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

We decided that the Plan does not have to pay forthe chest x-ray provided on April 29, 2020.You asked the Plan to pay forthe chest x-ray. You say that the enrollee revoked hospice service on April 23, 2020, which is prior to this date of service.The Plan denied yourrequest. 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. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.The enrollee ended Medicare Hospice benefits on April 23, 2020. The services in question were provided before the end of that month.Therefore, we decided that the Plan does not have to pay forthe chest x-ray provided on April 29, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvepanniculectomy and lipectomy.You asked the Plan to pre-approvepanniculectomy and lipectomy. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are coverable.  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 panniculectomy and lipectomy. Our reviewer says that the documentation does not support that the requested services are medically reasonableor necessary. Our reviewer found you reportedly underwent a previous panniculectomy. You have diagnoses of erythema intertrigo, scar conditions and fibrosis of skin, and excessive and redundant skin and subcutaneous tissue. The documentation does not support that you have a panniculus that hangs below the level of the pubis, and the medical records do not document that the panniculus causes chronic intertrigo that consistently recurs over three months while receiving appropriate medical therapy, or remainsrefractory to appropriate medical therapy over a period of three months. In addition, no preoperative photographs were provided. Therefore, you do not meet criteria for the requested services.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of panniculectomy and lipectomy have not been met.Therefore, we decided that the Plan does not have to pre-approvepanniculectomy and lipectomy.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forgenetic testing (81206, 81210, 81235, 81272, 81275, 81276, 81292, 81295, 81298, 81301, 81311, 81317, 81321) provided January 29, 2020.You asked the Plan to pay forthe genetic testing. You say that these services were medically necessary.The Plan denied your request. The Plan says the claim did not use a valid CPT code to describe the services provided.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 81206, 81210, 81235, 81272, 81275, 81276, 81292, 81295, 81298, 81301, 81311, 81317, and 81321 is not supported in the medical record. Specifically, Comprehensive Genomic Profile (CGP) testing is not defined as a targeted panel by MolDX. Per Medicare Local Coverage Article: Billing and Coding: MolDX: Targeted and Comprehensive Genomic Profile Sequencing Testing in Solid Tumor Cancers (A55624), this service should be billed using CPT code 81479. It cannot be paid as unbundled, separate codes. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met.Therefore, we decided that the Plan does not have to pay forgenetic testing (81206, 81210, 81235, 81272, 81275, 81276, 81292, 81295,81298, 81301, 81311, 81317, 81321) provided January 29, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided from April 13, 2020, through May 8, 2020.
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. 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 April 13, 2020 to May 8, 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 from April 13, 2020, through May 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on August 8, 2020.
You asked the Plan to waive the copayment for the specialist office visit. You say that you should be reimbursed for the office visit. 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 a $25 copayment for Medicare-covered vision services at an in-network specialist's office. You have been asked to pay a $25 copayment for the specialist office visit. The specialist office visit falls within the "Vision care" benefit category. The record shows you correctly paid your $25 copayment.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the specialist office visit provided on August 8, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health skilled nursing services.
You asked the Plan to pre-approve home health services. The Plan denied your request. The Plan says there are no identifiable skilled nursing needs.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 home health services. Our physician reviewer found that your wound has healed. A recent visit indicates no skin impairment. You have had medication and disease education. You are on a heart healthy diet. The records do not show that skilled nursing services are required to effectively provide treatment to improve your condition, or to prevent deterioration. Your conditions are chronic, and there is no evidence of complex wound care or other skilled nursing need. Therefore, the request for additional visits is not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health skilled nursing services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a stress test, cardiology visit, and injection
(93015, 99214, J2785, 78452) provided from July 8, 2020, to July 24, 2020.
You asked the Plan to waive the copayment for the stress test, cardiology visit, and injection. You say that the
copayments should be waived. The Plan denied your request. The Plan says the correct cost-sharing was
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 $30
copayment for specialist visits, a $100 copayment for nuclear stress tests, and a 20% coinsurance for Part B
drugs.
You have been asked to pay a $30 copayment for the cardiology visit, a $100 copayment for the stress test and
a 20% coinsurance for the injection used. 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 stress test,
cardiology visit, and injection (93015, 99214, J2785, 78452) provided from July 8, 2020, to July 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal scaling and root planing- four or more teeth per quadrant (D4341) provided on October 21, 2020.
You asked the Plan to pay for periodontal scaling and root planing. You say that the service should be covered. The Plan denied your request. The Plan says the service is not a covered 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. Only services listed in the Plan's EOC are covered. 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. Specifically, the service you received is not listed in the Plan's EOC, and therefore, not a covered benefit. Therefore, we decided that the Plan does not have to pay for periodontal scaling and root planing- four or more teeth per quadrant (D4341) provided on October 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay additionally for the dental extraction (D7140) provided on
August 31, 2020.
You asked the Plan to pay additionally for the dental extraction (D7140). You say that you would like the Plan
to reconsider your request. The Plan denied your request. The Plan says you are responsible for any amount
over the allowed amount paid 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. Providers are paid based on
the Maximum Allowable Charge (MAC). The contract says you are responsible for any amount greater than the
MAC payment made by the Plan to the provider. In this case, the Plan paid the dental provider the MAC of
$61. Any amount over the $61 you may be billed for by the out-of-network provider. Therefore, we decided
that the Plan does not have to pay additionally for the dental extraction (D7140) provided on August 31, 2020.
Your complaint about the Plan not providing you with the correct information 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient rehabilitation services provided
on September 9, 2020, and September 16, 2020.
You asked the Plan to waive the copayments for outpatient rehabilitation services. You say that you disagree
with the charges. 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 $30
copayment for outpatient rehabilitation services.
You received outpatient rehabilitation services provided on September 9, 2020, and September 16, 2020.
Therefore, you are responsible to pay a $30 copayment per each date of service. The total amount you owe is:
$60.
You have been asked to pay the total copayment amount of $60 for outpatient rehabilitation services.
Outpatient rehabilitation services fall within the outpatient rehabilitation services 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 outpatient rehabilitation services provided on September 9, 2020,
and September 16, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe emergency room services provided on September 21, 2020.You asked the Plan to waive the copayment forthe emergency room services. You say that you feelyou should not be responsible for this cost share amount and you would like the Plan to reconsider your request.The Plan denied your request. The Plan says you received emergency care services on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $120 copayment for each Medicare-covered emergency room visit. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received emergency room services on September 21, 2020. You have been asked to pay a $120 copayment for the emergency room services. The emergency room services fall within the Emergency 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 thePlan.Therefore, we decided that the Plan does not have to waive the copayment forthe emergency room services provided on September 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aid services (V5261) provided on July 7, 2020,
by an out-of-network (OON) provider.
You asked the Plan to pay for the hearing aid services. You say that you were never informed your provider
was OON. The Plan denied your request. The Plan says coverage is denied because you used a provider that
was OON.
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 purchased from the Plan's hearing aid vendor.
We looked at file and the Plan's rules. The file indicates that the services were received from a provider other
than the Plan's hearing aid vendor. Based on this information, we decided that the Plan's rules for coverage of
the hearing aid services have not been met. Therefore, we decided that the Plan does not have to pay for the
hearing aid services (V5261) provided on July 7, 2020, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora power operated vehicle (Pride Elite Traveler) purchased on June 9, 2020.You asked the Plan to pay forpower operated vehicle. You say that you were informed by the provider that this was covered.The Plan denied your request. The Plan says the denial of payment for this item is correct, because this equipment is not covered when indicated only for use outside of the home.The Plan must follow Medicare rules. Therules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home.The record shows that you were issued an advance beneficiary notice of non-coverage from the provider informing you that this may not be covered by Medicare. Therefore, we decided that the Plan does not have to pay fora power operated vehicle (Pride Elite Traveler) purchased on June 9, 2020
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services provided on August 22, 2019.
You asked the Plan to pay for critical care services (99291). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the physician may perform two procedures but a modifier was not billed on the claim.
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service. The claim was submitted originally with a catheterization procedure (36620) for the same physician on the same day. The claim was not submitted with a modifier. Based on this information, we decided that Medicare rules for coverage of services billed with a -59 modifier have not been met. Therefore, we decided that the Plan does not have to pay for critical care services provided on August 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), bitewings (D0274), and prophylaxis (D1110) provided on June 16, 2020.
You asked the Plan to pay for the periodic oral evaluation, bitewings, and prophylaxis. You say that you would like the Plan to pay the balance of $220.00 because they have not been transparent with the coverage. The Plan denied your request. The Plan says the total liability amount applied correctly as enrollee liability. The Plan also says that cost sharing is a contractual obligation that cannot be waived.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for the difference between the billed amount and allowed amount. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120), bitewings (D0274), and prophylaxis (D1110) provided on June 16, 2020.
Your complaint about being misled by the Plan's information 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 forthe periodic oral evaluation, prophylaxis, and bitewings provided onFebruary 18, 2020 by an OON provider.You asked the Plan to pay forthe periodic oral evaluation, prophylaxis, and bitewings. You say that your provider accepts your dental insurance, and you would like these services covered by the Plan.The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that you were advised prior to the services being rendered that this treating provider was not contracted with your 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 itemsor services are not covered when they are received OON.Therefore, we decided that the Plan does not have to pay forthe periodic oral evaluation, prophylaxis, and bitewings provided on February 18, 2020 by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to
the enrollee on November 8, 2019.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says this claim was not submitted with the required codes.
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 claim was submitted without the
codes required for this type of testing. Based on this information, we decided that Medicare rules for coverage
of this service have not been met. Therefore, we decided that the Plan does not have to pay for Comprehensive
Genomic Profile (CGP) testing provided to the enrollee on November 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe specialist visit provided on October 5, 2020.You asked the Plan to waive the copayment forthe specialist visit. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request.The Plan denied your request. The Plan says you received services provided by a specialist on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 copayment for specialist office visits. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received services provided by a specialist on October 5, 2020. You have been asked to pay a $44.86 copayment for the specialist visit, which is less than the contracted $45 copayment amount. The specialist visit falls within the Physician/Practitioner services 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 forthe specialist visit provided on October 5, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray provided on April 28, 2020.
You asked the Plan to pay for the diagnostic service. You say that the enrollee was not enrolled in hospice on
the date of service. The Plan denied your request. The Plan says the enrollee's claim would be covered under
Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the
last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify
the member's coverage before rendering services and to know proper billing procedures for a Medicare
Advantage member on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Original Medicare is responsible for payment for services until the first day of the month after the
hospice election has been revoked or terminated.
The enrollee ended Medicare Hospice benefits on April 23, 2020. The services in question were provided
before the end of that month. Therefore, we decided that the Plan does not have to pay for the chest x-ray
provided on April 28, 2020.