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

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on February 8, 2021 by an OON provider.
You asked the Plan to pay for the subsequent nursing facility care. You say that the enrollee was referred by the facility. The Plan denied your request. The Plan says this service was rendered by a non-participating provider. The Plan also says that prior authorization was not obtained.
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 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 subsequent nursing facility care provided on February 8, 2021 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services provided on November 9, 2020 by an out of network (OON) provider.
You asked the Plan to pay for outpatient 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 outpatient services provided on November 9, 2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on June 15, 2020.
You asked the Plan to waive the copayment for ambulance services. You say that the enrollee had no control over whether the provider was in-network or not. 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 $265 copayment for ambulance services. The enrollee has been asked to pay a $265 copayment for ambulance services. Ambulance services fall within the ambulance services 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 ambulance services provided on June 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), the periodontal maintenance (D4910), gingival irrigation (D4921 x 2), and the topical application of fluoride varnish (D1206) provided on December 14, 2020.
You asked the Plan to pay for the dental services. You say that you do not feel that you should have to pay for these services. You say that your dental office always calls the plan to get approval. You say that the dental office was advised the service would be covered. You also say that paying this bill would be a financial hardship for you. The Plan denied your request. The Plan says there is an annual maximum benefit of $2,000 for covered dental services. The Plan says that the annual maximum has been exhausted. The Plan also says that the gingival irrigation is not listed as a covered service.
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 and the oral evaluation, periodontal maintenance, and fluoride varnish are listed as covered services, the annual maximum benefit has been exhausted.
Date of Service
Plan Paid
1/9/2020
$150
5/29/2020
$43
5/29/2020
$107
8/31/2020
$1,003
8/31/2020
$678
12/14/2020
$19
TOTAL:
$2,000
Additionally, gingival irrigation is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120), the periodontal maintenance (D4910), gingival irrigation (D4921 x 2), and the topical application of fluoride varnish (D1206) provided on December 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).

You asked the Plan to pre-approve a pneumatic compression device. You say that you believe that the enrollee meets the criteria for this device, and this device has been deemed the most appropriate for his condition. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for this E0652 device.

The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. 

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, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care and chemical cauterization of granulation tissue provided on October 28, 2020.
You asked the Plan to pay for the subsequent nursing facility care and chemical cauterization of granulation tissue. You say that medically necessary services were provided. You also say that the services were provided prior to obtaining authorization to avoid delay in care. The Plan denied your request. The Plan says Hospice services and Medicare services that are not hospice related are to be billed directly to Original Medicare.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care and chemical cauterization of granulation tissue provided on October 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the determination of refractive state (92015) provided January 20, 2021.
You asked the Plan to pay for the determination of refractive state. You say that your previous eye exams have been covered and you do not understand why you are being billed for this service. The Plan denied your request. The Plan says you must submit an OON claim directly to the Plan's vision vendor for review of coverage showing that both an exam and refraction were completed.
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 when provided by an OON provider when you submit a claim form with itemized receipt to the vision vendor. We looked at the file and the Plan's rules. You received services from a provider who is not in the Plan's vision vendor's network. You have not submitted an OON claim form directly to the vision vendor. Based on this information, we decided that the Plan's rules for coverage of the determination of refractive state have not been
met. Therefore, we decided that the Plan does not have to pay for the determination of refractive state (92015) provided January 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for outpatient surgery services provided on October 8, 2020.
You asked the Plan to waive the coinsurance for outpatient surgery services. You say that you disagree with the charges because you should only owe a $430 copayment. 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 20% coinsurance for outpatient surgery, including services provided at hospital outpatient facilities. The record shows that you received outpatient surgery services on October 8, 2020. The total allowed amount is $19,447.35 and 20% of that is $3,889.47. You have been asked to pay the total coinsurance amount of $3,889.47 for outpatient surgery services. Outpatient surgery services fall within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 outpatient surgery services provided on October 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the molecular testing provided on October 9, 2019.
You asked the Plan to pay for the testing services. You say that the services may provide essential information for the enrollee's course of treatment. The Plan denied your request. The Plan says coverage criteria was not met.
The Plan must follow Medicare rules. Medicare rules say that next generation sequencing is only covered under certain medical indications. We looked at the file and Medicare rules. The records show that the testing services were ordered due to the enrollee's anemia. NGS testing is covered when the enrollee has either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the molecular testing provided on October 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram provided on January 4, 2020.

You asked the Plan to pay for the electrocardiogram (93010). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the claim was untimely.

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 the electrocardiogram (93010) was not filed until January 21, 2021. 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 for the electrocardiogram provided on January 4, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for hospital care (99233) provided on September 25, 2020.

You asked the Plan to pay for hospital care. You say that this code is supported. The Plan denied your request. The Plan says that codes 99233 and 99222 cannot be billed together.

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 99233 and 99222 cannot be billed together, but the Plan has not provided any documentation showing that code 99222 was billed on the date of service at issue. Without this information, the Plan's denial cannot be verified. Therefore, we decided that the Plan has to pay for hospital care (99233) provided on September 25, 2020.

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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an X-ray provided on October 1, 2020.
You asked the Plan to waive the deductible for an X-ray. You say that you feel that the charges are unnecessary. 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. Your contract with the Plan says that there is a $250 deductible for X-rays. You received an X-ray on October 1, 2020. The record shows that you had paid $0 toward the $250 deductible prior to receiving the services. Therefore, you are responsible to pay the allowed amount of $143.10. The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $250 deductible for X-rays. This cost sharing is a contractual obligation that had not been met at the time an X-ray was received on October 1, 2020. Therefore, we decided that the Plan does not have to waive the deductible for an X-ray provided on October 1, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on March 2, 2020 by an OON provider.
You asked the Plan to pay for the subsequent nursing facility care. You say that there is currently no in-network doctor who can treat the patients at the facility this enrollee is in. The Plan denied your request. The Plan says this service was rendered by an OON provider. The Plan also says that prior authorization was not obtained.
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 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 subsequent nursing facility care provided on March 2, 2020 by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical assistant services provided on May 14, 2020.
You asked the Plan to pay for assistant surgery services for anoscopy (46606). You say that the primary surgeon requested services from an assistant surgeon because he felt that it was in the best interest of the enrollee. The Plan denied your request. The Plan says payment for code 46606 for assistant at-surgery remains fully denied.
The Plan follows Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare rules say that for procedures with an assistant surgery indicator of 0, the payment restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to establish medical necessity. In this case, you billed assistant surgery services for Current Procedural Terminology (CPT) code 46606. The Medicare Fee Schedule Database contains a surgical indicator of 0 for this procedure. We looked at the file and Medicare rules. According to the 2020 Medicare Physician Fee Schedule Look-Up
Tool, surgical assistant is not payable for this procedure code. Based on this information, we decided that Medicare rules for coverage of assistant surgery services for anoscopy (46606) have not been met. Therefore, we decided that the Plan does not have to pay for the surgical assistant services provided on May 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a plethysmography and strapping provided from December 2, 2020, to December 22, 2020.
You asked the Plan to waive the copayments for a plethysmography and strapping. You say that you disagree with the charges. 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 $10 copayment for diagnostic procedures and tests. Your contract with the Plan also clearly says that you must pay a $200 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You received a plethysmography on December 2, 2020. Therefore, you are responsible to pay the $10 copayment. You received strapping at an outpatient hospital facility from December 2, 2020, to December 22, 2020. Strapping is considered an outpatient surgical procedure. Therefore, you are responsible to pay the total allowed amount of $126.72, which is less than the $200 copayment. The total amount you owe is: $136.72. You have been asked to pay the total copayment amount of $136.72 for plethysmography and strapping.
Plethysmography falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. Strapping falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 copayments for a plethysmography and strapping provided from December 2, 2020, to December 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the special anesthesia services rendered on December 10, 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 code 99100 is not separately payable.
The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is always bundled into payment for other services not specified. We looked at the file and Medicare rules. Billed procedure code 99100 (special anesthesia service) has a status indicator of B and no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for the special anesthesia services rendered on December 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the extraction (D7140) provided on December 12, 2020.
You asked the Plan to reimburse you for the dental service. You say that you know that you have coverage for dental extractions. You say that you paid $165 out of pocket for the extraction. You also say that this should be covered. The Plan denied your request. The Plan says extraction is not listed as a covered service.
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 reimburse you for the extraction (D7140) provided on December 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the cancer screening provided by an out-of-network provider on October 19, 2020.
You asked the Plan to pay for the cancer screening. You say that authorization was not obtained at the time of service but the service was medically necessary. You say that you are requesting retro authorization. The Plan denied your request. The Plan says prior authorization was required but not obtained.
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 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 cancer screening provided by an out-of-network provider on October 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit provided by an out-of-network provider on December 1, 2020.
You asked the Plan to pay for the home visit. You say that the physician provided medically necessary services and the claim should be processed for payment. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not 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 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 home visit provided by an out-of-network provider on December 1, 2020.