Persius/hicric huggingface dataset:
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 October 1, 2020.
You asked the Plan to pay for the knee orthosis and suspension sleeve. You say that these items were medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the enrollee 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 a 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 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 above 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 October 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for orthoses (L2397, L1833) provided October 8, 2020.
You asked the Plan to pay for the orthoses. You say that the items were medically necessary. The Plan denied your request. The Plan says the documentation does not support the items 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 L2397, & L1833 is not supported in the medical record. Specifically, there is no record of an in-person or telephonic visit with the ordering physician in the enrollee's claim history. Based on this information, we decided that Medicare rules for coverage of the orthoses have not been met. Therefore, we decided that the Plan does not have to pay for orthoses (L2397, L1833) provided October 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided November 11,
2020.
You asked the Plan to pay for the lumbar-sacral orthosis. You say that the item provided was medically
necessary for the enrollee's condition. The Plan denied your request. The Plan says coverage cannot be made
when the claim is initiated with an unsolicited phone call.
The Plan must follow Medicare rules. Medicare rules say that coverage is not available when an unsolicited
phone call is made by the durable medical equipment supplier.
We looked at the file and Medicare rules. In this case, the Plan has attested that the enrollee was contacted via
an unsolicited phone call regarding the provision of the item at issue. Based on this information, we decided
that Medicare rules for coverage of the lumbar-sacral orthosis have not been met. Therefore, we decided that
the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided November 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services (D5212, D0330, D0150).
You asked the Plan to pay for the dental services (D5212, D0330, D0150). You say that the plan should reimburse you more money. The Plan denied your request. The Plan says the correct cost share applied to the claim
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 payment is in excess of that covered under this benefit. The provider charged $750 for the dental services. The Plan provided you with $500 in reimbursement, the maximum dental allowance for 2020, therefore you are responsible for the remaining $250. Therefore, we decided that the Plan does not have to pay for the dental services (D5212, D0330, D0150).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for podiatry services (11721) provided December 8, 2020.
You asked the Plan to waive the copayment for the podiatry services. You say that the services were routine foot care and the copayment 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 $375 copayment for outpatient surgical services. You have been asked to pay the allowable amount of $192.75 for the podiatry services. The podiatry services fall within the outpatient surgical services benefit category. The allowable amount is less than the $375 copayment listed in the Evidence of Coverage. 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 podiatry services (11721) provided December 8, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation provided on August 9,
2019.
You asked the Plan to pay for the psychiatric diagnostic evaluation. You say that you did not receive proper
notice of the benefit determination which resulted in the untimely appeal. You also say that medically
necessary services were provided. The Plan denied your request. The Plan says this claim was submitted to the
Plan later than 365 days from when the enrollee received the service.
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 psychiatric diagnostic evaluation was not filed until October 12, 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 psychiatric diagnostic evaluation provided on
August 9, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion services (S9503) provided August 27, 2020 to September 2, 2020.
You asked the Plan to pay for the home infusion services. You say that the services were medically necessary. The Plan denied your request. The Plan says the CPT code billed is not eligible for Medicare payment.
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 S9503 is not supported in the medical record. Specifically, per the 2020 National Physician Fee Schedule, this CPT code is marked with a status of "I" which means it is not eligible for Medicare payment. Based on this information, we decided that Medicare rules for coverage of the home infusion services have not been met. Therefore, we decided that the Plan does not have to pay for home infusion services (S9503) provided August 27, 2020 to September 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye exam (92004) provided on December 29, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the eye exam. You say that you were told the eye exam would be covered and you did not know you had to use a provider in the Plan's network. The Plan denied your request. The Plan says they do not cover out-of-network items or services, except in limited circumstances. The provided eye exam was not urgent or pre-approved and could have been provided in-network.
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 an eye exam (92004) provided on December 29, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network
provider on January 12, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
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 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 the services provided to the enrollee by an out-of-network
provider on January 12, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for genetic testing (81479) provided November 9, 2020.
You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan denied your request. The Plan says that the testing was not ordered by the treating physician.
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. 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 has not provided any documentation of outreach to the treating physician. The records provided, including the order form, are signed by the treating oncologist. Therefore, we decided that the Plan has to pay for genetic testing (81479) provided November 9, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the deep sedation/general anesthesia (D9222), tooth
extraction (D7210) and unspecified procedure (D9999) provided on December 4, 2020.
You asked the Plan to pay for the dental services. You say that you believed that emergency services were
covered at 100%, but the Plan only paid $850. The Plan denied your request. The Plan says they will only pay
up to $850 per year for dental services, regardless of the situation. They are reviewing your complaint about
possible misinformation in a separate case.
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, services and items that exceed the
$850 annual maximum allowance are not among those covered under this benefit. Therefore, we decided that
the Plan does not have to pay for the deep sedation/general anesthesia (D9222), tooth extraction (D7210) and
unspecified procedure (D9999) provided on December 4, 2020.
Your complaint about possible misinformation from the Plan regarding coverage and costs is not a valid appeal
for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare
does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider on October 26, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the 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 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 the services provided to the enrollee by an out-of-network provider on October 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services (D1999 x 2).
You asked the Plan to pay for the dental services (D1999 x 2). You say that the requested services were surcharges to other covered dental services, therefore they should be covered. The Plan denied your request. The Plan says the requested services are not covered under your supplemental 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. The requested service is not listed in the Plan's schedule of benefits; therefore, it is not covered. Therefore, we decided that the Plan does not have to pay for the dental services (D1999 x 2).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider on October 20, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the 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 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 the services provided to the enrollee by an out-of-network provider on October 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar orthosis provided on October 22, 2020.
You asked the Plan to pay for the lumbar orthosis. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the documentation is missing required information.
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 does not contain relevant medical records which support medical necessity for the supplies provided
in this case. The documentation submitted does not indicate the provider discussed the need for the supplies
item provided. The record shows that the Plan made several attempts to obtain the necessary documentation
without success. Therefore, we decided that the Plan does not have to pay for the lumbar orthosis provided on
October 22, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the COVID-19 test provided on July 10, 2020.
You asked the Plan to pay for the COVID-19 test. You say that you have no knowledge of enrollee coverage prior to the specimen's arrival at the laboratory. 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 COVID-19 test provided on July 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a standard manual wheelchair.
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied
your request. The Plan says an electric wheelchair was received in June 2020.
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 pre-approve the wheelchair. Our reviewer says that
the requested wheelchair is not considered medically reasonable and necessary in this case. Our physician
reviewer found the documentation does not support that you have a mobility limitation that significantly
impairs the ability to complete MRADLs. The documentation does not reveal that the mobility deficit cannot
be resolved by a cane or walker. The documentation doesn't show that your home is appropriate for the
wheelchair. The documentation does not support that a manual wheelchair is needed in addition to a power
wheelchair.
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 wheelchair have not been met. Therefore, we decided that the Plan does not
have to pre-approve a standard manual wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit (99214) provided September 11, 2020.
You asked the Plan to waive the copayment for the office visit. You say that the copayment should be waived because this was an annual wellness visit. The Plan denied your request. The Plan says the visit included services that are not part of an annual wellness visit. The correct copayment 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 $5 copayment for primary care visits. You have been asked to pay a $5 copayment for the office visit. The office visit falls within the primary care 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 an office visit (99214) provided September 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you by an out-of-network provider on December 3, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 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 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 the services provided to you by an out-of-network provider on December 3, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an electrocardiogram (93000) provided November 20, 2020.
You asked the Plan to waive the copayment for the electrocardiogram. You say that the copayment was not charged in the past for this service, and it should be waived. The Plan denied your request. The Plan says the correct copayment 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 $25 copayment for diagnostic tests. You have been asked to pay the Medicare allowable amount of $18.51 for the electrocardiogram. The electrocardiogram falls within the diagnostic tests benefit category. The allowable amount is less than the $25 copayment listed in the Evidence of Coverage. 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 electrocardiogram (93000) provided November 20, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the CT of the head or brain and limited ultrasound scan of abdomen provided on September 15, 2020.
You asked the Plan to pay for the CT of the head or brain and limited ultrasound scan of abdomen. You say that the enrollee's hospice eligibility ended on September 11, 2020. 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 CT of the head or brain and limited ultrasound scan of abdomen provided on September 15, 2020.