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

We decided that the Plan does not have to pre-approve the transportation services.

You asked the Plan to pre-approve the transportation services. You say that you are wheelchair bound. 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 wheelchair van transport services. 

The services you have asked the Plan to pre-approve are wheelchair van transport services. Therefore, we decided that the Plan does not have to pre-approve the transportation services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a urology visit (99205) to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve the out-of-network urology visit. You say that the out-of-network consult is medically necessary. The Plan denied your request. The Plan says you can get a second opinion on your condition from a network provider.

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 a urology visit (99205) to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics (L3400).

You asked the Plan to pre-approve foot orthotics. You say that the orthotics are medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3400).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a syringe with a needle for an external insulin pump (A4232 x 3) and an external ambulatory infusion pump, insulin (E0784) to be rendered by the out of network (OON) provider.

You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are available in-network providers that can render the requested items.

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 items at issue in this appeal. We found no exception that would require the Plan to pre-approve these items. Therefore, we decided that the Plan does not have to pre-approve a syringe with a needle for an external insulin pump (A4232 x 3) and an external ambulatory infusion pump, insulin (E0784) to be rendered by the out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve general anesthesia (D9222, D9223) and therapeutic parenteral drug administration (D9610).

You asked the Plan to pre-approve the drug and anesthesia. You say that these services are necessary. The Plan denied your request. The Plan says these services are not covered by 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 pre-approve general anesthesia (D9222, D9223) and therapeutic parenteral drug administration (D9610).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services (D0120, D0274, D1110) received March 10, 2021 from the out-of-network provider.

You asked the Plan to pay for the dental services (D0120, D0274, D1110). You say that the Plan should cover the requested services The Plan denied your request. The Plan says services performed by an out-of-network provider are excluded from coverage.

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 when they are performed by an out-of-network provider. Therefore, we decided that the Plan does not have to pay for the dental services (D0120, D0274, D1110) received March 10, 2021 from the out-of-network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic exercises provided on February 5, 2021.

You asked the Plan to pay for the therapeutic exercises. The Plan denied your request. The Plan says the documentation submitted on appeal consists of duplicates of medical documents previously reviewed.

The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 

We looked at the file and Medicare rules. The file shows that you did not submit sufficient medical documents to justify payment of the claim. Based on this information, we decided that Medicare rules for coverage of the therapeutic exercises have not been met. Therefore, we decided that the Plan does not have to pay for therapeutic exercises provided on February 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical nutrition therapy.
You asked the Plan to pre-approve these services. You say that you would like a consultation. The Plan denied your request. The Plan says you do not have a condition for which the services are covered.
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes. Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does not have to pre-approve medical nutrition therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a shower chair provided on March 13, 2021.

You asked the Plan to pay for a shower chair. You say that your unable to stand or sit in the shower. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. 

While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pay for a shower chair provided on March 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) received March 5, 2021.
You asked the Plan to pay for the extraction. You say that you thought extractions were included with the dental insurance. The Plan denied your request. The Plan says the requested service 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 extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) received March 5, 2021.
Your complaint about not receiving a booklet of what is covered by the Plan 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam provided on February 18, 2021.
You asked the Plan to waive the copayment for the eye exam. You say that this visit was strictly a left-eye post-operative visit and should not have been related to your right eye. 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 $45 copayment for each in-network Medicare-covered exam to diagnose and treat diseases or conditions of the eye.
You have been asked to pay a $45 copayment for the eye exam. The eye exam falls within the "Vision care"
benefit category. The medical record shows the reason for visit was a cataract check of the right eye. 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 eye exam provided on February 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy provided on January 20, 2021, by an OON
provider.
You asked the Plan to pay for the psychotherapy. You say that you would like the claim reprocessed. You say
the service provided are covered under the mental health outpatient benefit. The Plan denied your request. The
Plan says 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 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 psychotherapy provided on January 20, 2021,
by an OON provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on June 23, 2020.
You asked the Plan to pay for the laboratory services. 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 member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
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 laboratory services provided on June 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment from $155 to $45 for the office visit (99214) and the transthoracic echocardiography (93351) provided on February 17, 2021.
You asked the Plan to adjust 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 services 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 $45 copayment for specialist physician services and a $110 copayment for Medicare-covered diagnostic radiology services. Additional cost-sharing applies for diagnostic and radiology services received at physician offices.
You have been asked to pay $155 ($45 copayment + $110 copayment) for the specialist physician service and the diagnostic radiology service 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 adjust the copayment from $155 to $45 for the office visit (99214) and the transthoracic echocardiography (93351) provided on February 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services provided on January 5, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the psychotherapy services. You say that you disagree with the plan's denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 psychotherapy services provided on January 5, 2021 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0675).
You asked the Plan to pay for a pneumatic compression device. You say that you would like this claim
reprocessed for medical necessity. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that a pneumatic compression device coded as E0675
to treat peripheral artery disease is not eligible for reimbursement.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of a pneumatic compression device have not been met. Therefore, we decided that the Plan does not
have to pay for a pneumatic compression device (E0675).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pay for the COVID vaccine rendered on February 10, 2021 and March 4, 2021.

You asked the Plan to pay for these services. You say that the services should be covered. The Plan denied your request. The Plan says that the services are not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan states that the COVID vaccine is not covered; however, the Plan has not provided any documentation or Medicare rules to support that the services are not covered. Medicare rules state that COVID vaccines are exceptions to the immunization rule. Therefore, we decided that the Plan has to pay for the COVID vaccine rendered on February 10, 2021 and March 4, 2021.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on February 12, 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 claim was billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on February 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on December 22, 2020.
You asked the Plan to waive the copayment for the office visit. You say that the copayment was not asked for at check in or discharge, and you are now receiving a bill. You say that they did not perform any procedure to bill your insurance. 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 a $40 copayment for services obtained from a specialist, or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's office (as permitted under Medicare rules). You have been asked to pay a $40 copayment for the office visit. The office visit falls within the "Physician/Practitioner Services, Including Doctor's Office Visits" benefit category. The records show services were provided during the 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 office visit provided on December 22, 2020.
Your complaint about the charge being fraudulent 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the comprehensive oral evaluation (D0150), the prophylaxis (D1110), the intraoral - complete series of radiographic images (D0210), and the resin-based composite - three surfaces, anterior (D2332) received January 28 and February 4, 2021 from the out-of-network provider.

You asked the Plan to pay an additional amount for the dental services (D0150, D1110, D0210, D2332). You say that you went to a local dentist because you broke your tooth. The Plan denied your request. The Plan says if you choose to see an out-of-network dentist you might be billed for charges above what the Plan pays, even for services listed as $0 copayment.

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 payment is in excess of what is covered under this benefit. The Plan contract states that if you choose to see an out-of-network dentist you might be billed for charges above what the Plan pays, even for services listed as $0 copayment. The Plan agreed to pay 100% of the cost of the allowable charge for the requested services. You are responsible for the difference between what was charged by the out-of-network provider and what was covered by the Plan. The Plan has provided payment in accordance with the Plan contract. Therefore, we decided that the Plan does not have to pay an additional amount for the comprehensive oral evaluation (D0150), the prophylaxis (D1110), the intraoral - complete series of radiographic images (D0210), and the resin-based composite - three surfaces, anterior (D2332) received January 28 and February 4, 2021 from the out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for moderate sedation (99153) provided December 23, 2020.

You asked the Plan to pay for the moderate sedation services. You say that the services were medically necessary. The Plan denied your request. The Plan says this CPT code is not eligible for separate payment. A corrected claim is needed.

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 99153 is not supported in the medical record. Specifically, CPT code 99153 has a Professional Component (PC)/Technical Component (TC) indicator of 3 per the January 2021 National Physician Fee Schedule. There is no work component RVU associated with this CPT code. Based on this information, we decided that Medicare rules for coverage of the moderate sedation services have not been met.

Therefore, we decided that the Plan does not have to pay for moderate sedation (99153) provided December 23, 2020.