Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the office visit provided on August 4, 2020.

You asked the Plan to reimburse you for the office visit. You say that you have been going to this provider. The Plan denied your request. The Plan says they have confirmed the provider opted out of Medicare on April 1, 2012 and previous payments were made in error.

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 reimburse you for the office visit provided on August 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a lipid panel (80061) and infectious agent testing (87389) provided on September 23, 2020.
You asked the Plan to pay for a lipid panel and infectious agent testing. You say that these services should be covered. The Plan denied your request. The Plan says these were performed for screening purposes.
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, a lipid panel and infectious agent testing, 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 a lipid panel (80061) and infectious agent testing (87389) provided on September 23, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the adjacent tissue transfer or rearrangement services coded
14301 and 14302 provided on October 29, 2020.

You asked the Plan to pay for the adjacent tissue transfer or rearrangement 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 14301 and 14302 are not supported in the medical record. Specifically, the operative
report did not include documentation of an adjacent tissue transfer or rearrangement of any area; defect 30.1sq
cm to 60.0sq cm; therefore, code 14301 cannot be verified. The operative report did not include documentation
of an adjacent tissue transfer or rearrangement of any area for each additional 30.0sq cm, or part thereof
(listed separately in addition to code for primary procedure); therefore, code 14302 cannot be verified. Based
on this information, we decided that Medicare rules for coverage of the adjacent tissue transfer or
rearrangement services have not been met. Therefore, we decided that the Plan does not have to pay for the
adjacent tissue transfer or rearrangement services coded 14301 and 14302 provided on October 29, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the hearing test, endoscopy and office visit provided on December 4, 2020.

You asked the Plan to waive the copayment for the hearing test, endoscopy, and office visit. You say that you cannot pay all the copayments that were charged under the office visit. The Plan denied your request. The Plan says the copayments 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 a $40 copayment for an exam to diagnose and treat hearing and balance issues, a $50 copayment for all other diagnostic procedures and tests and a$40 copayment for each specialist in-person office visit. 

You have been asked to pay a total of $130 for the hearing test, endoscopy, and office visit.

The hearing test falls within the "Hearing services" benefit category. The endoscopy falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" 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 the hearing test, endoscopy and office visit provided on December 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (G0482) provided on October 7,
2020.

You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on
the records submitted. The Plan denied your request. The Plan says the submitted claim form indicates the
laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation
and/or claim history indicates that the specimen was obtained in an office setting POS 11.

The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare
Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting
where the beneficiary receives the face to-face service.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the drug testing services have not been met. Specifically, the submitted claim was billed with a
laboratory place of service code but the record indicates that the member's face-to-face service was rendered in
an office setting. Therefore, we decided that the Plan does not have to pay for the drug testing services (G0482)
provided on October 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the triamcinolone acetonide injection (J3301) provided on August 7, 2020.

You asked the Plan to pay for the triamcinolone acetonide injection. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the provider billed with CPT/HCPCS codes which are considered as unconditionally packaged services.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that CPT code J3301 is not supported in the record. Specifically, per the Outpatient Prospective Payment System, CPT code J3301 has a status indicator of N. This means that payment for this service is packaged into payment for other services and there is no separate Ambulatory Payment Classifications payment. Based on this information, we decided that Medicare rules for coverage of the triamcinolone acetonide injection have not been met. Therefore, we decided that the Plan does not have to pay for the triamcinolone acetonide injection (J3301) provided on August 7, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81225, 81226, 81227, 81230, 81231, 81240, 81241, 81291, 81328, 81355, 81401, 81479) provided on February 12, 2020.

You asked the Plan to pay for genetic testing. You say that these services should be covered. The Plan denied your request. The Plan says these services were billed with an incorrect POS.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).

We looked at the file and Medicare rules. The services at issue were billed with POS 81 for an independent laboratory, but the records show that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (81225, 81226, 81227, 81230, 81231, 81240, 81241, 81291, 81328, 81355, 81401, 81479) provided on February 12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided to the enrollee on October 30,
2020, by an out-of-network provider.

You asked the Plan to pay for the genetic testing. You say that the claim should be paid. The Plan denied your
request. The Plan says the services are 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, the genetic testing, 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 provided to the enrollee on October 30, 2020, by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for (CPT code 81479) provided to the enrollee on October 22,
2020.

You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your
request. The Plan says per Part B Addendum of OPPS Payment, CPT Code 81479 has an SI Indicator of A
which means that code is not payable. The Plan states also there was no pricing sample provided by the
appellant.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.

Based on this information, we decided that Medicare rules for coverage of the services have not been met. You
have to submit the service under a different code type for Medicare claims if it has an I status indicator.
Therefore, we decided that the Plan does not have to pay for (CPT code 81479) provided to the enrollee on
October 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the records do not support your ability to tolerate an intensive rehab therapy program 3 hours a day.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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 physician reviewer found that you were admitted to the acute hospital for lower extremity edema and syndrome of inappropriate antidiuretic hormone secretion (SIADH). Your medical problems are stable. There are no complex nursing needs. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. 

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 services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray provided on October 6, 2020, by an
OON provider.

You asked the Plan to pay for the panoramic x-ray. You say that you would like to appeal this service. The Plan
denied your request. The Plan says services performed by an OON provider are not covered because your
healthcare plan does not have OON benefits.

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, you are responsible for 100% of the
cost for dental services rendered by an out-of-network provider. Therefore, we decided that the Plan does not
have to pay for the panoramic x-ray provided on October 6, 2020, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre 2 sensor kit for the enrollee.
You asked the Plan to pre-approve a Freestyle Libre 2 sensor kit. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that the enrollee does not meet criteria for coverage.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre 2 sensor kit have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 2 sensor kit for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye exam provided by an out-of-network provider on
November 23, 2020.

You asked the Plan to pay for the eye exam. You say that a provider performing services in a nursing home
facility is not responsible to obtain authorization. You say that the Plan should be reimbursed for all services
rendered. The Plan denied your request. The Plan says this is not a participating provider with the Plan and
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 eye exam provided by an out-of-network
provider on November 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist visit provided on January 13, 2021.
You asked the Plan to waive the copayment for the specialist visit. You say that there should not be a copayment for a phone call that followed-up a mammogram. The Plan denied your request. The Plan says you have been asked to pay 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 a $15 copayment for each covered visit or consultation in an outpatient location with a specialist. You have been asked to pay a $15 copayment for the specialist visit. The specialist visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows you had a telehealth visit. 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 specialist visit provided on January 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the mandibular partial denture - flexible base (D5226).
You asked the Plan to pay for the mandibular partial denture. You say that the partial denture is for your bottom front teeth that shows all the time. The Plan denied your request. The Plan says the requested item is not covered under your supplemental 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 for the mandibular partial denture - flexible base (D5226).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the recliner chair provided on October 26, 2020.

You asked the Plan to pay for the recliner chair. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says a recliner chair is not covered by Medicare or the Plan.

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 pay for the recliner chair provided on October 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the telehealth visit provided by a specialist on January 25, 2021.

You asked the Plan to waive the copayment for the telehealth visit provided by a specialist. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says the enrollee received a telehealth visit provided by a specialist on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per the enrollee's contract with the Plan.

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 $15 copayment for each covered telehealth visit or consultation in an outpatient location with a specialist.

We looked at the file, the Plan's contract and Medicare rules. The file shows that the enrollee received a telehealth visit provided by a specialist on January 25, 2021. The enrollee has been asked to pay a $15 copayment for the telehealth visit provided by a specialist. The telehealth visit provided by a specialist falls within the Physician/Practitioner 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 the telehealth visit provided by a specialist on January 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0673, E0675) provided to the enrollee on November 11, 2020.
You asked the Plan to pay the device. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that devices coded with E0675 are not covered. This type of device is not eligible for reimbursement. Based on this information, we decided that Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have the device a pneumatic compression device (E0673, E0675) provided to the enrollee on November 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam image capture (D0364) and pulp vitality test (D0460) provided on December 17, 2020.

You asked the Plan to pay for the dental services. You say that these services were medically necessary, and you cannot afford them. The Plan denied your request. The Plan says these services are not covered by Medicare or by the Plan's supplemental dental benefit under any circumstances.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the cone beam image capture (D0364) and pulp vitality test (D0460) provided on December 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiovascular risk assessment testing (CPT code(s): 81286, 81404, 81407, 81408, 81479 provided to the enrollee on July 22, 2020.

You asked the Plan to pay for the testing. You say that the claim should be paid. The Plan denied your request. The Plan says review of the file shows that the enrollee's diagnosis is: Z8249- Family history of ischemic heart disease. The Plan states Medicare denies coverage for all cardiovascular risk assessment testing / panels, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular disease.

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, the testing, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Medicare denies coverage for all cardiovascular risk assessment testing / panels, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular disease. Therefore, we decided that the Plan does not have to pay for cardiovascular risk assessment testing (CPT code(s): 81286, 81404, 81407, 81408, 81479 provided to the enrollee on July 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit, x-ray and wound care provided by an out-of-network provider.

You asked the Plan to pay for the office visit, x-ray and wound care. You say that you enclosed billing info for the immediate care. The Plan denied your request. The Plan says prior authorization was not obtained, and 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 the office visit, x-ray and wound care provided by an out-of-network provider.