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

We decided that the Plan does not have to pay for the ambulance service and ground mileage provided on November 2, 2020.
You asked the Plan to pay for the ambulance service and ground mileage. You say that the enrollee's diagnosis is not related to hospice, and the trip is not related to hospice care. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the ambulance service and ground mileage provided on November 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the orthotics rendered on August 21, 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 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 orthotics rendered on August 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compression device (E0673) provided August 14, 2020.
You asked the Plan to pay for pneumatic compression device. You say that the records provided should support the necessity of the service in dispute. The Plan denied your request. The Plan says pneumatic compression devices are not covered by Medicare to prevent deep vein thrombosis during and/or following surgery, at home or in any setting.
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers. We find that the enrollee used the equipment in the facility during and/or after surgery. Payment for this service would have been included under the facility claim. Payment for this service is the responsibility of the facility or hospital that provided the surgery. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device (E0673) provided August 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a SNF stay provided from December 1, 2020, to December 8, 2020.
You asked the Plan to waive the copayment for a SNF stay. You say that you disagree with the charges because you are unhappy with the service you received. 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 $0 copayment for days 1-20, and a $125 copayment for days 21-100 for SNF care. You had a SNF stay from November 17, 2020, to December 8, 2020. You are not being charged a copayment for days 1-20 (November 17, 2020, to December 6, 2020). You are responsible to pay a copayment for day 21 (December 7, 2020). The total amount you owe is: $125. You have been asked to pay a $125 copayment for a SNF stay. A SNF stay falls within the SNF care 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 SNF stay provided from December 1, 2020, to December 8, 2020.
We note your complaint about the service you received. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services rendered on October 28, 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 provider type is not covered.
The Plan must follow Medicare rules. The rules say that Medicare makes payment for an assistant at surgery when the procedure is authorized for an assistant and the person performing the service is a physician, PA, NP, or CNS. We looked at the file and Medicare rules. The file shows that the assistant surgeon is not a physician, PA, NP, or CNS. 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 assistant surgeon services rendered on October 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound care provided to the enrollee on November 23, 2020, by an out-of-network provider.
You asked the Plan to pay for the wound care. You say that the services were medically necessary. You state the services were provided prior to obtaining authorization to avoid delay in care. The Plan denied your request. The Plan says there are many in-network providers that could help manage the enrollee's pressure sores within thirty (30) miles of their residence.
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 wound care provided to the enrollee on November 23, 2020, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the reline of a complete maxillary denture (D5750) and reline of a mandibular partial denture (D5761) provided on December 30, 2020.

You asked the Plan to pay for the denture relines. You say that you believe these services should be covered. The Plan denied your request. The Plan says these services are not covered benefits under your dental plan.

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 reline of a complete maxillary denture (D5750) and reline of a mandibular partial denture (D5761) provided on December 30, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance service, advanced life support, non-emergency transport (A0426) provided on December 21, 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 $245 copayment for each one-way Medicare-covered ground ambulance trip provided.

You have been asked to pay a $245 copayment for the one-way Medicare-covered ground ambulance trip 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 copayment for the ambulance service, advanced life support, non-emergency transport (A0426) provided on December 21, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency care services provided on July 18, 2019.

You asked the Plan to pay for emergency care. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this claim was not submitted within the timely filing limit.

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 emergency care was not filed until February 18, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for emergency care services provided on July 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office visits (99214, 99213) provided from May 1, 2019 to July 2, 2019.

You asked the Plan to pay for office visits. You say that this was billed correctly. The Plan denied your request. The Plan says this was not billed with valid diagnosis codes for the dates of service at issue.

The Plan must follow Medicare rules. Medicare rules say that ICD-9 codes will no longer be accepted on claims on or after October 1, 2015. 

We looked at the file and Medicare rules. The services at issue were billed with ICD-9 diagnosis codes. Based on this information, we decided that Medicare rules for coverage of office visits have not been met. Therefore, we decided that the Plan does not have to pay for office visits (99214, 99213) provided from May 1, 2019 to July 2, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an intracept procedure.
You asked the Plan to pre-approve an intracept procedure. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 pre-approve an intracept procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the intracept procedure remains experimental. More research is needed to show the safety and efficacy of the intracept procedure as a treatment for low back pain. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an intracept procedure.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (CPT 74018) provided to the enrollee on September 8, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Current Procedural Terminology (CPT) code 74018 (1 unit) remains 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 74018 is "radiological examination, abdomen; 1 view." 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found a review of the records show a note on 9/8/20 by the urologist as a film of the abdomen showing a right kidney stone. There is however no separate report for this examination to support reimbursement. Even if this film was generated in the physician's office, Medicare requires a distinct report in order to reimburse for this exam.
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 services have not been met. Therefore, we decided that the Plan does not have to pay for radiology services (CPT 74018) provided to the enrollee on September 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for cervical or vaginal cancer screening; pelvic and clinical breast examination (CPT code G0101) provided on February 1, 2021.
You asked the Plan to pay for the services. You say that you have not had an exam in one and a half years and feel this service should be covered by the health plan. The Plan denied your request. The Plan says you exhausted your benefit.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Review of the file shows that you had the same service on June 24, 2019.
Your 2021 EOC states that for all women: Pap tests and pelvic exams are covered once every twenty-four (24) months. Therefore, you did not wait the 24 months to have your next exam. Therefore, we decided that the Plan does not have to pay for cervical or vaginal cancer screening; pelvic and clinical breast examination (CPT code G0101) provided on February 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (CPT 80307 and HCPCS G0483) provided to the enrollee on July 15, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Healthcare Common Procedure Coding System (HCPCS) code G0481 (1 Unit) and Current Procedural Terminology (CPT)code 80307 (1 Unit) remain 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. We find that CPT code 80307 and HCPCS G0483 are not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing services (CPT 80307 and HCPCS G0483) provided to the enrollee on July 15, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda.
You asked the Plan to pre-approve Keytruda. You say that the medication is necessary. The Plan denied your request. The Plan says since the member is enrolled in a clinical trial, the requested drug is deemed a routine cost.
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services. In this case, you asked the Plan to pre-approve Keytruda as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-approve Keytruda.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the deluxe frames (V2025) and progressive lenses (V2781) provided October 16, 2020.

You asked the Plan to pay for the deluxe frames and progressive lenses. You say that you were told that the eyewear would be covered at the OON provider. The Plan denied your request. The Plan says coverage for routine vision benefits is not available at OON providers and they did not find evidence that misinformation was provided.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine eyewear when provided by a network provider.

We looked at the file and the Plan's rules. The requested provider in this case is not a network provider with the Plan at the time of the service. 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. Based on this information, we decided that the Plan's rules for coverage of the deluxe frames and progressive lenses have not been met. Therefore, we decided that the Plan does not have to pay for the deluxe frames (V2025) and progressive lenses (V2781) provided October 16, 2020.

Your complaint about potentially receiving misinformation about coverage 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 pay for the neuromuscular diagnostic procedure described by current procedural terminology (CPT) code 95999 provided on September 27, 2019.
You asked the Plan to pay for CPT code 95999. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
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 95999 is Unlisted neurological or neuromuscular diagnostic procedure.
We find that CPT code 95999 is not supported in the medical record. Specifically, the record shows that train of four testing was performed, and this is not the appropriate code for this service. Per Medicare guidelines, it is inappropriate to bill unlisted neurological or neuromuscular diagnostic CPT codes for train of four monitoring. There is no separate code for train for four monitoring. Based on this information, we decided that Medicare rules for coverage of CPT code 95999 have not been met. Therefore, we decided that the Plan does not have to pay for the neuromuscular diagnostic procedure described by current procedural terminology (CPT) code 95999 provided on September 27, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from August 22, 2020, to August 30, 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 ongoing stay in the SNF is not medically necessary. The Plan says that the enrollee did not have skilled nursing needs.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from August 22, 2020, to August 30, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for endoscopic retrograde ERCP (CPT code 43264), esophagogastroduodenoscopy (CPT Code 43259) and ERCP; with sphincterotomy/papillotomy (CPT Code 43262) provided to the enrollee on January 13, 2021, by a non-participating provider.
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 they did not authorize any services. The Plan states the services are not considered urgent/emergent in nature. The Plan states that prior authorization was not obtained as required under the plan benefits.
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 endoscopic retrograde ERCP (CPT code 43264), esophagogastroduodenoscopy (CPT Code 43259) and ERCP; with sphincterotomy/papillotomy (CPT Code 43262) provided to the enrollee on January 13, 2021, by a non-participating provider.