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

We decided that the Plan does not have to waive the copayment for the laboratory services provided on July 8, 2020.

You asked the Plan to waive the copayment for the laboratory services. You say that you should not be paying for two different laboratory tests. The Plan denied your request. The Plan says the copayment applied correctly in this case.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment for laboratory tests, non-radiological diagnostic tests, flat film X-rays, and ultrasounds. 

You have been asked to pay a $40 copayment for the two laboratory services received on the same date. The services provided fall within the laboratory tests, non-radiological diagnostic tests, flat film X-rays, and ultrasounds 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 laboratory services provided on July 8, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the binaural hearing aids provided on February 27, 2020.

You asked the Plan to pay for the binaural hearing aids. You say that you have a valid physician order. The Plan denied your request. The Plan says that the documentation submitted did not include a valid physician order.

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 up to $1000 allowance for hearing aids every 3 years.

We looked at the file and the Plan's rules. The provider provided a physician order dated February 18, 2020. Based on this information, we decided that the Plan's rules for coverage of the binaural hearing aid have been met. Therefore, we decided that the Plan has to pay for the binaural hearing aids provided on February 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on June 22, 2020 by an out of network provider.

You asked the Plan to pay for the physician services. You say that the facility failed to obtain necessary authorization. The Plan denied your request. The Plan says you did not request prior authorization for the non-emergent services.

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 services 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 these services. Therefore, we decided that the Plan does not have to pay for the physician services provided on June 22, 2020 by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy provided on June 30, 2020 by an out of network (OON) provider. You asked the Plan to pay for psychotherapy. You say that you provided medically necessary services rendered in good faith. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services rendered by an out-of-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 the psychotherapy provided on June 30, 2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services (A0427) provided on May 10, 2020.

You asked the Plan to waive the copayment for the ambulance services. You say that you wanted to drive to the hospital but were informed you needed to take an ambulance. The Plan denied your request. The Plan says the copayment applied correctly in this case.

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 ambulance services. 

You have been asked to pay a $250 copayment for the ambulance services. These services fall within the ambulance 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 the ambulance services (A0427) provided on May 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (36415, 80053, 82306, 82607, 82670, 84153, 84270, 84403, 84436, 84443, 84481, 85027, 86376) provided November 12, 2019.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

We find that CPT codes 36415, 80053, 82306, 82607, 82670, 84153, 84270, 84403, 84436, 84443, 84481, 85027, & 86376 are not supported in the medical record. Specifically, a valid order for these tests was not included in the record. The orders were not signed or dated by the requesting physician. 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 lab services (36415, 80053, 82306, 82607, 82670, 84153, 84270, 84403, 84436, 84443, 84481, 85027, 86376) provided November 12, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9502) provided on December 1, 2019, through December 2, 2019.

You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code S9502 has a status indicator of I and is not valid for Medicare purposes.

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 S9502 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code S9502 has a status indicator of I. This means that CPT code S9502 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9502) provided on December 1, 2019, through December 2, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the portable oxygen concentrator purchased on January 28, 2020.

You asked the Plan to reimburse you for the portable oxygen concentrator. You say that the portable oxygen that you were using could not go as high as the setting you required. The Plan denied your request. The Plan says per Medicare guidelines payment is not made for purchases of oxygen equipment.

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. Portable oxygen is not covered for patients who qualify for oxygen solely based on blood gas studies obtained during sleep.  

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 portable oxygen concentrator purchased on January 28, 2020.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for ambulance services (A0428 and A0425) provided.

You asked the Plan to pay for the ambulance services. You say that you would like reconsideration because the services rendered were medically necessary. The Plan denied your request. The Plan says that this claim was filed beyond the timely filing limit of 180 days.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after, must be filed no later than one calendar year after the date of service.

The record shows that a claim for the ambulance services. This means that less than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan has to pay for ambulance services (A0428 and A0425) provided.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency physician services provided on June 19, 2020.

You asked the Plan to pay for the emergency physician services. You say that the Plan should pay this claim. The Plan denied your request. The Plan says it is not appropriate to report unspecified, or left and right diagnosis codes when a more specific code is available.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate ICD-10 code.

In this case, the ICD-10-CM Official Guidelines for Coding and Reporting says each unique ICD-10-CM diagnosis code may be reported only once for an encounter.

We find that the diagnosis code M17 was reported unilaterally but has a bilateral code. Based on this information, we decided that Medicare rules for coverage of the emergency physician services have not been met. Therefore, we decided that the Plan does not have to pay for the emergency physician services provided on June 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient skilled nursing facility (SNF) services provided March 1, 2020 to March 4, 2020.

You asked the Plan to waive the copayment for the inpatient SNF services. You say that you were not aware of the copayment for skilled nursing facility care. The Plan denied your request. The Plan says the copayment applied correctly in this case.

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 $0 copayment for days 1 to 20 and a $160 copayment for days 21 to 51 for skilled nursing facility (SNF) care. 

You have been asked to pay a $0 copayment for days 1 to 20 and a $160 copayment for days 21 to 51 for the inpatient SNF services. Since you spent a total of 22 days in SNF care, you have been asked to pay a total copayment of $320. The services provided falls within the skilled nursing facility (SNF) care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient skilled nursing facility (SNF) services provided March 1, 2020 to March 4, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the cleaning (D1110) provided on August 3, 2020.

You asked the Plan to pay for the dental service. You say that you were advised that this provider was in network with the Plan. You say the service should be covered.  The Plan denied your request. The Plan says that 2 cleanings per year are covered. The Plan also says that the frequency limit has been exceeded.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the dental service when the services are medically necessary and reasonable.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental service have been met. The record shows that the plan did not pay for the previous cleanings that you received in 2020. The Plan has to pay for the service in order for it to count towards the benefit. Additionally, the record shows that the provider in this case is in network with the Plan. Therefore, we decided that the Plan has to pay for the cleaning (D1110) provided on August 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis provided on July 6, 2020.

You asked the Plan to pay for the prophylaxis. You say that this was your first and only cleaning in 2020. You say that you want to know why payment was denied. The Plan denied your request. The Plan says you have already been reimbursed the maximum dental allowance.

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 also have a maximum yearly dental allowance of $525. The Plan paid $525 toward dental services received on January 6, 2020 and July 6, 2020, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the prophylaxis provided on July 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility services (99318) provided on June 1, 2020 by an out of network (OON) provider.

You asked the Plan to pay for nursing facility services. You say that you provided medically necessary services in good faith. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services rendered by an out-of-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 the nursing facility services (99318) provided on June 1, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the lab services provided on June 15, 2020.

You asked the Plan to pay for the lab services. You say that you have no control over the coding. The Plan denied your request. The Plan says that the services are not covered.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules.

The file shows that the services at issue were provided by a contract provider. The file does not show that the Plan provided notice that the lab services would not be covered. Under Medicare rules, this means the lab services is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the lab services provided on June 15, 2020. 

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 pre-approve the therapeutic parenteral drug injection (D9612), initial 15 minutes of deep sedation (D9222), and an additional 15 minutes of deep sedation (D9223).

You asked the Plan to pre-approve the dental services. You say that the requested services are necessary. The Plan denied your request. The Plan says therapeutic parenteral drug injection is not listed as a covered service. The Plan says deep sedation is not listed as a covered service. The Plan also says if a service is not listed on the above benefit chart or listed with NC then it 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.

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 the therapeutic parenteral drug injection (D9612), initial 15 minutes of deep sedation (D9222), and an additional 15 minutes of deep sedation (D9223).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy (90832) provided on March 2, 2020, by an out of network (OON) provider.

You asked the Plan to pay for the psychotherapy. You say that the services provided were medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained by the facility or the provider; therefore, payment has been correctly denied.

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 the psychotherapy (90832) provided on March 2, 2020, by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve insertion of a LINX reflux management system. 
 
You asked the Plan to pre-approve LINX reflux management system. You say that there is no basis upon which 
the Plan can support its claim that LINX is not covered, not medically necessary, or 
experimental/investigational. The Plan denied your request. The Plan says that the denial of authorization for 
this service is correct, because LINX is experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 LINX reflux management system. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found the LINX reflux management system is Food & Drug Administration (FDA) 
approved for treatment of gastroesophageal reflux disease (GERD) and has been shown to be a safe, effective, 
and durable treatment modality. Exclusions include prior gastric surgery, body-mass index (BMI) above 35, 
and age under 18 years, as well as caution with Barrett's esophagus. The enrollee has longstanding GERD not 
completely treated by medication and has no exclusions to the treatment which have been shown in published 
studies and guidelines. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of LINX reflux management system have been met. Therefore, we decided that the 
Plan has to pre-approve insertion of a LINX reflux management system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a new Continuous Positive Air Pressure (CPAP) 
machine (E0601). 
 
You asked the Plan to pre-approve the new CPAP. You say that the new machine is medically necessary. The 
Plan denied your request. The Plan says there is no documentation to support the need for the new CPAP 
machine. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a CPAP machine currently. This CPAP serves the same purpose as the requested 
equipment. No documentation has been provided showing that the current CPAP machine is damaged beyond 
repair or is otherwise in need of replacement. Therefore, we decided that the Plan does not have to pre-approve 
a new Continuous Positive Air Pressure (CPAP) machine (E0601).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the complete upper denture and lower partial denture. 
 
You asked the Plan to pre-approve the complete upper denture and lower partial denture. You say that you 
don't have any teeth on bottom, and you need a new plate. The Plan denied your request. The Plan says the 
services are not covered benefits. 
 
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 the 
complete upper denture and lower partial denture.