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

We decided that the Plan does not have to pay for the continuous glucose monitor supplies rendered on January 13, 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 there is no valid proof of delivery.

The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS suppliers are required to maintain proof of delivery. 

We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor supplies rendered on January 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services provided on July 22, 2020, through August 4, 2020 and August 7, 2020, through August 13, 2020.

You asked the Plan to waive the copayment for inpatient hospital services. You say that the services should be covered. The Plan denied your request. The Plan says the cost share was applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay you have a $225 per day for days 1 to 8 for inpatient hospital services. 

You have been asked to pay you have a $225 per day for days 1 to 8 for inpatient hospital services. These services fall within the inpatient 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 inpatient hospital services provided on July 22, 2020, through August 4, 2020 and August 7, 2020, through August 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the amalgam-one surface, primary or
permanent (D2140) provided on January 11, 2021.

You asked the Plan to waive the cost share. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the cost share has been applied correctly to the
service provided.

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 30%
cost share for minor restorative services (fillings and crown repair) as the Plan pays 70% of the services
provided.

You have been asked to pay $29.10 (Plan allowed amount of $97 x 30% cost share) for the amalgam filling provided. 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 cost share for the amalgam-one surface, primary or permanent (D2140) provided on January 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a trigger point injection provided on January 4, 2021.

You asked the Plan to waive the copayment for a trigger point injection. You say that you disagree with the charges because you feel that the injection should not be considered a surgical procedure. 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 $350 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. 

You have been asked to pay the allowed amount of $306.06, which is less than the $350 copayment for a trigger point injection. A trigger point injection 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 copayment for a trigger point injection provided on January 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B drug provided on December 22,
2020.

You asked the Plan to waive the coinsurance for the Part B drug. You say that you have been paying $20.52 for
the same service. The Plan denied your request. The Plan says the claim was reprocessed with a $20.52
member responsibility.

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 Medicare Part B covered drugs at an in-network PCP's office, specialist's office, and pharmacy.

You have been asked to pay $20.52 which is 20% of the allowed amount for the Part B drug. The allowed
amount is $102.58. ($102.58 x 20% = $20.52). The Part B drug falls within the "Medicare Part B prescription
drugs" 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 the Part B drug provided on
December 22, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 81291, 81226, 81227, and
81225 provided on August 28, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services were not billed correctly.

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 81291, 81226, 81227, and 81225 are not supported in the medical record. Specifically,
if two or more single genes are tested, rather than a multi-gene panel, then the record must reflect that a
clinician individually ordered each gene. There is no documentation in the medical records that the treating
physician ordered or intended to order this testing, nor that there was a specific treatment regimen for a
particular condition the physician was considering that would need such testing. Based on this information, we
decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 81291, 81226, 81227, and 81225 provided on August 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an additional pair of eyeglasses purchased on January 13, 2021.

You asked the Plan to pay for an additional pair of eyeglasses. You say that the Plan contract does not mention how many pairs of glasses are available under the Plan benefit. The Plan denied your request. The Plan says the benefit has been exhausted for the calendar year.

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 provides a $300 benefit toward the purchase and fitting of eyeglasses and pair of lenses or contact lenses (1 per calendar year).

We looked at the file and the Plan's rules. The Plan contract indicates that coverage is limited to 1 pair of eyeglass or contact lenses per calendar year. Based on this information, we decided that the Plan's rules for coverage of an additional pair of eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for an additional pair of eyeglasses purchased on January 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the application of skin substitute graft services coded 15275
provided on November 4, 2020.

You asked the Plan to pay for the application of skin substitute graft services. You say that you would like the
plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not
supported by the documentation.

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 15275 is application of skin substitute graft to face, scalp,
eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to
100 sq cm; first 25 sq cm or less wound surface area.

We find that CPT code 15275 is not supported in the medical record. Specifically, the operative report did not include documentation of an application of a skin substitute graft to the face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, for total wound surface area up to 100 sq cm, for first 25 sq cm or less wound surface area; therefore, code 15275 cannot be verified. Based on this information, we decided that Medicare rules for coverage of the application of skin substitute graft services have not been met. Therefore, we decided that the Plan does not have to pay for the application of skin substitute graft services coded 15275 provided on November 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual wellness visit received by an opt out provider on November 12, 2020.

You asked the Plan to pay for the annual wellness visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit.

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 the annual wellness visit received by an opt out provider on November 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses and additions provided on October 9, 2020.

You asked the Plan to pay for the knee orthoses and additions. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the documentation does not support a
relationship between the enrollee and the ordering physician.

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 valid relevant medical records which support medical necessity for the supplies provided in this case. The file does not contain evidence of an established relationship between the enrollee and the ordering physician. 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 the knee orthoses and additions provided on October 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided by an out-of-network provider on December 1, 2020.

You asked the Plan to pay for the laboratory services. You say that you attached documents for proof of medical necessity. The Plan denied your request. The Plan says in-network providers were available.

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 laboratory services provided by an out-of-network provider on December 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided from October 6, 2020, to November 19, 2020.

You asked the Plan to pay for the dental services. You say that you were advised that dental services were covered up to $1,000 per year. You say that the full amount was not paid initially. You say that a plan representative advised that the services should have been paid in full. You also say that you received a new Evidence of Benefits (EOB) saying that payment was fully denied. The Plan denied your request. The Plan says

the provider in this case has opted out of Medicare. The Plan also says that payment cannot be made for dental services performed by providers who have opted out of Medicare.

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 dental services when the services are medically necessary and reasonable. 

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does not have to pay for the dental services provided from October 6, 2020, to November 19, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an ECG provided on August 20, 2020.

You asked the Plan to waive the coinsurance for an ECG. You say that the monitoring device didn't work so
you should not be responsible for 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 15%
coinsurance for non-radiological diagnostic services.

You received an ECG on August 20, 2020. The total allowed amount is $660.59 and 15% of that is $99.09.

You have been asked to pay the total coinsurance amount of $99.09 for an ECG. An ECG 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 coinsurance for an ECG provided on August 20, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on December 3, 2020.

You asked the Plan to pay for this claim. You say that this claim should be paid. The Plan denied your request. The Plan says due to the enrollee's hospice status on the date of service, this claim should be submitted to Original Medicare

The Plan says that they understand the enrollee revoked his hospice coverage on December 03, 2020. This means he was not under the care of a hospice provider as of revoke date. However, under Medicare guidelines Original or Traditional Medicare is still responsible for payment until the start of the next month after revocation. The Centers for Medicare and Medicaid Services (CMS) website shows the enrollee was enrolled in hospice from July 20, 2020 to October 17, 2020, October 18, 2020 to December 03, 2020 and December 08, 2020 to January 18, 2021. In accordance with Medicare guidelines, the provider needs to bill Original Medicare, using the proper modifiers, for services rendered on December 03, 2020. Per the regulations above, the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. It is the provider's responsibility to verify the member's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on December 3, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on December 14, 2020.

You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. The Plan denied your request. The Plan says these services are not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on December 14, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on December 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wrist hand orthosis (L3916) provided November 25,
2020.

You asked the Plan to pay for the orthosis. You say that claim was denied as insurance needs medical records
to process the claim further. So sending the same. Please take it into consideration and process the claim for
further payment. The Plan denied your request. The Plan says documentation indicates services are not
necessary for treatment of the enrollee's condition.

The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone
regarding the furnishing of a covered item except under specific circumstances.

We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the past 15 months. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the wrist hand orthosis (L3916) provided November 25, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on October 7, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. 

In this case, the MUE for CPT code 15777 is 1. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services rendered on October 7, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a diagnostic mammogram and an ultrasound provided on December 21, 2020.

You asked the Plan to waive the copayments for a diagnostic mammogram and an ultrasound. You say that you disagree with the charges because you thought they were preventative. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for diagnostic radiology.

You received a diagnostic mammogram on December 21, 2020. Therefore, you are responsible to pay the $50 copayment. 

You received an ultrasound on December 21, 2020. Therefore, you are responsible to pay the $50 copayment. 

The total amount you owe is: $100. 

You have been asked to pay the total copayment amount of $100 for a diagnostic mammogram and an ultrasound. A diagnostic mammogram and an ultrasound fall 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 copayments for a diagnostic mammogram and an ultrasound provided on December 21, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from November 13, 2020, to November 23, 2020.

You asked the Plan to pay for the SNF services. You say that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not receive any skilled level services through the dates of service.

The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from November 13, 2020, to November 23, 2020.