare rules for coverage of CPT code J0280 have not been met. Therefore, we decided that the Plan does not have to pay for current procedural terminology (CPT) code J0280 provided on October 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve trial of electrical treatment (Spinal Cord Stimulator).

You asked the Plan to pre-approve trial of electrical treatment (Spinal Cord Stimulator). You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.

The Plan follows Medicare rules. Medicare rules say that spinal cord stimulators are only covered for certain 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 trial of electrical treatment (Spinal Cord Stimulator). Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has chronic low back pain with radicular symptoms and facet arthropathy. The enrollee has had Epidural Steroid injections and physical therapy. The enrollee's current pain medications include CBD extract, Gabapentin, Norco, Topamax, Diclofenac topical gel, Mobic, methocarbamol and Tizanidine. The enrollee had a psychological evaluation was cleared for a spinal cord stimulator (SCS) trial. The documentation does not support that the enrollee has an evidence based indication for a SCS trial as delineated in both the LCD.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of trial of electrical treatment (Spinal Cord Stimulator) have not been met. Therefore, we decided that the Plan does not have to pre-approve trial of electrical treatment (Spinal Cord Stimulator).