Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe eye exam or provide additional reimbursement for the eyewear provided on December 11, 2019.You asked the Plan to waive the copayment forthe eye exam and provide additional reimbursement for the eyewear. The Plan denied your request. The Plan says that you are financially liable for any cost sharing applied, including deductibles, coinsurance and 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 $20 copayment for routine eye exams and that they will provide reimbursement for up to $120 per calendar year towards the purchase of eyeglasses or contact lenses.You have been asked to pay a $20 copayment for the eye exam.The eye exam falls within the routine eye exams 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.The file shows that the plan has approved the maximum calendar benefit of $120 for the eyewear. There is no provision in the contract which would require the plan to approve more than this amount. Therefore, we decided that the Plan does not have to waive the copayment forthe eye exam and provide additional reimbursement for the eyewear provided on December 11, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the CT scan coded 70450 provided on September 5, 2019.
You asked the Plan to pay for the CT scan. You say that you would like the plan to reconsider their denial. The
Plan denied your request. The Plan says the services billed are a duplicate.
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 70450 is computed tomography, head or brain; without
contrast material.
We find that CPT code 70450 is not supported in the medical record. Specifically, there were two claims for
the exact same services provided on the same date of service from the same provider. There is no other
information found on the claim which would indicate that these services may have been repeated by the
provider. Therefore, these services are a duplicate. Based on this information, we decided that Medicare rules
for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not have to pay for
the CT scan coded 70450 provided on September 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional third unit destruction of lower/sacral spinal facet joint nerves for the enrollee.You asked the Plan to pre-approve the additional injection. You say that this is medically necessary.The Plan denied your request. The Plan says the third neurotomy cannot be covered.The Plan must follow Medicare rules. Medicare rules say that radiofrequency neurotomy is covered two times per year.The plan has approved the first two units of this request. This represents the maximum benefits allowed per year for this service. Based on this information, we decided that Medicare rules for coverage of the additional injection have not been met.Therefore, we decided that the Plan does not have to pre-approve an additional third unit destruction of lower/sacral spinal facet joint nerves for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis and shoulder orthosis provided on December 6, 2019.
You asked the Plan to pay for the lumbar-sacral orthosis (L0650) and shoulder orthosis (L3670). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the documentation submitted did not include a Proof of Delivery or a Delivery Ticket.
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 for the supplies provided in this case. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis and shoulder orthosis provided on December 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the portable oxygen concentrator purchased on December 19, 2019.
You asked the Plan to reimburse you for the portable oxygen concentrator. You say that you purchase the portable oxygen concentrator to get to and from doctor appointments. The Plan denied your request. The Plan says purchased oxygen equipment is statutorily non-covered.
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home.
We looked at the file and Medicare rules. Medicare rules say that only rented oxygen equipment is eligible for coverage. Based on this information, we decided that Medicare rules for coverage of the portable oxygen concentrator have been met. Therefore, we decided that the Plan does not have to reimburse you for the portable oxygen concentrator purchased on December 19, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on January 17, 2019 to February 4, 2019 by an out of network (OON) provider.You asked the Plan to pay for physician services. You say that the patient was referred to their office by the long-term care facility where he resides, and the care that was rendered to him was medically necessary.The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that no prior authorization was 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 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 physician services provided on January 17, 2019 to February 4, 2019 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 the ambulance transport provided on
January 1, 2020.
You asked the Plan to waive the copayment for the ambulance transport. You say that you had to be transferred
because there was no trauma team at the hospital. You say that the copayment should be waived. The Plan
denied your request. The Plan says the copayment 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 $222 for
a Medicare-covered one-way trip.
You have been asked to pay a $222 copayment for the ambulance transport. The ambulance transport falls
within the "Ambulance services" benefit category. The records show that you were transferred by ambulance to
a higher level of care. 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 ambulance transport
provided on January 1, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from December 20, 2019.
You asked the Plan to pay for home health services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the claim form does not have the appropriate home health data.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the claim form does not have the appropriate home health data to process and pay the claim. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from December 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Tempur-Pedic mattress (E1399).You asked the Plan to pre-approve the mattress. You say that the mattress is medically necessary.The Plan denied your request. The Plan says the requested mattress is not a medical item. The enrollee has not trialed a medical type mattress topper or a hospital bed.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approve a Tempur-Pedic mattress (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on January 17, 2020 through January 24, 2020.
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration because CPT code S9328 is valid per CMS. The Plan denied your request. The Plan says CPT code S9328 has a status code of I which is not valid for Medicare purposes.
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 code S9328 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code S9328 has a status code of I. This means that CPT code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) provided on January 17, 2020 through January 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that the items are necessary. The Plan denied your request. The Plan says the requested items are not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing rendered on September 24, 2019.
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 testing is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the genetic testing
rendered on September 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for custom-fitted mandibular sleep apnea appliance (E0486) purchased September 18, 2019.
You asked the Plan to pay for the oral appliance. You say that you are appealing the denial of coverage due to the necessity of an oral appliance to help with your mild sleep apnea. The Plan denied your request. The Plan says this oral
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 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 the oral appliance. Our reviewer says that
the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the enrollee did not meet criteria 2 and 3 and no mention of inability in using a PAP appliance was noted. The results of the sleep studies could not establish the diagnosis of Obstructive Sleep Apnea. 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 oral appliance have not been met. Therefore, we decided that the Plan does not have to pay for custom-fitted mandibular sleep apnea appliance (E0486) purchased September 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on June 18, 2019.
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 codes 95937 and 95861 are not supported.
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 95937 is neuromuscular junction testing (repetitive
stimulation, paired stimuli), each nerve, any 1 method. The definition of code 95861 is needle
electromyography; 2 extremities with or without related paraspinal areas.
We find that CPT codes 95937 and 95861 are not supported in the medical record. Specifically, there is no
documentation of needle electromyography was performed to support code 95861 or neuromuscular junction
testing to support code 95937. 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 testing services
rendered on June 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided on July 19,
2018.
You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial
for payment. The Plan denied your request. The Plan says that the enrollee does not reside in an area where
Medicare allows telehealth services.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the item ordered following the noncovered visit is likewise
noncovered. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650)
provided on July 19, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the replacement prosthetic services to be provided by an out of network provider.You asked the Plan to pre-approve the replacement lower limb prosthetic services from an out-of-network provider. You say that you want to use an out-of-network provider for the services.The Plan denied your request. The Plan says the services requested are available in-network.Medicare rules say that plans can require enrollees toget care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested 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. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approve the replacement prosthetic services to be provided by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay fora comprehensive oral exam (D0150) and intraoral periapical radiographs (D0220, D0230) provided January 15, 2020.You asked the Plan to pay for the comprehensive exam and intraoral periapical radiographs. You say that the services should be covered.The Plan denied your request. The Plan says the services performed are not covered under your dental benefit.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 fora comprehensive oral exam (D0150) and intraoral periapical radiographs (D0220, D0230) provided January 15, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay fora chest x-ray (71010) provided March 20, 2017.You asked the Plan to pay forthe chest x-ray. You say that the claim should be paid.The Plan denied your request. The Plan says the claim was not filed timely.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 chest x-ray was not filed until September 13, 2019. 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 fora chest x-ray (71010) provided March 20, 2017.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the pacemaker surgery provided from September 23, 2019 to September 24, 2019.You asked the Plan to waive the coinsurance for the pacemaker surgery. You say that your facility cost share should be reduced to an inpatient cost share.The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for all other services at an in-network outpatient hospital services (including observation). You have been asked to pay $2,309.68 which is 20% of the allowed amount for the pacemaker surgery. The allowed amount is $11,548.39. ($11,548.39 x 20% = $2,309.68). Thepacemaker surgeryfalls within "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 the pacemaker surgery provided from September 23, 2019 to September 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services for a consultation with an out-of-network provider.You asked the Plan to pre-approve physician's services for a consultation with an out-of-network provider.The Plan denied your request. The Plan says the service is available within the network and your condition is not an emergency.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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physician's services for a consultation with an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) immunization provided on December 16, 2019.
You asked the Plan to pay for the Tdap immunization. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Tdap immunization. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the Tdap immunization. Therefore, we decided that the Plan does not have to pay for the Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) immunization provided on December 16, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services coded 80307 and G0480 provided
on December 4, 2019.
You asked the Plan to pay for the drug testing 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.
We find that CPT codes 80307 and G0480 are not supported in the medical record. Specifically, the submitted
medical records do not indicate a valid and signed laboratory order by the requesting physician. Based on this
information, we decided that Medicare rules for coverage of the drug testing services have not been met.
Therefore, we decided that the Plan does not have to pay for the drug testing services coded 80307 and G0480
provided on December 4, 2019.