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

We decided that the Plan does not have to pay for the hearing aids, digital, binaural, ite (V5260) purchased
January 12, 2021.

You asked the Plan to pay for the hearing aids. You say that you had contacted the Plan concerning hearing
aids on 2 occasions and was assured that your insurance would cover either $999.00 each for premium or
$699.00 for advanced hearing aids depending on which one you purchased. The Plan denied your request. The
Plan says this claim was processed correctly per the Evidence of Coverage. Enrollee's must receive their
hearing services from the designated in-network provider.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for
hearing aids only when purchased from the designated in-network vendor.

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for
the hearing aids, digital, binaural, ite (V5260) purchased January 12, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for the assistant surgeon services rendered on January 22, 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 that the claim is billed incorrectly.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan states that billed procedure code 49505-AS-LT (repair initial inguinal
hernia, age 5 years or older; reducible) was billed incorrectly; however, the Plan has not provided any further
explanation as to how the claim was incorrectly billed. There is no documentation or Medicare rules to support
that the claim cannot be processed as billed. Therefore, we decided that the Plan has to pay for the assistant
surgeon services rendered on January 22, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids provided on March 24, 2021.
You asked the Plan to reimburse you for the hearing aids. You say that you purchased the best hearing aids you could find. You say this provider was very helpful and you can hear very well in many settings. The Plan denied your request. The Plan says there is no coverage if hearing aids or related services are received from an out-of-network provider.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when provided by the Plan's hearing aid provider. We looked at the file and the Plan's rules. The file shows that the hearing aids were provided by an out-of-network provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids provided on March 24, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tempus xT panel gene testing provided on June 26,
2020.
You asked the Plan to pay for the Tempus xT panel gene testing. You say that you would like the Plan to
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare has specific coverage criteria for this testing. Medicare has a
specific code requirement for reporting this type of testing. Therefore, we decided that the Plan does not have
to pay for the Tempus xT panel gene testing provided on June 26, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional PT visits.
You asked the Plan to pre-approve additional PT visits. You say that you are learning to walk and gain balance since your amyotrophy diagnosis. You say you are also diabetic but getting stronger every day after being in a wheelchair for 9 months, and physical therapy has been helping you to improve and you need this ongoing care. The Plan denied your request. The Plan says additional PT is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that based on review of the available records, you do not meet Medicare coverage criteria for the requested continued services by a physical therapist with additional visits. After 21 PT visits, you have made good progress and at this stage, skilled therapy is not warranted. You were given HP for exercises. The additional PT visits are not reasonable and not medically necessary. The documentation does not support the need for the requested additional therapy visits. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional PT visits.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee from December 3, 2020, to December 8, 2020.
You asked the Plan to pay for these services. You say that these services should be paid for by the Plan. The Plan denied your request. The Plan says due to the enrollee's hospice status at the time of service, this claim must be submitted to Original Medicare first for review.
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 December 3, 2020, to December 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided to the enrollee on February 19, 2021 and billed under codes S1015 and S8301.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says while code 99199 was paid, codes S1015 and S8301 have a status code indicator of "I" which is excluded from payment on Medicare claims. Medicare uses another code to report this service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, the status code indicator of "I" for these codes excluded payment under the Medicare billing guidelines. Therefore, we decided that the Plan does not have to pay for services provided to the enrollee on February 19, 2021 and billed under codes S1015, and S8301.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided from March 25,
2021, to April 22, 2021.
You asked the Plan to pay for these services. You say that the Plan contract is not clear that you need prior
authorization for these services. The Plan denied your request. The Plan says you did not have prior
authorization for out of network care.
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 Plan contract clearly states in several sections that in most
cases, care received from an out-of-network provider (a provider who is not part of the plan's network) will not
be covered. The Plan contract states it is your responsibility to be sure that prior authorization is obtained, and
the services are approved by the plan to be eligible for coverage
The provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the services at issue in this appeal. The Plan did not pre-approve these services. Even
if a specific service does not indicate prior authorization, this Plan contract is an HMO with general prior
authorization requirements and specifically stated out of network coverage rules. 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
out of network physician services provided from March 25, 2021, to April 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) rendered by the out-of-network (OON) provider on March 9, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 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 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 domiciliary or rest home visit (99336) rendered by the out-of-network (OON) provider on March 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your
request. The Plan says you do not appear to meet the Medicare criteria for this monitor.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four t imes per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results and have had an in-person visit with their treating physician to assesses
adherence to their CGM regimen and diabetes treatment plan.
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least
three daily injections or require frequent self-adjustment of insulin dosage based on the blood glucose testing
results. Based on this information, we decided that Medicare rules for coverage of the monitor have not been
met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve six (6) additional PT visits.
You asked the Plan to pre-approve six (6) additional PT visits. You say that you are in constant pain and you believe that the physical therapy helps and is medically necessary. The Plan denied your request. The Plan says additional PT is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve six (6) additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that based on review of the available records, you do not meet Medicare coverage criteria for the requested continued services by a physical therapist with additional visits. Since beginning PT, you made marginal progress and at this stage, skilled therapy is not warranted. You were given HP exercises. The additional PT visits are not reasonable and not medically necessary. The documentation does not support the need for the requested additional therapy visits. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of six (6) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve six (6) additional PT visits
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids purchased December 15, 2020 from an out of network provider.
You asked the Plan to pay for the hearing aids. You say that you called to check and make sure that the Plan would cover your hearing aids before you signed the papers to agree to the amount. If you knew this was not covered, you would not have agreed to receive them. The Plan denied your request. The Plan says enrollee's must receive their hearing services from an in-network provider.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when purchased from the designated in-network vendor. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids purchased December 15, 2020 from an out of network provider
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a colonoscopy (45378) provided on March 12, 2021.

You asked the Plan to waive the copayment for a colonoscopy. You say that you did not have anything removed when you had your colonoscopy done. You also say that this procedure should be considered preventative, and it should be a $0 copayment. The Plan denied your request. The Plan says the copayment you are being charged is correct.

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 $400 copayment for same-day outpatient hospital services including diagnostic procedures.

You have been asked to pay a $400 copayment for a colonoscopy. The records show that the procedure was performed due to changes in bowel habits and a history of diverticulitis. The records also show that this was not ordered as a preventative procedure but was determined to be a diagnostic procedure. The EOC confirms $400 is the required copayment for this service. A colonoscopy falls within the outpatient hospital services 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 colonoscopy (45378) provided on March 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81240, 81225, 81227, 81226) provided February 23, 2021.
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 the documentation does not support the billed services.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes 81240, 81225, 81227, & 81226 are not supported in the medical record. Specifically, Medicare rules state that if a laboratory procedure produces multiple reportable test results, only a single HCPCS/CPT code shall be reported for the procedure. If there is no HCPCS/CPT code that describes the procedure, the laboratory shall report a miscellaneous or unlisted procedure code with a single unit of service. In this case, multiple unbundled CPT codes were billed for a single laboratory procedure. 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 (81240, 81225, 81227, 81226) provided February 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a core build-up and crown (D2950, D2740) provided
February 10, 2021.
You asked the Plan to pay for the dental services. You say that the dental services are a covered benefit. The
Plan denied your request. The Plan says these services are not covered under the enrollee's 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 a core
build-up and crown (D2950, D2740) provided February 10, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network chiropractic services provided to the enrollee on January 25, 2021.

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 enrollee did not have prior authorization for out of network care.

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 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 out of network chiropractic services provided to the enrollee on January 25, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 29, 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 services were 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 January 29, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on April 14, 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 services were 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 April 14, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment emergency care received from December 2, 2020, to December 3, 2020.

You asked the Plan to waive the copayment the services. You say that your physician advised you to go to the emergency room due to coronavirus, congestion, and breathing problems. The Plan denied your request. The Plan says you are responsible for the applied copayments.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copayment for emergency care. 

You have been asked to pay a $90 copayment for the services. The services fall 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 emergency care received from December 2, 2020, to December 3, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on December 23, 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 due to the enrollee's hospice status at the time of service, this claim must be submitted to Original Medicare first for review.
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 on December 23, 2020.