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

 
We decided that the Plan does not have to pay for the home infusion supplies (A4223) provided on June 8, 
2019, through July 1, 2019. 
 
You asked the Plan to pay for the home infusion supplies. You say that you would like reconsideration because 
these supplies should be covered along with the antibiotic. The Plan denied your request. The Plan says 
payment for these supplies is included in the payment for the antibiotic. 
 
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 A4223 is infusion supplies not used with external 
infusion pump, per cassette or bag (list drugs separately). 
 
We find that CPT code A4223 is not supported in the record. Specifically, home infusion supplies are payable 
with the use of a covered external infusion pump. In this case, there is no indication that an external infusion 
pump is being used, therefore the billed supplies are non-covered. Based on this information, we decided that 
Medicare rules for coverage of the home infusion supplies have not been met. Therefore, we decided that the 
Plan does not have to pay for the home infusion supplies (A4223) provided on June 8, 2019, through July 1, 
2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay additionally for the vision services with CPT codes 92014,
V2799, V2303, V2300, and V2020 provided on September 11, 2020.
You asked the Plan to pay additionally for the vision services. You say that you would like the Plan to
reconsider your request. The Plan denied your request. The Plan says the Plan has paid your yearly allowance
of $125 towards the vision care services you received on September 11, 2020. The Plan says, per your contract,
you are responsible for any amount above this eye wear coverage limit.
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. We looked at the file and the Plan's rules. The file shows that the Plan has paid your yearly allowance of $125
towards the vision care services you received on September 11, 2020. Your contract with the Plan clearly says
you are responsible for any amount above this eye wear coverage limit. Please note, though the Plan is not
responsible for additional payment of these services, the Plan did confirm with your provider that you will not
be held responsible for the eye exam with CPT code 92014 in the amount of $65. Therefore, we decided that
the Plan does not have to pay additionally for the vision services with CPT codes 92014, V2799, V2303,
V2300, and V2020 provided on September 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe durable medical equipment (DME) defined by codes B4035 and B4154 that wereprovided to the enrollee on May 1, 2020 to May 31, 2020.You asked the Plan to pay forthe DME. You say that the claims should be paid.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 for the billed date of service.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 and relevant medical records which support medical necessity for the supplies provided in this case. The documentation submitted did not include an itemized shipping/billing invoice to indicate the specific supplies, or proof of delivery for the billed date of service. Therefore, the billed code cannot be verified.  The record shows that the Plan made several attempts to obtain the necessary documentation without success.Therefore, we decided thatthe Plan does not have to pay forthe durable medical equipment (DME) defined by codes B4035 and B4154 that were provided to the enrollee on May 1, 2020 to May 31, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse the full amount for the periodic oral evaluation (D0120) 
and the prophylaxis (D1110) provided on August 10, 2020. 
 
You asked the Plan to reimburse the full amount for the dental service. You say that you were not aware that 
the provider was out of network. You say that the provider did not tell you they were out of network until you 
were in the chair that day. You also say that you should not be responsible for the out of network benefits 
applied to your claim. The Plan denied your request. The Plan says the provider in this case is out of network. 
The Plan also says that you may be billed more by an out of network provider if the charge is greater than 
MAC. 
 
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, dental services that you receive out of 
network may have a higher cost share. Cost sharing is a contractual obligation under the plan and cannot be 
waived.  
CPT Code Billed Amount Allowed Amount Plan Paid Your Responsibility 
D0120 $42.76 $25 $25 $17.76 
D1110 $82.24 $52 $52 $30.24 
 
Additionally, the record shows that you were advised by a plan representative, prior to receiving the services, 
that the provider was out of network and what the plan would cover. Therefore, we decided that the Plan does 
not have to reimburse the full amount for the periodic oral evaluation (D0120) and the prophylaxis (D1110) 
provided on August 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more forthe comprehensive oral evaluation (D0150) and prophylaxis (D1110) provided on June 22, 2020.You asked the Plan to pay more forthe dental services. You say that you were unhappy with your previous dental experience. You say that you they just want your money. You say that you went to a new dentist this time. You also say that the services are not covered now.The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that you may still be billed by an out of network provider for any amount greater than the MAC payment made by the plan to the provider. The Plan says that comprehensive oral evaluation is covered once every 3 plan years. The Plan also says that the frequency limit for this service has been exceeded.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, dental services that you receive out of network are subject to a higher cost share. The Evidence of Coverage clearly states that an out of network provider can bill you for any amount greater than the MAC payment made by the plan to the provider. Additionally, the frequency limit of 1 comprehensive oral evaluation every 3 calendar years has been exceeded. The record shows that the Plan paid for this service that you received on February 27, 2020.Therefore, we decided that the Plan does not have to pay more forthe comprehensive oral evaluation (D0150) and prophylaxis (D1110) provided on June 22, 2020.
Your complaint about your experience at the previous dental office 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for complete bilateral breast ultrasound 
(76642) provided September 22, 2020. 
 
You asked the Plan to waive the copayment for the breast ultrasound. You say that you feel that the ultrasound 
should have been covered in full due to the NY state mandate and your family history of breast cancer. The 
Plan denied your request. The Plan says the claim was processed and the correct copayment was applied per the 
Evidence of Coverage. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $45 
copayment for each Medicare covered standard x-ray and ultrasound.  
 
You have been asked to pay $45 copayment for the breast ultrasound. The breast ultrasound 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 complete bilateral breast ultrasound (76642) provided September 22, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay forchest x-ray (71046) provided September 17, 2020.You asked the Plan to pay forthe x-ray services. You say that the procedure was performed at the request of the referring doctor, as the enrollee's medical condition proved the medical necessity for the serviceThe Plan denied your request. The Plan says that the report does not support the medical necessity of the service.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review thecase file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the x-ray services. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a history of prior smoking but quantification of pack years, duration of smoking and whether the patient is currently smoking are factors not included in the submitted records.  Thus, based upon the informationincluded it cannot be determined if the enrollee would have qualified for a low dose lung CT which would have been a higher yielding screening exam. The plan has provided a single published article which talks about the advantages of low dose lung CT for the detection of lung cancer.  There is no argument against that position however absent qualifying for a low dose CT a chest x-ray as a screening would be reasonable based upon the enrollee's age and history of non-quantified smoking.  Note the plan's position does NOT constitute a standard of care within the community and a single screening chest x-ray in a patient with the given history is adequate reason for screening for lung cancer.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the x-ray services have been met.Therefore, we decided that the Plan has to pay forchest x-ray (71046) provided September 17, 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: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forthe acute inpatient hospital care provided from November 18, 2019, to November 19, 2019.You asked the Plan to pay foracute inpatient hospital care. You say that the services provided were medically necessary.The Plan denied your request. The Plan says that inpatient care was notmedically necessary,and care could have been provided at the observation level.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.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 pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee had an elevated troponin and was admitted to the hospital. He had acute coronary syndrome and associated hypertensive urgency warranting inpatient services which were expected to cross twomidnights due to the complexity and severity of the patient's acute and comorbid conditions.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met.Therefore, we decided that thePlan has to pay forthe acute inpatient hospital care provided from November 18, 2019, to November 19, 2019.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 copayment for a computed tomography (CT) scan of soft 
tissue of the neck (70490) and CT scan of the thorax (71250) provided on September 5, 2020. 
 
You asked the Plan to waive the copayment for CT scan of the neck and thorax. You say that the services 
should be covered. The Plan denied your request. The Plan says the cost share 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 $150 
per day, per provider, for Medicare-covered diagnostic radiology services after your yearly deductible is met 
for Outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay a $150 per day, per provider, for Medicare-covered diagnostic radiology services 
after your yearly deductible is met for CT scan of the neck and thorax. CT scan of the neck and thorax 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. You had $122 left of your 
deductible before the copay of $150 went into effect ($122+$150=$272). 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 computed tomography (CT) scan of soft tissue of the neck (70490) and CT scan 
of the thorax (71250) provided on September 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that you have made great progress in the IRF.The Plan denied your request. The Plan says the records show you do not require supervision of a rehab doctor or aggressive therapies.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.

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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for surgical treatment of a hip fracture after a fall. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs.

The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program.

There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and service
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the health club membership from October 15, 2019, to September 15, 2020.
You asked the Plan to pay for the health club membership. You say that you would like these claims reprocessed and approved for payment. The Plan denied your request. The Plan says rules for health club membership have not been met.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers gym benefits only when you show your Health ID card and enroll in a membership at the gym. The Plan's rules for coverage of gym benefits have not been met because the file indicates that you have had the same contract since 2016 and would not have shown your Health ID card when you signed up for membership at the gym. Therefore, we decided that the Plan does not have to pay for the health club membership from October 15, 2019, to September 15, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the MRI of the lumbar spine (72148) 
provided on June 25, 2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment 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 $275 
copayment for each advanced imaging service (MRI, CT and PET scans, nuclear medicine, and stress tests).  
 
You have been asked to pay a $233.20 copayment for the advanced imaging service provided. This is the Plan 
allowed amount, which is less than the applicable copayment. 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 MRI of the lumbar spine (72148) provided on June 25, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee's condition does not require acute 
hospital care, or intensive therapy. The Plan denied your request. The Plan says therapy is required to regain 
muscle tone 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the documentation does not support that the complexity of the enrollee's nursing, 
medical and rehabilitation needs requires an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. Based on the documentation, it would not be reasonable to expect that this enrollee would 
be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network lab services provided on March 18, 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 the enrollee did not have prior authorization for out of network care. The ordering 
provider was also out of network. 
 
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 has network providers available who can provide 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 lab services 
provided on March 18, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided to the enrollee on January 19, 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 Guardant 360 testing was denied due to the coverage criteria. The records show the 
enrollee had cancer of the tongue. This test is not currently covered for this diagnosis. 
 
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, tongue cancer is not listed as a 
covered diagnosis or cancer type for this testing.  Medicare rules for coverage of this service have not been 
met. Therefore, we decided that the Plan does not have to pay for lab testing provided to the enrollee on 
January 19, 2020.