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

We decided that the Plan does not have to pay forthe ambulance services provided on August 13, 2019.You asked the Plan to pay forthe ambulance services. You say that the services were medically necessary.The Plan denied your request. The Plan says you did not request prior authorization.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 forthe ambulance services provided on August 13, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray (D0330), and the analgesia (D9230) provided on August 21, 2019.You asked the Plan to pay for the panoramic x-ray, and analgesia. You say that you were not informed of these claims ahead of time before going through these procedures. You say that you would not have gone through with them if you had been informed. The Plan denied your request. The Plan says the annual maximum benefit has been exceeded.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceedsMedicare 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 and the services are listed as covered, the annual maximum benefit of $2,500 has been reached. The record shows that the Plan paid $175 for date of service August 19, 2019, $638 for date of service August 21, 2019, and $1,687 for date of service September 16, 2019 for a total of $2500.Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330), and the analgesia (D9230) provided on August 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora domiciliary or rest home visit (99337) provided on September 11, 2019.You asked the Plan to pay fora domiciliary or rest home visit. You say that this was medically necessary.The Plan denied your request. The Plan says this service 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 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 fora domiciliary or rest home visit (99337) provided on September 11, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for microsurgical techniques, requiring use of operating microscope (69990) provided on August 7, 2019.You asked the Plan to pay for the microsurgical technique. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says Medicare says that this is a packaged service/item and no separate payment will be made. The cost is included in the surgery.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 69990 is not supported in the medical record. Specifically, this service was billed with surgery codes 63045 and 63048. Per Medicare, 69990 should not be reported with these codes even if an operating microscope is used. Based on this information, we decided that Medicare rules for coverage of the microsurgical technique have not been met. Therefore, we decided that the Plan does not have to pay for microsurgical techniques,requiring use of operating microscope (69990) provided on August 7, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forarthrocentesis (D7870) provided on March 25, 2019.You asked the Plan to pay for the arthrocentesis. You say that you would like reconsideration as you believe this service should be covered under your medical benefit. The Plan denied your request. The Plan says this service is non-covered under your medical and dental 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 arthrocentesis (D7870) providedon March 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse $150 towards the 2019 Dental Allowance benefit forthe periodontal maintenance (D4910) provided on April 3, 2019.You asked the Plan to reimburse $150 towards the 2019Dental Allowance benefit forthe dental service. You say that you get your teeth cleaned 4 times per year. You also say that you need to get a deep cleaning because you had pockets before.The Plan denied your request. The Plan says that periodontalmaintenance is not listed as a covered preventive dental service.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, periodontal maintenance is not among those covered under this benefit.Therefore, we decided that the Plan does not have to reimburse $150 towards the 2019 Dental Allowance benefit forthe periodontal maintenance (D4910) provided on April 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay formoderate sedation services (99152) provided on July 11, 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 include documentation of 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 July 11, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy (HIT) services provided from December 19, 2018 to March 26, 2019.You asked the Plan to pay for the HIT services. You say that these claims should be paid due to medical necessity.The Plandenied your request. The Plansaysthis is not a valid code for Medicare billing.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.CPT code S9328 has a status indicator of "I" meaning that it is invalid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the HIT services have not been met.Therefore, we decided that the Plandoes not haveto pay forthe home infusion therapy (HIT) services provided from December 19, 2018 to March 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the opthalmology visit on May 1, 2019.You asked the Plan to waive the copayment for the visit. You say that you should not pay anything because it was not your fault your doctor scratched your retina.The Plan denied your request. The Plan says that this was not a routine eye exam but a medical office visit.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 $50 copayment for a specialist visit. You have been asked to pay $50 copayment for the visit. The visit falls within the specialist visit 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 opthalmology visit on May 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancet device provided from June 21, 2019 to September 9, 2019.You asked the Plan to pay forthe glucose monitor (E0607), test strips (A4253), lancets (A4259), control solution (A4256), and lancet device (A4258). You say that the Plan should pay this claim.The Plandenied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the 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 proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered.Therefore, we decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancet device provided from June 21, 2019 to September 9, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient specialist visits provided by your doctors on July 4, 2019 to July 5, 2019. 

You asked the Plan to waive the copayment for the specialists visits. You say that you were admitted to the hospital on the dates of service and do not recall seeing these doctors. The Plan denied your request. The Plan says the cost share was applied correctly as outlined by the plan benefits.

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 $20 copayment for Physician/Practitioner Services, Including Doctor's Office Visits. 

You have been asked to pay $40. The plan says you have a $20 copayment for specialist services. ($20x2=$40) for the specialists visits. The specialist visits fall within the Physician/Practitioner Services, Including Doctor's Office Visits 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 outpatient specialist visits provided by your doctors on July 4, 2019 to July 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99203) provided on August 24, 2019 by out of network provider.You asked the Plan to pay for an office visit. You say that you are appealing claim payment denial for services rendered to the Plan's member on date of service August 24, 2019.The Plan denied your request. The Plan says non-emergent services rendered by non-participating providers in non-participating facilities require prior authorization as outlined in the enrollee's EOC.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 foran office visit (99203) provided on August 24, 2019 by out of network provider,.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 28, 2019 by out of network provider.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 the services were rendered by a non-contracted provider without prior authorization.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 medical services provided on January 28, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit, therapy services, and manual manipulation provided on September 5, 2019.You asked the Plan to pay for chiropractic services. You say that you were only told that these services would be covered and were not told of any limitations.The Plan denied your request. The Plan says the denial of payment for these services is correct, because these services are not covered by Medicare or the Plan when performed by a chiropractor.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.Furthermore, the manual manipulation service was performed as maintenance therapy which is not covered by Medicare. Therefore, we decided that the Plan does not have to pay foran office visit, therapy services, and manual manipulation provided on September 5, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ED visit, wound repair, CT scans, x-ray, and laboratory services provided on July 18, 2019.
You asked the Plan to pay for the ED visit and services. You say that this claim has not been paid in full or under the terms of the contract for services provided to the enrollee. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the ED visit, wound repair, CT scans, x-ray, and laboratory services provided on July 18, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray (72170) provided on September 5, 2019 by out of network provider.You asked the Plan to pay for an x-ray. You say that this service was medically necessary.The Plan denied your request. The Plan says this service 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 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 foran x-ray (72170) provided on September 5, 2019 by out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that the shower chair is needed for your safety and
as a preventative measure to avoid a fall. You say that it is difficult for you to shower because of your knee
pain. You stated that you cannot stand for more than a few minutes and your shower is slippery. You believe
the shower chair would remedy the situation. The Plan denied your request. The Plan says this item is not a
covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are
not primarily medical in nature.
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Bisacodyl EC and Levofloxacin provided on July 31, 2019.
You asked the Plan to pay for these drugs. You say that you were not told these medications were not covered. The Plan denied your request. The Plan says that these drugs are not covered by Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the Bisacodyl EC and Levofloxacin provided on July 31, 2019.
Benefits for these drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe immediate maxillary denture (D5130), and the immediate mandibular denture (D5140) provided from April 26, 2018 to August 29, 2018.You asked the Plan to reimburse you forthe dental items. You say that you should not be held liable for the cost share as you did not receive the dentures until 2019.The Plan denied your request. The Plan says immediate dentures are not a covered service.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 dentures youreceived are not among those covered under this benefit.Therefore, we decided that the Plan does not have to reimburse you forthe immediate maxillary denture (D5130), and the immediate mandibular denture (D5140) provided from April 26, 2018 to August 29, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe panoramic x-rays (D0330), and a full mouth debridement to enable a comprehensive evaluation and diagnosis (D4355) provided on July 30, 2019.You asked the Plan to pay forthe dental services. You say that you went for a simple cleaning. You say that you explained to the provider that your insurance does not cover full mouth x-rays. You say that the dentist advised you needed a deep cleaning.The Plan denied your request. The Plan says the dental services are not listed as covered services.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 dental services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe panoramic x-rays (D0330), and a full mouth debridement to enable a comprehensive evaluation and diagnosis (D4355) provided on July 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forprolotherapy injections provided from December 3, 2018 to July 22, 2019.You asked the Plan topay forthe prolotherapy injections. You say that you feel that these should be covered because they are helpful. Your doctor has provided additional information regarding the efficacy and need for these treatments.The Plan denied your request. ThePlan says Medicare does not cover this type of treatment.The Plan must follow Medicare rules. Medicare rules say that prolotherapy is nationally noncovered as it has not been found to be considered medically necessary due to a lack of scientifically controlled studies showing effectiveness.Although these treatments may have been helpful for you, Medicare does not allow payment for these services.Therefore, we decided that the Plan does not have to pay forprolotherapy injections provided from December 3, 2018 to July 22, 2019.