Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies rendered on February 27, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid proof of delivery.
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS suppliers are required to maintain proof of delivery. We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies rendered on February 27, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 87798, 87486, 87541, 87581, 87640, 87633, and 87635 provided on May 18, 2020.
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 CPT code 87798, 87486, 87541, 87581, 87640, 87633, and 87635 is not supported in the medical record. Specifically, these codes have a status code of "X". A status code of X means that these does are a statutory exclusion and are not considered "physician services" for fee schedule payment purposes. No payment amounts are shown for these codes, and no payment may be made under the physician fee schedule.
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 coded 87798, 87486, 87541, 87581, 87640, 87633, and 87635 provided on May 18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 22, 2020, billed with two units of code 95999.

You asked the Plan to pay for the medical services as billed. You say that this is billed correctly. The Plan denied your request. The Plan says it is not appropriate to report more than one unit of code 95999.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 95999 is unlisted neurological or neuromuscular diagnostic procedure.

We find that CPT code 95999 is not supported in the medical record. Specifically, the submitted documentation is not legible so it cannot be determined whether the criteria for this code are met. Based on this information, we decided that Medicare rules for coverage of the medical services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the medical services provided on December 22, 2020, billed with two units of code 95999.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 60 additional routine transportation trips.

You asked the Plan to pre-approve the 60 additional routine transportation trips. You say that you are on
dialysis and require more routine trips to your medical appointments. The Plan denied your request. The Plan
says the requested amount of routine transportation trips exceeds the benefit limit.

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 52 one-way routine transportation trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that your request for an additional 60 one-way routine transportation trips would exhaust the Plan maximum
benefit for coverage of routine transportation. The Plan is only required to approve 52 one-way routine
transportation trips per calendar year. Therefore, we decided that the Plan does not have to pre-approve 60
additional routine transportation trips.

You may contact the Plan directly for clarification regarding how many routine transportation trips you have
already used for the 2021 calendar year.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the retroperitoneal ultrasound provided on
January 26, 2021.
You asked the Plan to waive the copayment for the retroperitoneal ultrasound. You say that your specialist
wanted to check how your kidneys were from the antibiotics and pain you were experiencing so you should not
be liable. 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 $100
copayment for Outpatient Diagnostic Procedures, Outpatient Hospital.
You have been asked to pay a $97.08 copayment for the retroperitoneal ultrasound. The retroperitoneal
ultrasound falls within the Outpatient Diagnostic Procedures, Outpatient Hospital benefit category. Your
copayment is less because the Medicare allowable amount for this procedure was less than your required
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 retroperitoneal ultrasound provided on January 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, prophylaxis, and three resinbased
composites provided on March 2, 2021, and April 6, 2021 by an OON provider.
You asked the Plan to pay for the periodic oral evaluation, prophylaxis, and resin-based composites. You say
that if a person does not take care of their teeth it can cause a stroke or heart attack, and you believe you should
be reimbursed for these services. The Plan denied your request. The Plan says services performed by an OON
provider are not covered because your healthcare plan does not have OON benefits. The Plan also says that you
did not contact the Plan prior to these dates of service to verify benefits or provider eligibility.
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 100% of the
cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay
for the periodic oral evaluation, prophylaxis, and three resin-based composites provided on March 2, 2021, and
April 6, 2021 by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the arthrocentesis provided on January 21, 2021.
You asked the Plan to waive the copayment for the arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance (20610). You say that this was not a surgery. The Plan denied your request. The Plan says you were charged the 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 $250 copayment for Outpatient Surgery.
You have been asked to pay a $250 copayment for the arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance (20610). The arthrocentesis falls within the Outpatient Surgery benefit category. The place of service from the claim form is 22- On Campus-Outpatient Hospital. Medicare considers this procedure as a surgical procedure. 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 arthrocentesis provided on January 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system (E2300).
You asked the Plan to pre-approve a power seat elevation system. You say that the item is necessary. The Plan
denied your request. The Plan says the item is not primarily medical in nature. Therefore, coverage criteria
have not been met.
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) and
power standing feature (E2301) are non-covered because they are not primarily medical in nature.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of a power seat elevation system have not been met. Therefore, we decided that the Plan does not
have to pre-approve a power seat elevation system (E2300).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pay for the outpatient facility services provided on June 27, 2019.

You asked the Plan to pay for the chemotherapy. You say that you met your out of pocket limit in 2019. The Plan denied your request. The Plan says that you met your out of pocket limit for 2019 but the claim was submitted in 2021 when the out of pocket has not been met.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that you have a out of pocket maximum for in network services. 

The Plan says you must pay 20% coinsurance for chemotherapy. Based on the Plan contract, however, you cannot be asked to pay more for 2019 services than the maximum out of pocket for 2019. The 2019 services must be designated to the 2019 maximum out of pocket. The Plan has stated you met your 2019 out of pocket maximum in 2019. Therefore, we decided that the Plan has to pay for the outpatient facility services provided on June 27, 2019.

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 waive the copayment for lab work provided by a participating provider on October 5, 2020.
You asked the Plan to waive the copayment for lab work. You say that you already met your out-of-pocket maximum. 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 $10 copayment for outpatient diagnostic tests/lab services. You have been asked to pay a $10 copayment for lab work. At the time of these services, only $4,225 of the max out-of-pocket amount of $4,250 had been met; therefore, the correct copayment has been applied. Lab work falls within the outpatient diagnostic tests/lab 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 for lab work provided by a participating provider on October 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

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

We decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on February 18, 2021.

You asked the Plan to pay for the ambulance response and treatment with no transport. The Plan denied your request. The Plan says the bill that you received in the amount of $250.00 is your financial responsibility.

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 February 18, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. The record shows that you signed a refusal form acknowledging that you said you did not want to be transported to the hospital, and were advised of the consequences if you were not transported. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on February 18, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on August 5, 2020.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.

The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.

We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on August 5, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on June 3, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not
separately payable.
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other
than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all
necessary covered services to the beneficiary either directly or under arrangements made with outside
providers. Payment for all fees related to this service would have been included under the facility claim.
Therefore, we decided that the Plan does not have to pay for the services provided on June 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care provided after 1:00 am February 17, 2019 through February 20, 2019.

You asked the Plan to pay for post-stabilization care. You say that the post-stabilization care was medically necessary. The Plan denied your request. The Plan says the enrollee's emergency medical condition was stabilized by 1:00 am on February 17, 2019 and the enrollee could have been transferred to a network facility.

The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required.

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 post-stabilization care. Our reviewer says that post-stabilization care was not medically necessary. Our physician reviewer found the medical records demonstrate the enrollee's emergency medical condition was stabilized by 1:00 am on February 17, 2019. No material deterioration of his condition was likely to result from, or occur during, transfer, had the enrollee had been transferred to a network facility on February 17, 2019. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of post-stabilization care have not been met. Therefore, we decided that the Plan does not have to pay for inpatient care provided after 1:00 am February 17, 2019 through February 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an evaluation and dental extraction to be performed by an oral surgeon.
You asked the Plan to pre-approve an evaluation and dental extraction to be performed by an oral surgeon. 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.
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 an evaluation and dental extraction to be performed by an oral surgeon.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services of an RN (G0162) provided on February 10, 2021.
You asked the Plan to pay for the services of an RN. You say that you would like reconsideration because the services rendered were medically necessary and payable. The Plan denied your request. The Plan says these services were not provided by an RN.
The Plan must follow Medicare rules. Medicare rules say that coverage of services incident to the professional services of a physician or non-physician practitioner (NPP) is limited to situations in which there is direct supervision of auxiliary personnel. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services of an RN have not been met. Specifically, the record does not show that the billing provider was present in the home or directly supervising the RN who rendered the billed service. Therefore, we decided that the Plan does not have to pay for the services of an RN (G0162) provided on February 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the periodontal maintenance provided on February 8,
2021.
You asked the Plan to pay more for the periodontal maintenance. You say that you only wanted a routine
cleaning and were not advised you would receive a periodontal maintenance. The Plan denied your request.
The Plan says the periodontal maintenance was covered but your responsibility applied in the amount of
$112.00.
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 a $100
deductible total per Benefit Year, plus a 50% coinsurance for periodontic services. The record shows that you
had not paid any of your deductible prior to this date of service, leaving you responsible for the full $100
deductible, plus a 50% coinsurance of the remaining amount ($12). Therefore, we decided that the Plan does
not have to pay more for the periodontal maintenance provided on February 8, 2021.
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 the additional transportation is needed. The Plan denied your request. The Plan says the benefit has been exhausted.
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 30 one-way transportation trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. 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 office visit provided on September 28, 2020 by an out-of-network provider.

You asked the Plan to pay for the office visit. You say that the Plan should pay this claim. The Plan denied your request. The Plan says prior authorization was not obtained as required under the plan benefits.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for the service. Therefore, we decided that the Plan does not have to pay for the office visit provided on September 28, 2020 by an out-of-network provider.