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

We decided that the Plan does not have to pre-approve a travel nebulizer. 
 
You asked the Plan to pre-approve a travel nebulizer. You say that you need a travel nebulizer for when you are away from home errand running and at doctor appointments. The Plan denied your request. The Plan says you have a nebulizer and there is no indication it is not functional. 
 
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 nebulizer. Your nebulizer serves the same purpose as the nebulizer at issue. Medicare covers equipment that is needed inside the home. Therefore, we decided that the Plan does not have to pre-approve a travel nebulizer.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services. 
 
You asked the Plan to pay for the ambulance services. You say that you do not think that you should be responsible for the entire bill. You stated that on the date of service, someone from security called an ambulance for you. You say that when the responders arrived you were assessed, not treated, and you told them you did not want to go to the hospital because you were feeling better. You say that you believe since you did not call for the ambulance and only allowed them to check your blood pressure, you should not be responsible for the entire charge. 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 November 20, 2019. 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.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy services (HCPCS S9328) provided to the enrollee from December 19, 2019 to December 26, 2019. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this code 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. 
 
In this case, the CPT Code Manual definition of code S9328 is "Home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem." 
 
We find that HCPCS code S9328 is not supported in the medical record. Specifically, this code has a status indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for Medicare purposes. 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 infusion therapy services (HCPCS S9328) provided to the enrollee from December 19, 2019 to December 26, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the outpatient hospital services provided from December 20, 2019 to December 23, 2019. 
 
You asked the Plan to waive the coinsurance for the outpatient hospital services. 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 outpatient surgery on the dates of service at issue in this appeal. The Plan states the correct coinsurance 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 20% coinsurance for Outpatient surgery and all other professional services at an outpatient hospital.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows you received outpatient surgery during an outpatient hospital stay from December 20, 2019 to December 23, 2019. You have been asked to pay a 20% coinsurance for the outpatient surgery, totaling $2446.27. The outpatient hospital services fall within the Outpatient surgery benefit category. The file also shows you received outpatient physician services from December 20, 2019 to December 23, 2019, totaling $257.99. The outpatient physician services fall within the Physician/Practitioner services benefit category. This means that you have been asked to pay the correct amounts 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 coinsurance for the outpatient hospital services provided from December 20, 2019 to December 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-ofnetwork provider on September 4, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency for these 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 services 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 medical services provided to the enrollee by an out-of-network provider on September 4, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses and suspension sleeves provided on December 19, 2019. 
 
You asked the Plan to pay for the knee orthoses (L1833) and suspension sleeves (L2397). You say that the orthoses were medically necessary. The Plan denied your request. The Plan says the documentation submitted did not indicate the provider discussed the need for the billed supply codes, therefore the billed supply codes cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.  
 
We looked at the file and Medicare rules. The medical records do not mention or support medical necessity for the orthoses. Based on this information, we decided that Medicare rules for coverage of the knee orthoses (L1833) and suspension sleeves (L2397) have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthoses and suspension sleeves provided on December 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray, palliative (emergency) treatment of dental pain, and problem focused limited oral evaluation provided on October 17, 2019. 
 
You asked the Plan to pay for the first intraoral periapical x-ray, palliative treatment of dental pain, and problem focused limited oral evaluation. You say that the dental card that you received was dated October 6, 2019. You also say that the dental office assistant called to verify coverage while you were at your appointment. The Plan denied your request. The Plan says your enrollment records indicate that you were not on an active dental plan during the time the services were rendered. The Plan also says that neither you nor your provider contacted the Plan prior to the date of service to verify eligibility. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical xray, palliative (emergency) treatment of dental pain, and problem focused limited oral evaluation provided on October 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the oxygen concentrator rental, provided on February 28,
2019.
You asked the Plan to pay for the oxygen concentrator rental. You say that the services were medically
necessary. The Plan denied your request. The Plan says Medicare does not cover items provided/used outside
the United States and its territories.
The Plan must follow Medicare rules. Medicare rules say that items provided outside the United States and its
territories are not covered.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the oxygen concentrator rental have not been met. Therefore, we decided that the Plan does not
have to pay for the oxygen concentrator rental, provided on February 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (HCPCS J7307) provided to the enrollee on September 19, 2019. 
 
You asked the Plan to pay for the services. You say that this should be paid or. The Plan denied your request. The Plan says this is code 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. 
 
In this case, the CPT Code Manual definition of HCPCS code J7307 is "Etonogestrel (contraceptive) implant system, including implant and supplies." 
 
We find that CPT code J7307 is not supported in the medical record. Specifically, this code is not valid for Medicare purposes, as it has a status indicator of "I." 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 physician services (HCPCS J7307) provided to the enrollee on September 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for dermatology services provided on September 19, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for OON dermatology services. You say that this should be paid. The Plan denied your request. The Plan says these services were not authorized. 
 
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 dermatology services provided on September 19, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for excision of benign lesion (D7410) provided November 18, 2019. 
 
You asked the Plan to pay for excision of benign lesion. You say that you had went to your dentist and was told that you needed a biopsy and now you have received a bill for $247. The Plan denied your request. The Plan says this service is not covered under the plan 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 pay for excision of benign lesion (D7410) provided November 18, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that an acute inpatient rehabilitation facility admission is medically necessary. The Plan denied your request. The Plan says that you do not meet criteria for coverage of an IRF admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 
 
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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that you are medically stable with no recent evidence of complex medical issues that require monitoring by an inpatient physical medicine and rehabilitation (PMR) physician three times per week or have a need for acute rehabilitation nursing care. While you may benefit from continuing physical and occupational therapy, there is no evidence of a need for an intensive therapy program. An inpatient rehabilitation facility admission is not medically necessary based on your current functional status and medical stability. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Bone Density Scan (77080) provided December 16, 2019. 
 
You asked the Plan to waive the coinsurance for the bone scan. You say that the coinsurance 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 40% coinsurance for outpatient diagnostic services.  
 
You have been asked to pay a 40% coinsurance for the bone scan. The bone scan falls within the outpatient diagnostic 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 coinsurance for a Bone Density Scan (77080) provided December 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a refraction (92015) provided on September 5, 2019.
You asked the Plan to pay for a refraction. You say that you told your provider not to do a refraction and shouldn't be responsible. The Plan denied your request. The Plan says the frequency limitation for this service was exceeded.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services once every 12 months. We looked at the file and the Plan's rules. The record shows that you previously received a refraction in February of 2019. Based on this information, we decided that the Plan's rules for coverage of a refraction have not been met. Therefore, we decided that the Plan does not have to pay for a refraction (92015) provided on September 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoes and inserts provided on December 13, 2019.
You asked the Plan to pay for the shoes (A5500) and inserts (A5512). You say that the Plan should pay this
claim. The Plan denied your request. The Plan says the documentation submitted does not contain a valid
physician order, Proof of Delivery, or a Delivery Ticket.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.
The record shows that the Plan made several attempts to obtain the physician order and proof of delivery
documentation for the items at issue in this appeal. The record does not contain a valid physician order and
proof of delivery for the supplies provided in this case. There is no itemized delivery ticket, itemized shipping
invoice, or proof of delivery. Therefore, we decided that the Plan does not have to pay for the shoes and inserts
provided on December 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MyoPro 2, Motion G motion orthotic device. 
 
You asked the Plan to pre-approve a powered upper extremity range of motion assist device (L8702). You say that that this device would restore function to the dysfunctional arm and the ability to perform activities of daily living. The Plan denied your request. The Plan says a review of the current medical literature indicates that this device is considered experimental and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary, and are experimental, are not covered.  
 
We looked at the file and Medicare rules. There is insufficient medical record information submitted to show this orthosis would be preferred or more effective than the traditional upper orthosis types that are covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the powered upper extremity range of motion assist device (L8702) have not been met. Therefore, we decided that the Plan does not have to pre-approve the MyoPro 2, Motion G Orthotic device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided an out-ofnetwork provider on December 17, 2019. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you normally have a $40 copayment for these services. 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 $65 copayment for physician/practitioner services/out-of-network/specialist.  
 
You have been asked to pay a $65 copayment for a specialist office visit. A specialist office visit falls within the physician/practitioner services/out-of-network/specialist 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 a specialist office visit provided by an out-of-network provider on December 17, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular diagnostic testing provided on March 29, 2019.
You asked the Plan to pay for the molecular diagnostic testing. The Plan denied your request. The Plan says the
Plan requires utilization of network providers when possible and available, and requires authorization for
certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency
situation, has been documented.
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 did not pre-approve the
services 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 molecular diagnostic testing provided on March 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for moderate sedation services (99152) provided on September 10, 2019. 
 
You asked the Plan to pay for the moderate sedation services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted did not indicate the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status. 
 
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 99152 is moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older. We find that CPT code 99152 is not supported in the record. Specifically, the record does not indicate the presence of an independent trained observer. Based on this information, we decided that Medicare rules for coverage of the moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay for moderate sedation services (99152) provided on September 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visits provided from August 3, 2016 to August 31, 2016. 
 
You asked the Plan to pay for the office visits. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the claims were billed incorrectly. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the office visits was not filed until July 25, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the office visits provided from August 3, 2016 to August 31, 2016.