Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services provided on July 1, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the outpatient mental health services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.

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 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 outpatient mental health services provided on July 1, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection services coded 20553 provided on August 18, 2020.

You asked the Plan to pay for the injection services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not payable.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied.In this case, the MUE for CPT code 20553 is1. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the injection services have not been met.Therefore, we decided that the Plan does not have to pay for the injection services coded 20553 provided on August 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the occlusal orthotic device (D7880), and the oral occlusal appliance (D1399) provided on May 4, 2020.

You asked the Plan to pay for the occlusal orthotic device. You say that services with an out of plan provider were previously approved by the Plan. You say that now the services are being denied as not covered. The Plan denied your request. The Plan says Medicare does not cover routine dental services or oral appliances for TMJ (tempo-mandibular joint). The Plan also says that oral appliances are not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Additionally, the item you are asking the Plan to pay for involves 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 occlusal orthotic device (D7880), and the oral occlusal appliance (D1399) provided on May 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on April 23, 2020 to December 18, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the physician services. You say that you were not aware that the provider was not in network and you do not have any information on how to check for in-network providers. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

The plan must follow Medicare rules. Medicare rules say that this PPO plan will generally cover your medical care as long as the care you receive is considered medically necessary and you receive your care from a provider who is eligible to provide services under Original Medicare. As a member of the PPO plan you can receive your care from either a network provider or an out-of-network provider. Per page 87-88 of the EOC, prior authorization is required for physician visits. 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 physician services provided on April 23, 2020 to December 18, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the specialist office visit provided on July 17, 2020.

You asked the Plan to reduce the copayment for the specialist office visit. You say that the copayment for a physician's assistant is $20. The Plan denied your request. The Plan says you have been asked to pay 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 $30 copayment for each specialist visit for Medicare-covered benefits. 

You have been asked to pay a $30 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows you were seen at a cardiology office which is considered a specialty. 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 reduce the copayment for the specialist office visit provided on July 17, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on November 20, 2020.

You asked the Plan to pay for the ambulance services. 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, 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 on November 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (86077) provided November 6, 2020.

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 units billed exceeds the allowed amount.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. 

In this case, the MUE for CPT code 86077 is 1. You billed 2 units of this code, exceeding the MUE. 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 (86077) provided November 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a neuromuscular stimulator (E0745) and supplies (A4595) provided July 16, 2020.

You asked the Plan to pay for a neuromuscular stimulator and supplies. You say that these items were medically necessary for the enrollee. The Plan denied your request. The Plan says there was no established relationship between the enrollee and the prescribing physician.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

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 a neuromuscular stimulator and supplies. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is a 76-year-old woman with a chief complaint of knee pain, wrist pain, shoulder pain, and ankle pain. There is no documentation of a physical examination of the areas of pain. In this case, the limited documentation in the case file does not support that the neuromuscular stimulator (E0745) and supplies (A4595) are medically reasonable and necessary for the enrollee.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a neuromuscular stimulator and supplies have not been met. Therefore, we decided that the Plan does not have to pay for a neuromuscular stimulator (E0745) and supplies (A4595) provided July 16, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the positron emission tomography (PET) scan provided on September 28, 2020.

You asked the Plan to waive the cost share for the PET scan. You say that the plan approved the test prior to it being performed. The Plan denied your request. The Plan says the claim processed 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 10% of the cost for each complex imaging service. 

You have been asked to pay 10% of the cost for the PET scan. The PET scan falls within the outpatient diagnostic tests 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 cost share for the positron emission tomography (PET) scan provided on September 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the re-treatment of previous root canal therapy - molar (D3348) and post removal (D2955) provided September 29, 2020.

You asked the Plan to pay for the root canal re-treatment and post removal. You say that the services were medically necessary. The Plan denied your request. The Plan says the services are not covered under your dental 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 pay for the re-treatment of previous root canal therapy - molar (D3348) and post removal (D2955) provided September 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99212) provided on January 18, 2021.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service is not covered under your contractual policy or by Medicare.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the office visit (99212) provided on January 18, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the ambulance transportation services (A0427, A0425) provided from November 7, 2020, through November 11, 2020.

You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to the services provided.

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 $275 copayment per Medicare-covered one-way transport provided by an in-network and out-of-network provider.

You have been asked to pay $825 ($275 copayment x 3) for the one-way Medicare-covered ambulance transports provided. 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 the ambulance transportation services (A0427, A0425) provided from November 7, 2020, through November 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for dermatology services provided on February 10, 2021 by an out of network (OON) provider.

You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says the services were not urgent, emergent, or approved in advance.

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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 dermatology services provided on February 10, 2021 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injections (62323) provided October 6, 2020.

You asked the Plan to pay for the injections. 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 code 62323 is not supported in the medical record. Specifically, insufficient medical records were provided to support the billed service. No procedure note was provided. The plan made multiple requests for additional records and none were received. Based on this information, we decided that Medicare rules for coverage of the injections have not been met. Therefore, we decided that the Plan does not have to pay for injections (62323) provided October 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397) provided September 17, 2020.
You asked the Plan to pay for the knee orthosis and suspension sleeve. You say that the items provided were medically reasonable. The Plan denied your request. The Plan says the patient did not receive video or telephonic visit by the ordering physician in order to warrant the codes billed.
The Plan follows Medicare rules. Medicare rules say that the knee orthosis and suspension sleeve are subject to the criteria listed in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the knee orthosis and suspension sleeve. Our reviewer says that the requested items were not medically reasonable and necessary. Our physician reviewer found There is no documentation of recent injury to, or recent surgical procedure on the enrollee's knee, there is insufficient documentation of an appropriate evaluation of the enrollee, and there is insufficient credible objective documentation of joint laxity. Claims for L1833 will be denied as not reasonable and necessary when the beneficiary does not meet the criteria for coverage. For example, they will be denied if only pain or a subjective description of joint instability is documented. In addition, the item coded L2397 (sleeve) is not separately payable when the base item is not covered. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the knee orthosis and suspension sleeve have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397) provided September 17, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychiatric services (HCPCS S9485) provided to the enrollee
on September 14, 2020.
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 code.
We find that HCPCS code S9485 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 psychiatric services (HCPCS
S9485) provided to the enrollee on September 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive cardiac gene panel provided on July 27, 2020.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The testing at issue was requested for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for the comprehensive cardiac gene panel provided on July 27, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the emergency room services provided from October 25, 2020, to October 28, 2020.
You asked the Plan to waive the copay for the services provided. You say that the rejection of services should be reconsidered. The Plan denied your request. The Plan says the claim processed 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 $90 copay for emergency care. You have been asked to pay a $90 copay for the services provided. The 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 the Plan. Therefore, we decided that the Plan does not have to waive the copay for the emergency room services provided from October 25, 2020, to October 28, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the echocardiogram provided on November 5, 2020.
You asked the Plan to reduce the copayment for the echocardiogram. You say that your provider's office told you there would be a $40 copayment for the service. The Plan denied your request. The Plan says you have been asked to pay 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 $150 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in an in-network physician's office or at an in-network freestanding facility (such as a radiology center or medical clinic). You have been asked to pay a $150 copayment for the echocardiogram. The echocardiogram falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" 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 reduce the copayment for the echocardiogram provided on November 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the automatic external defibrillator (K0606) provided October 23, 2019.
You asked the Plan to pay for the automatic external defibrillator. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this claim was submitted untimely.
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 automatic external defibrillator was not filed until December 7, 2020. 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 automatic external defibrillator (K0606) provided October 23, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (84153, 80061, 83036, 36415) provided on November 4, 2020 by an out of network (OON) provider.
You asked the Plan to pay for OON laboratory services. You say that you did not know this provider was out-of-network. The Plan denied your request. The Plan says this was 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 had network providers available who could have provided 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 laboratory services (84153, 80061, 83036, 36415) provided on November 4, 2020 by an out of network (OON) provider.