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

We decided that the Plan does not have to reimburse you for the periodic oral evaluation (D0120) and periodontal maintenance (D4910) provided on December 16, 2019.
You asked the Plan to reimburse you for the dental services. You say that you have 2 dental plans. You say that the services should be covered between the 2 plans. You say that you have had 2 cleanings, 1 on September 23, 2019 and one on December 16, 2019. You say that the office staff forced you to have the second cleaning on December 16, 2019. You also say that they advised the cleaning would be covered. The Plan denied your request. The Plan says 1 oral exam is covered per calendar year. The Plan says periodontal maintenance is not listed as a covered service.
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 oral exams are a covered service, the frequency limit of once per calendar year has been exceeded. The record shows that the Plan paid for an oral exam that you received on May 13, 2019. Additionally, periodontal maintenance is not among those covered under this benefit. The record also shows that you were only active in the 1 dental plan through the  Dental PPO. Therefore, we decided that the Plan does not have to reimburse you for the periodic oral evaluation (D0120) and periodontal maintenance (D4910) provided on December 16, 2019.
Your complaint about being manipulated by the staff at the provider's office 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 for the inhalation of nitrous oxide/analgesia and resin-based composite provided by an OON provider on September 3, 2019.
You asked the Plan to pay for the inhalation of nitrous oxide/analgesia and resin-based composite. You say that this provider only deals with people that have a very strong fear of the dentist like you. You also say that no in-network dentist could address your problems. The Plan denied your request. The Plan says the dentist that did this treatment is not part of the Plan's network. The Plan also says that services done by an OON dentist are not covered.
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 covered when they are received out-of-network. Therefore, we decided that the Plan does not have to pay for the inhalation of nitrous oxide/analgesia and resin-based composite provided by an OON provider on September 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on December 20, 2019 by an out of network (OON) provider.
You asked the Plan to pay for skilled nursing services. You say that these services were provided in a skilled nursing facility. You say that it is not the doctor's responsibility to obtain prior authorization. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the member was not referred by an in-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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for skilled nursing services provided on December 20, 2019 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 lumbar-sacral orthosis (L0650) provided to the enrollee on November 4, 2019.You asked the Plan to pay for the orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the durable medical equipment have not been met. Specifically, medical records do not support a prior face-to-face examination with the ordering physician within 6 months of ordering the DME or an appropriate use of telehealth. The submitted consultation notes do not support that a physical examination was performed. The information submitted does not confirm that Medicare coverage criteria have been met.Therefore, we decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on November 4, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services coded S9500 provided on January 3, 2020.You asked the Plan to pay for the home infusion therapy 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 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, the CPT Code Manual definition of code S9500 is home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 24 hours;administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.We find that CPT code S9500 is not supported in the medical record. Specifically, code S9500 has a status code of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of and payment for these services. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy services have not been met.Therefore, we decided that the Plan does not have to pay for the home infusion therapy services coded S9500 provided on January 3, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurancethe spinal injection provided on February 20, 2020.You asked the Plan to waive the coinsurancethe spinal injection. You say that you do not feel that the injection should cost $178.73. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance per visit. You have been asked to pay $178.73 which is 20% of the allowed amount for the spinal injection. The allowed amount is $893.65. ($893.65 x 20% = $178.73). The spinal injection falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurancethe spinal injection provided on February 20, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha SureClick self-injectors.You asked the Plan to pre-approve the Repatha Sure Click injectors. You say that this medication is necessary for the enrollee's condition.The Plan denied your request. The Plan says this medication is self-injected and is not covered by Medicare Part B.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 pre-approve Repatha SureClick self-injectors.Benefits for the Repatha SureClick injectors 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: Favorable

We decided that the Plan has to pay for an office visit (99214) and electrocardiogram (93000) provided on September 18, 2019.
You asked the Plan to pay for the office visit and electrocardiogram. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that certain Medicare Non-Par providers, such as Nurse Practitioners, are not recognized as payable by Medicare. The Plan must follow Medicare rules. Medicare rules say that nurse practitioners must be billing for their services under their own NPI and not furnishing services incident to physicians' services.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the office visit and electrocardiogram have been met. Specifically, the provider in this case is a NP, for which Medicare states payment can be made. The NP has their own NPI on the claim form (in addition to the Billing Provider's NPI). Therefore, we decided that the Plan has to pay for an office visit (99214) and electrocardiogram (93000) provided on September 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on May 14, 2018.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on May 14, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ophthalmologist services provided by a
participating provider on January 27, 2020.
You asked the Plan to waive the copayment for ophthalmologist services. You say that this was a routine visit.
The Plan denied your request. The Plan says the correct copayment has been applied.
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 vision care/services to diagnose and/or treat a condition.
You have been asked to pay a $45 copayment for ophthalmologist services. The services that were provided
went beyond an eye visit; therefore, the correct copayment has been applied. Ophthalmologist services within
the vision care/services to diagnose and/or treat a condition 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 ophthalmologist services provided by a participating provider on January 27, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe 1 mg Lorazepam tablet and 20mg Potassium Chloride tablet provided on January 13, 2020.You asked the Plan to pay forthe Lorazepam and Potassium Chloride. You say that you were given your prescribed medications while in the hospital.The Plan denied your request. The Plan says these are self-administered medications not covered under Part B. The Plan also says that your medical benefit does notcover self-administered drugs.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 forthe 1 mg Lorazepam tablet and 20mg Potassium Chloride tablet provided on January 13, 2020.Benefits for the Lorazepam and Potassium Chloride may be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the Inogen G5 IS-500 portable oxygen concentrator purchased on September 25, 2019.
You asked the Plan to reimburse you for the portable oxygen concentrator. You say that this unit is necessary during transport to your office visits and you believed this device was covered by Medicare. The Plan denied your request. The Plan says Medicare rules say that only rented oxygen equipment is eligible for coverage.
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home. Medicare rules say only rented oxygen equipment is eligible for coverage. We looked at the file and Medicare rules. Purchased oxygen equipment is statutorily non-covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the portable oxygen concentrator have not been met. Therefore, we decided that the Plan does not have to reimburse you for the Inogen G5 IS-500 portable oxygen concentrator purchased on September 25, 2019.We decided that the Plan does not have to reimburse you for the Inogen G5 IS-500 portable oxygen concentrator purchased on September 25, 2019.
You asked the Plan to reimburse you for the portable oxygen concentrator. You say that this unit is necessary during transport to your office visits and you believed this device was covered by Medicare. The Plan denied your request. The Plan says Medicare rules say that only rented oxygen equipment is eligible for coverage.
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home. Medicare rules say only rented oxygen equipment is eligible for coverage. We looked at the file and Medicare rules. Purchased oxygen equipment is statutorily non-covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the portable oxygen concentrator have not been met. Therefore, we decided that the Plan does not have to reimburse you for the Inogen G5 IS-500 portable oxygen concentrator purchased on September 25, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee on November 4, 2019.
You asked the Plan to pay for the services. You say that this was denied in error. The Plan denied your request. The Plan says 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. In this case, the CPT Code Manual definition of HCPCS code G0299 is "Direct skilled nursing services of a registered nurse (rn) in the home health or hospice setting, each 15 minutes." We find that HCPCS code G0299 is not supported in the medical record. Specifically, the claim was billed with an incorrect type of bill code. 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 home health services provided to the enrollee on November 4, 2019.
Appeal type: Drugs
Decision: Partially Favorable

We decided that the Plan has to waive the coinsurance for the therapeutic injection. We decided that the Plan does not have to waive the coinsurance for the denosumab injection.
You asked the Plan to waive the coinsurance for the therapeutic injection. You say that you were not informed there was coinsurance for the injections. The Plan says that the coinsurance applied correctly.
We decided that the Plan has to waive the coinsurance for the therapeutic injection.
The Plan contract says that enrollees pay a $0 copayment for provider and professional services at an in-network outpatient hospital. The therapeutic injection is considered a physician service. Therefore, we decided that the Plan has to waive the coinsurance for the therapeutic injection.
We also decided that the Plan does not have to waive the coinsurance for the denosumab injection.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare Part B covered drugs. Therefore, we decided that the Plan does not have to waive the coinsurance for the denosumab injection.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial periapical x-ray (D0220), the additional periapical
x-ray (D0230), the endodontic therapy for a molar (D3330), the treatment of a root canal obstruction (D3331),
and the consultation, including an oral evaluation, (D9310) provided on October 3, 2019.
You asked the Plan to pay for the dental services. You say that you were directed to this office for the dental
services. You say that you were advised that the services were approved. You also say that you were never
advised to see a specific dentist. The Plan denied your request. The Plan says the provider in this was is not a
network provider. The Plan also says that dental services that you receive out of network are not covered.
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, dental services that you receive out of
network are not covered. Therefore, we decided that the Plan does not have to pay for the initial periapical xray
(D0220), the additional periapical x-ray (D0230), the endodontic therapy for a molar (D3330), the
treatment of a root canal obstruction (D3331), and the consultation, including an oral evaluation, (D9310)
provided on October 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the special pump services rendered on November 8, 2019.You asked the Plan to pay for these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are statutorily excluded. The provider submitted a claim for procedure code 99190 (special pump services). This code has a status indicator of X and no separate Medicare payment. Payment is included in the payment to the facility.Therefore, we decided that the Plan does not have to pay forthe special pump services rendered on November 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on November 22, 2019.You asked the Plan to waive the copayment for the office visit. You say that you paid for the colonoscopy and paid for the results. You say that the provider is double dipping.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 provider and professional services at an in-network specialist's office. 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. 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 November 22, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for Inpatient Mental Health services provided June 22 to June 28, 2019.You asked the Plan to pay for the Inpatient Mental Health services. You say that inpatient services were medically necessary.The Plan denied your request. The Plan says rules for coverage were not met after June 21, 2019.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 Inpatient Mental Health services. Our reviewer says that the inpatient level of care was not medically necessary. Our physician reviewer found the records provided for the admission of this enrollee did not meet the criteria for continued acute inpatient mental health treatment after June 22, 2019. The enrollee was not shown to be a danger to self or others. The enrollee was cooperative with treatment while not showing any threats the safety.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on November 25, 2019.
You asked the Plan to pay for the laboratory 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 the laboratory services are not supported in the medical record. Specifically, there are no progress
notes submitted that are required to determine the clinical utility of the testing provided. Based on this
information, we decided that Medicare rules for coverage of the laboratory services have not been met.
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on November 25,
2019.