Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services provided by an out-of-network provider on November 3, 2020.
You asked the Plan to waive the copayment for specialist services. You say that you do not agree with this copayment. 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 specialist services. Specialist services fall 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 specialist services provided by an out-of-network provider on November 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gingival irrigation (D4921), and the unspecified preventive service (D1999) provided on October 22, 2020.
You asked the Plan to pay for the gingival irrigation and unspecified preventive service. You say that extractions are covered at 100%. You say that if you knew that the extraction was not covered, you would not have had it done. The Plan denied your request. The Plan says gingival irrigation is not listed as a covered service. The Plan says unspecified preventive service is not listed as a covered service either. The Plan also says that you did not call the Plan to verify benefits or provider eligibility.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the dental services you received are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the gingival irrigation (D4921), and the unspecified preventive service (D1999) provided on October 22, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the excision services rendered on July 30, 2020.
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 procedure codes 11404 and 11403 are not supported.
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 11404 is excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 3.1 to 4.0 cm. The definition of code 11403 is excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 2.1 to 3.0 cm. We find that CPT codes 11403 and 11404 are not supported in the medical record. Specifically, there is no documentation of excision of a benign lesion from 2.1 to 3.0 cm to support code 11403. There is no documentation of excision of a benign lesion from 3.1 to 4.0 cm to support code 11404. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the excision services rendered on July 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the unspecified preventive service (D1999) provided on November 4, 2020.
You asked the Plan to pay for the unspecified preventive service. You say that when you changed your plan to a PPO, you were advised that this provider was in network. You say that if you go out of network, the plan still should pay 45%. You also say that you know the x-rays were sent twice. The Plan denied your request. The Plan says unspecified preventive service is not listed as 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 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 unspecified preventive service (D1999) provided on November 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on February 4, 2020.
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 are not covered.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on February 4, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve an oxygen concentrator.
You asked the Plan to pre-approve an oxygen concentrator. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested item is not medically necessary.
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. To qualify for home oxygen, the patient must meet one of the following blood gas levels: 1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during sleep for a patient who have hypoxia symptoms during sleep; 3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for patients who have hypoxia symptoms during exercise; 4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of dependent edema, pulmonary hypertension, or erythrocythemia.
For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, there is a rebuttable presumption of non-coverage. 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 an oxygen concentrator. Our reviewer says that the documentation supports that the requested oxygen concentrator is medically reasonable and necessary. Our physician reviewer found you chronic obstructive pulmonary disease and panlobular emphysema and are on supplemental oxygen at home. Portable oxygen is covered if the enrollee qualifies for home oxygen. The elements of the national coverage determination are satisfied. Therefore, you meet criteria for the requested oxygen concentrator. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an oxygen concentrator have not been met. Therefore, we decided that the Plan has to pre-approve an oxygen concentrator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthotics (L1833, L2397) provided on September 10, 2020.
You asked the Plan to pay for knee orthotics. You say that these items should be covered. The Plan denied your request. The Plan says these items were provided following an unsolicited phone call.
The Plan must follow Medicare rules. Medicare rules say that a supplier of a covered item of durable medical equipment (DME) may not contact an individual by telephone regarding the furnishing of a covered item to the individual. If a supplier knowingly contacts an individual in violation of this prohibition, no payment may be made for any item subsequently furnished to the individual by the supplier. We looked at the file and Medicare rules. The Plan has confirmed that the enrollee received an unsolicited phone call from the supplier of the items at issue. Based on this information, we decided that Medicare rules for coverage of knee orthotics have not been met. Therefore, we decided that the Plan does not have to pay for knee orthotics (L1833, L2397) provided on September 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Zoster shingles vaccine rendered on August 14, 2020.
You asked the Plan to pay for these services. You say that you were not told that the vaccine wasn't covered. The Plan denied your request. The Plan says the services are not covered.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide these services. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the Zoster vaccine. Therefore, we decided that the Plan does not have to pay for the Zoster shingles vaccine rendered on August 14, 2020.
Benefits for these services 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the initial hospital care provided on November 8, 2020.
You asked the Plan to waive the deductible for the initial hospital care. You say that you should not be responsible for this bill. 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. Your contract with the Plan says that there is $1,500 deductible that applies towards out-of-network provider and professional services at an inpatient hospital. The initial hospital care you asked the Plan to waive the deductible for falls within the "Inpatient hospital care" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $1,500 deductible that applies towards out-of-network provider and professional services at an inpatient hospital. This cost sharing is a contractual obligation that had not been met at the time the initial hospital care was received on November 8, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the initial hospital care provided on November 8, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for nerve conduction studies (95885, 95910, 95937) provided May 29, 2020.
You asked the Plan to pay for the nerve conduction studies. 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. In this case, the CPT Code Manual definition of codes 95885, 95910 and 95937 are Nerve conduction studies, 7-8 studies, Limited needle electromyography per each extremity with related paraspinal areas when performed, and Neuromuscular junction testing. We find that CPT codes 95885, 95910 and 95937 are not supported in the medical record. Specifically, the technical report provided did not provide sufficient information to verify the billed services were performed. Based on this information, we decided that Medicare rules for coverage of the nerve conduction studies have not been met. Therefore, we decided that the Plan does not have to pay for nerve conduction studies (95885, 95910, 95937) provided May 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on
August 23, 2020.
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 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 subsequent nursing facility care provided on August 23, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance trip provided by a participating provider on November 7, 2020.
You asked the Plan to waive the copayment for an ambulance trip. You say that transportation was organized and was provided to take you back home. You say that you think this copayment should be waived. 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 $220 copayment for ambulance services. You have been asked to pay a $220 copayment for an ambulance trip. The correct copayment has been applied to the services that were provided. An ambulance trip falls 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 an ambulance trip provided by a participating provider on November 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lumbar-sacral orthosis (CPT code L0651) provided to the enrollee on November 19, 2020, by a non-participating provider.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not covered by Medicare.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met. Documentation submitted does not meet the code criteria per review. No delivery confirmation document or documentation in the exam notes validating the enrollee received the device or supplies. Therefore, we decided that the Plan does not have to pay for lumbar-sacral orthosis (CPT code L0651) provided to the enrollee on November 19, 2020, by a non-participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis (L1833) and suspension sleeve (L2397) provided September 4, 2020.
You asked the Plan to pay for a knee orthosis and suspension sleeve. You say that these items were medically necessary. The Plan denied your request. The Plan says the patient did not receive a 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 a knee orthosis and suspension sleeve. Our reviewer says that the items provided were not medically reasonable and necessary. Our physician reviewer found there is insufficient documentation of an appropriate evaluation of the enrollee, and there is insufficient credible objective documentation of joint laxity. 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 a knee orthosis and suspension sleeve have not been met. Therefore, we decided that the Plan does not have to pay for a knee orthosis (L1833) and suspension sleeve (L2397) provided September 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 2, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the physician's services. 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 physician's services provided on October 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the breast protheses provided on October 26, 2020.
You asked the Plan to waive the coinsurance for the breast prostheses. You say that there was no mention of any out-of-pocket costs and you should not have to pay $99.84 for the prosthetics. 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 20% coinsurance for an in-network prosthetics provider. You have been asked to pay $99.84 which is 20% of the allowed amount for the breast prostheses. The allowed amount is $498.71. ($498.71 x 20% = $99.84). The breast prostheses fall within the "Prosthetic devices and related 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 waive the coinsurance for the breast protheses provided on October 26, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for Percepta bronchial genomic classifier testing provided on October 20, 2020.
You asked the Plan to pay for genetic testing. You say that this testing is covered by Medicare. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because the enrollee did not meet the coverage criteria for Percepta testing.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 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 has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not specify whether the ordering physician was in-network or out-of-network with the Plan. The documentation submitted does not include prior notice from the Plan that this testing would not be covered. Without this information, we cannot determine whether the lab order made constituted plan-directed care. Therefore, the Plan has not shown that its decision to deny payment for this testing is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for Percepta bronchial genomic classifier testing provided on October 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve allogeneic stem cell therapy with an out of network provider.
You asked the Plan to pre-approve allogeneic stem cell therapy. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that stem cell therapy is only covered for certain indications. 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 allogeneic stem cell therapy. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found you have stage 4 panlobular emphysema and are on home oxygen. This diagnosis does not satisfy the elements of the national coverage determination. There is insufficient evidence to support the use of stem cell therapy in emphysema. This means the requested therapy remains experimental and investigational. Therefore, you do not meet criteria for the requested services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of allogeneic stem cell therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve allogeneic stem cell therapy with an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (back brace) provided on November 16, 2020.

You asked the Plan to pay for back brace. You say that this claim falls under Medicare guidelines for medical necessity. The Plan denied your request. The Plan says the denial of payment for this item is correct, because proof of delivery for the billed item was not provided at the enrollee indicated that this item was never received.

The Plan must follow Medicare rules. Medicare rules say that the supplier must furnish sufficient information to the Plan to determine whether payment is due. This information may include proof of delivery for a billed DMEPOS item. 

We looked at the file and Medicare rules. Proof of delivery was not submitted for the back brace billed on this claim. Based on this information, we decided that Medicare rules for coverage of back brace have not been met. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (back brace) provided on November 16, 2020.