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

We decided that the Plan does not have to pay for the Hearing aids (V5261) provided June 25, 2020 provided by an out-of-network (OON) provider.

You asked the Plan to pay for the hearing aids. You say that you believe you should be reimbursed for the hearing aids. The Plan denied your request. The Plan says hearing aids are not covered when provided by an OON provider.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when they are provided by the Plan's specified hearing provider. 

We looked at the file and the Plan's rules. You were provided hearing aids from an OON provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the Hearing aids (V5261) provided June 25, 2020 provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.

You asked the Plan to pre-approve additional routine transportation. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says you are only covered for up to 36 one-way trips per calendar year. The Plan says once you have used all 36 one-way trips, additional trips will not be approved.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 36 one-way transportation trips per year.

We looked at the file, the Plan's contract and Medicare rules. The Plan covers 36 one-way trips per calendar year. The file shows that you have used 17 of the 36 allotted trips for the 2021 benefit year. Once you have used all 36 one-way trips, you will have exhausted your transportation benefit. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services coded 01936 provided on October 12, 2020.

You asked the Plan to pay for the anesthesia 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 separately payable.

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, we have confirmed that code 01936 for the anesthesia services has a bundled relationship with codes 64493, 64494, and 64495 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services coded 01936 provided on October 12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider on August 6, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.

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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider on August 6, 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 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. 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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care. 

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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from November 7, 2020, to November 24, 2020.

You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you are being billed for extra days. You say your hospital stay started on November 10, 2020. 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 $300 copayment per day for days 1-6, then $0 copayment after day 6. 

You have been asked to pay a $300 copayment for days 1 to 6 of the inpatient hospital stay. The record shows you met your maximum out-of-pocket amount and have been asked to pay a $1,425 copayment, which is less than the standard amount. The inpatient hospital stay falls within the "Inpatient hospital 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 the inpatient hospital stay provided from November 7, 2020, to November 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 64999) provided on July 13, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed incorrectly.

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 asked our coding 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 use of CPT code 64999 is not supported by the records provided. Our coding reviewer found that CPT code 64999 should not be billed by an anesthesia practitioner as anesthesia services are billed with procedure codes 00100 -01999 when billed by an anesthesia practitioner who may be a physician, a certified registered nurse anesthetist (CRNA) with or without medical direction, or an anesthesia assistant (AA) with medical direction. Therefore, this service is not eligible to be billed by this provider and is not eligible for reimbursement.

We looked at this coder'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 the services (CPT 64999) provided on July 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for an office visit (99213) and diagnostic pathology services (88342, 88341, 88305) provided on January 5, 2021.

You asked the Plan to waive the cost-sharing for an office visit and diagnostic pathology services. You say that you do not believe these services took place. The Plan denied your request. The Plan says these services processed 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 20% coinsurance for diagnostic procedures and tests and a $40 copayment for specialist office visits.

You have been asked to pay a $40 copayment for an office visit and a $26.86 coinsurance ($134.32 allowed amount x 20% = $26.86) for diagnostic pathology services. Your provider has submitted medical records documenting that these services were performed. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost-sharing for an office visit (99213) and diagnostic pathology services (88342, 88341, 88305) provided on January 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglass frames and lenses (V2100, V2020) provided March 2, 2020 to August 12, 2020.

You asked the Plan to pay for the eyeglass frames and lenses. You say that the frames should be covered. The Plan denied your request. The Plan says the items were obtained out-of-network. The plan paid the 60% required towards the post-cataract surgery eyewear. The additional frames were obtained out-of-network and are not covered.

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 these services when obtained from network vision providers.

We looked at the file and the Plan's rules. The plan paid the 60% towards the post-cataract surgery eyewear as listed in the Evidence of coverage. The additional frames were considered routine vision care and were obtained out-of-network. The plan does not cover routine eyewear obtained out-of-network. Based on this information, we decided that the Plan's rules for coverage of the eyeglass frames and lenses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglass frames and lenses (V2100, V2020) provided March 2, 2020 to August 12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the multiplex respiratory viral panel for 3-5 pathogens provided on June 12, 2020 billed with code 87631.

You asked the Plan to pay for the respiratory viral panel testing. You say that this should be covered.The Plan denied your request. The Plan says this was ordered for screening purposes. All other codes were approved for payment.

The Plan must follow Medicare rules. Medicare rules say that the type of testing described by code 87631 is only covered when ordered in a setting equipped to care for critically ill patients or when ordered by an infectious disease specialist. 

In this case, the order shows that this was ordered for a patient at an assisted living facility, which is not equipped to care for critically ill patients. The ordering provider has a specialty of psychiatry & neurology. There is no evidence that an infectious disease specialist was not available. Based on this information, we find that the Medicare criteria for coverage of this specific testing have not been met.Therefore, we decided that the Plan does not have to pay for the multiplex respiratory viral panel for 3-5 pathogens provided on June 12, 2020 billed with code 87631.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for outpatient hospital services provided on December 17, 2020.

You asked the Plan to reduce the copayment for the outpatient hospital services. You say that your physician copayment should only be $5.The Plan denied your request. The Plan says you were charged this copayment 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 $20 copayment for Outpatient HospitalServices. 

You have been asked to pay a $20 copayment for the outpatient hospital services. The outpatient hospital services fall within the Outpatient Hospital Services benefit category. The provider submitted the bill as a facility-based provider. 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 reduce thecopayment for outpatient hospital services provided on December 17, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on December 6, 2020.

You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says these services are not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on December 6, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay for the ambulance services provided on December 6, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the insulin injection provided on November 18, 2020.

You asked the Plan to pay for the insulin. You say that you believe this service should be covered because you needed the insulin to bring your glucose level back to normal.The Plan denied your request. The Plan says an insulin injection is a self-administered drug. The Plan also says that insulin is not Part B covered.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pay for the insulin injection provided on November 18, 2020.

Benefits for insulin may be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the specialist services rendered on November 13, 2020 and November 20, 2020.

You asked the Plan to waive the copayments for these services. You say that you did not receive treatment. The Plan denied your request. The Plan says the copayments were 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 $35 copayment for each specialist visit.

Review of the file shows that you received specialist services on November 13, 2020 and November 20, 2020. You have been asked to pay a $35 copayment peer visit for these services, for a total of $70. These services fall within the specialist visit benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the specialist services rendered on November 13, 2020 and November 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on June 16, 2020.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.

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 services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay for physician's services provided on June 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and the cleaning (D1110) provided on August 10, 2020.

You asked the Plan to pay for the dental services. You say that prior to your appointment, you checked with your provider and were advised he accepts your dental plan. You say that due to the lack of communication between the provider's office and the fact that the website is not always accurate, you feel these services should be paid for by the plan.The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that dental services that you receive out of network are not covered. The Plan also says that there are in network dentists available in your area.

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 and the services are listed as covered, dental services performed out of network are not covered.The Evidence of Coverage clearly states that care rendered by a provider that is not part of our supplemental dental network is not covered. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and the cleaning (D1110) provided on August 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided from November 1, 2020, through November 21, 2020.

You asked the Plan to pay for the physician's services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.

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 services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided from November 1, 2020, through November 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2740) and core buildup, including any pins when required (D2950) provided on January 11, 2021.

You asked the Plan to pay for the crown and core buildup. You say that you believed up to 50% of these services would be covered. The Plan denied your request. The Plan says these procedures are not covered under your dental plan. The Plan also says that you did not contact the Plan prior to this date of service to verify your dental plan benefits for 2021.

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 crown (D2740) and core buildup, including any pins when required (D2950) provided on January 11, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G04836 and 80307 provided on July 14, 2020.

You asked the Plan to pay for the drug testing. 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 G04836 and 80307 are not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G04836 and 80307 provided on July 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis (D1110) and periodic oral evaluation (D0120) provided December 1, 2020, and the resin-based composite (D2392) provided December 7, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for the dental cleaning, exam and composite. You say that it isn't fair that the Plan does not cover any portion of the cost. The Plan denied your request. The Plan says since services were provided by an OON provider, they are not covered by the 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. The Plan covers the dental cleaning, exam and composite when the services are rendered by a network provider.

We looked at the file and Medicare rules. You received dental services from an OON provider. Based on this information, we decided that the Plan does not have to pay for the prophylaxis (D1110) and periodic oral evaluation (D0120) provided December 1, 2020, and the resin-based composite (D2392) provided December 7, 2020 by an out-of-network (OON) provider.