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

We decided that the Plan does not have to pay for the Epifix application provided on December 17, 2020, billed with code 15271.
You asked the Plan to pay for the skin substitute application as billed. You say that it is felt that this should be paid. The Plan denied your request. The Plan says the correct code was not used to describe this service.
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 15271 is Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area. We find that CPT code 15271 is not supported in the medical record. Specifically, the progress note documents that the wound being treated was on the scalp, and not the trunk, arm, or leg. Based on this information, we
decided that Medicare rules for coverage of the skin substitute application as billed have not been met. Therefore, we decided that the Plan does not have to pay for the Epifix application provided on December 17, 2020, billed with code 15271.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM)
and supplies.
You asked the Plan to pre-approve a Freestyle Libre CGM and supplies. You say that the services are
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria
has not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results.
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least
three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle
Libre CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a
Freestyle Libre continuous glucose monitor (CGM) and supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic eye exam (92004) received February 3, 2021.
You asked the Plan to waive the copayment for the diagnostic eye exam. You say that the requested service was a routine eye exam; therefore, there should be a $0 copayment. The Plan denied your request. The Plan says the requested service was Medicare-covered vision care, therefore the correct cost share applied to the claim.
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 $35 copayment for Medicare-covered vision care. You have been asked to pay a $35 copayment for the diagnostic eye exam. The diagnostic eye exam falls within the Medicare-covered vision 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 copayment for the diagnostic eye exam (92004) received February 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the rest home visit provided on December 30, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the rest home visit. You say that the hospital staff failed to obtain authorization and the doctor should not be penalized. You say the services were medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
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 rest home visit provided on December 30, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug provided on June 11, 2020.
You asked the Plan to waive the coinsurance for a Medicare Part B drug. You say that you were not aware that you would receive a Medicare Part B drug and cannot afford the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 Medicare Part B prescription drugs. You received a Medicare Part B drug on June 11, 2020. The total allowed amount is $596.29 and 20% of that is $119.26. You have been asked to pay the total coinsurance amount of $119.26 for a Medicare Part B drug. A Medicare Part B drug falls within the Medicare Part B prescription drugs benefit category. This means that you have been
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug provided on June 11, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the non-emergency ambulance services (A0428, A0425) provided on February 5, 2021.
You asked the Plan to waive the copayment for the non-emergency ambulance services. You say that this transportation was medically necessary and other claims for this same service were previously paid with no copayment required. You say this should be processed as in-network, as you cannot choose the ambulance providers. The Plan denied your request. The Plan says the required copayment is the same regardless of the network status of the ambulance company. Non-emergent ground ambulance services require a $290 copayment, which was applied 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $290 copayment for non-emergency ground ambulance services.
The enrollee has been asked to pay a $290 copayment for the non-emergency ground ambulance services. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the non-emergency ambulance services (A0428, A0425) provided on February 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for naturopathic preventive medicine counseling service provided on December 8, 2020.
You asked the Plan to pay for naturopathy service. You say that this service was the same as reading, interpreting, and explaining the results of an X-Ray or computed tomography scan, and you were not qualified to interpret the lab results. The Plan denied your request. The Plan says the denial of payment for this service is correct, because naturopath services are not covered under any conditions.
The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services. The services at issue in this appeal are naturopathic services. Therefore, we decided that the Plan does not have to pay for naturopathic preventive medicine counseling service provided on December 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy duty power scooter (K0801) with a power seat (K0108).
You asked the Plan to pre-approve a heavy duty power scooter with a power seat. You say that the requested items are a medical necessity for you. The Plan denied your request. The Plan says rules for durable medical equipment have not been met.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. According to the provide documentation, the items at issue in this appeal are for use outside of the home. Although these items may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a heavy duty power scooter (K0801) with a power seat (K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (S1015, S8301) provided September 23, 2020.
You asked the Plan to pay for the anesthesia services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services billed are 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 codes S1015, & S8301 are not supported in the medical record. Specifically, per the 2020 National Physician Fee Schedule, the billed codes are marked with a status of "I" which means they are invalid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the
anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia services (S1015, S8301) provided September 23, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a participating provider on January 20, 2021.
You asked the Plan to waive the copayment for an outpatient surgery. You say that this was done in an office, not a hospital. 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 $250 copayment for outpatient surgery/in-network/outpatient surgery. You have been asked to pay a $250 copayment for an outpatient surgery. The facility where the surgery was performed is owned by a hospital; therefore, the correct copayment has been applied. An outpatient surgery falls within the outpatient surgery/in-network/outpatient surgery 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 outpatient surgery provided by a participating provider on January 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for bitewings - four radiographic images (D0274), prophylaxis - adult (D1110), periodic oral evaluation (D0120), crown - porcelain/ceramic (D2740), resin-based composite - one surface, anterior (D2330) and resin-based composite - two surfaces, anterior (D2331) provided January 4, 2021 and January 14, 2021 from an out-of-network (OON) provider.
You asked the Plan to provide additional payment for the bitewing x-rays, dental cleaning, periodic oral exam, crown and resin-based composites. You say that you thought in and out-of-network dental benefits were the same and were not told you would pay more OON. The Plan denied your request. The Plan says the benefits were applied correctly.
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. The Plan covers the bitewing x-rays, dental cleaning, periodic oral exam, crown and resin-based composites when the services are medically necessary and reasonable. You may pay more for services when they are rendered by an OON provider. We looked at the file and Medicare rules. In this case you obtained dental services from an OON provider. The Plan has provided coverage up to the Plan's allowed amount for the services. Since services were obtained OON you are responsible for the difference between the Plan's allowed amount and the total cost billed by the OON provider. Therefore, we decided that the Plan does not have to provide additional payment for bitewings - four radiographic images (D0274), prophylaxis - adult (D1110), periodic oral evaluation (D0120), crown - porcelain/ceramic (D2740), resin-based composite - one surface, anterior (D2330) and resin-based composite - two surfaces, anterior (D2331) provided January 4, 2021 and January 14, 2021 from an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on February 23, 2021.
You asked the Plan to waive the copayment for a specialist visit. You say that copayments are waived due to COVID-19 and you should not owe a copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $35 copayment for specialist visits. You had a specialist visit on February 23, 2021. COVID-19 waivers only applied in 2020. Therefore, you are responsible to pay the $35 copayment. You have been asked to pay a $35 copayment for a specialist visit. A specialist visit falls 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 a specialist visit provided on February 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Superion interspinous spacer for the enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that this service is considered experimental and investigational.
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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The superion spacer is experimental. More research is needed to show safety and efficacy of the device. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Superion interspinous spacer for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the frames (V2020) and polycarbonate lenses (V2784) provided July 8, 2020.
You asked the Plan to pay for the frames and polycarbonate lenses. You say that you believe your eye wear should be covered in full. The Plan denied your request. The Plan says coverage has been provided up to the maximum eye wear allowance.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when up to a $170 maximum eyewear allowance. We looked at the file and the Plan's rules. In this case the Plan has paid $170.73 towards your routine eye wear. Based on this information, we decided that the Plan's rules for coverage of the frames and polycarbonate lenses have not been met. Therefore, we decided that the Plan does not have to pay for the frames (V2020) and polycarbonate lenses (V2784) provided July 8, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care (99309) debridement, muscle and/or fascia (11043) provided on July 17, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the nursing facility care. You say that services provided were medically necessary. Medical documentation supporting need for services attached. Please review the documentation and reprocess the claim for payment. 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.
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 subsequent nursing facility care (99309) debridement, muscle and/or fascia (11043) provided on July 17, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME and related supplies provided from October 20, 2021, to January 20, 2021.
You asked the Plan to waive the coinsurance for DME and related supplies. You say that you were told that you would owe $0 for the services. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 DME and related supplies. You received DME and related supplies on October 20, 2020. The total allowed amount is $88.89 and 20% of
that is $17.78. You received DME and related supplies on November 20, 2020. The total allowed amount is $88.89 and 20% of that is $17.78. You received DME and related supplies on December 20, 2020. The total allowed amount is $88.89 and 20% of that is $17.78. You received DME and related supplies on January 20, 2021. The total allowed amount is $88.89 and 20% of that is $17.78. The total amount you owe is: $71.12. You have been asked to pay the total coinsurance amount of $71.12 for DME and related supplies. DME and related supplies fall within the DME 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 DME and related supplies provided from October 20, 2021, to January 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services coded 99140 provided on December 25, 2020.
You asked the Plan to pay for the anesthesia 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 separately payable.
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 99140 is anesthesia complicated by emergency conditions (specify) (List separately in addition to code for primary anesthesia procedure). We find that CPT code 99140 is not supported in the medical record. Specifically, this code has a status code of "B". A status code of B means that this is a bundled service. This code is a bundled service to the primary code
billed (00910). This means that this code is not separately payable. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services coded 99140 provided on December 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the vaccine provided on February 9, 2021.
You asked the Plan to pay for the Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) (90715). You say that the Plan told you the vaccine was covered with no copayment. The Plan denied your request. The Plan says this vaccine is not covered under your Medicare Part B benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) (90715). The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) (90715). Therefore, we decided that the Plan does not have to pay for the vaccine provided on February 9, 2021.
Benefits for the Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) (90715) may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.