Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for Ophthalmology services (92004, 92134).

You asked the Plan to pay for the Ophthalmology services. You say that the services were medically necessary. The Plan denied your request. The Plan says there were network providers available.

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 Ophthalmology services (92004, 92134).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99310) 
rendered by the out of network (OON) provider on July 28, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service 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 this service. Therefore, we decided that the Plan 
does not have to pay for the subsequent nursing facility care, per day (99310) rendered by the out of network 
(OON) provider on July 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to adjust the coinsurance for the extraction of an erupted tooth (D7210) 
provided on September 23, 2020. 
 
You asked the Plan to adjust the coinsurance. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to 
the service provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 50% 
coinsurance for an extraction of an erupted tooth provided by an in-network provider.   
 
You have been asked to pay $155.50 (Plan allowed amount of $311 x 50% coinsurance) for the tooth extraction 
rendered by an in-network provider. 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 adjust the coinsurance for the extraction of an 
erupted tooth (D7210) provided on September 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services.

You asked the Plan to waive the copayment for the inpatient hospital services. You say that you were under observation and not inpatient level of care. The Plan denied your request. The Plan says that the cost share 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). Your contract with the Plan clearly says that you must pay a $250 copayment for each day in a hospital for the first five days.

You have been asked to pay a $500 copayment for the inpatient hospital services. The inpatient hospital services fall within the each day in a hospital for the first five days 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 inpatient hospital services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140).

You asked the Plan to pay for the dental service. You say that you have had a problem with this tooth on a continuing basis. You say that you went to see your regular dentist and a specialist. You say that you did not receive a treatment plan. You say that the pain continues for you. You also say that you cannot afford further care. The Plan denied your request. The Plan says 1 limited oral evaluation per plan year is covered. The Plan also says that the frequency limit for this service has been exceeded.

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 frequency limit of 1 limited oral evaluation per plan year has been exceeded. The record shows that the Plan paid for a limited oral evaluation. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for wheelchair van services (A0130).

You asked the Plan to pay for the wheelchair van services. You say that the service was medically necessary and should be covered. The Plan denied your request. The Plan says this is not a covered service.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport services.

The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided that the Plan does not have to pay for wheelchair van services (A0130).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.

You asked the Plan to pay for the ambulance service. You say that the ambulance services were medically necessary. The Plan denied your request. The Plan says the ambulance services are not covered.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules.

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 ambulance service. Our reviewer says that the ambulance services were not medically necessary. Our physician reviewer found based on the documentation provided, transportation via ambulance from the enrollee's residence to her doctor's office was not medically necessary. The enrollee did not require the expertise of trained personnel or the equipment available only on an ambulance in order to effectuate a safe transport. Transportation could have been provided by other means (stretcher van, wheelchair van, private car, taxi) without endangering the enrollee's condition.

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 ambulance service have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician inpatient hospital care.

You asked the Plan to pay for the physician inpatient hospital care. You say that the Plan should pay this claim because hospice was revoked on this date of service. The Plan denied your request. The Plan says Original Medicare is responsible for this claim.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.

You ended Medicare Hospice benefits on September 13, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the physician inpatient hospital care.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pegfilgrastim.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 

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 services are not medically necessary. Our physician reviewer found the enrollee has bladder cancer. Pegfilgrastim is FDA approved to decrease the incidence of infection (as manifested by febrile neutropenia) in patients with nonmyeloid malignancies receiving myelosuppressive cancer chemotherapy associated with a clinically significant incidence of febrile neutropenia. This enrollee is only documented as receiving low dose cisplatin at 20 mg/m2. There is no documentation provided to assess if other risk factors are making his risk higher from prior treatment or comorbidities. The service is not reasonable or medically necessary. 

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 pegfilgrastim.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the compression stockings provided on August 28, 2020.

You asked the Plan to waive the coinsurance for the compression stockings. You say that the coinsurance should be waived because you were not able to use the stockings. The Plan denied your request. The Plan says you have been charged 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 10% coinsurance for covered items and related supplies. 

You have been asked to pay $12.60 which is 10% of the allowed amount for the compression stockings. The allowed amount is $126. ($126 x 10% = $12.60). The compression stockings fall within the "Durable medical equipment (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 the compression stockings provided on August 28, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic exercises (97110) provided on August 27, 
2020. 
 
You asked the Plan to pay for the therapeutic exercises. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says this service was not billed with the required 
modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. For 
therapy codes, the claim must include a GN, GO or GP modifier to distinguish the discipline of the plan of care 
under which the service is delivered. 
 
We find that CPT code 97110 is not supported in the record. Specifically, CPT code 97110 is a therapy code 
and has not been billed with the require GN, GO or GP modifier. Based on this information, we decided that 
Medicare rules for coverage of the therapeutic exercises have not been met. Therefore, we decided that the Plan 
does not have to pay for the therapeutic exercises (97110) provided on August 27, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergency ambulance services (A0425, A0428).

You asked the Plan to pay for the non-emergency ambulance services. You say that the care provided was medically necessary. The Plan denied your request. The Plan says ambulance transport to an outpatient office is not a covered benefit.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules.

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 non-emergency ambulance services. Our reviewer says that the service was not medically necessary and reasonable. Our physician reviewer found the documentation did not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for this patient. The documentation did not support that the patient needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport.

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 non-emergency ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the non-emergency ambulance services (A0425, A0428).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for pulpal debridement, primary and permanent teeth (D3211), 
resin-based composite - one surface, anterior (D2330) and endodontic therapy, anterior tooth (D3310) provided 
on July 6, 2020, August 10, 2020 and August 27, 2020. 
 
You asked the Plan to pay for pulpal debridement, resin-based composite and endodontic therapy. You say that 
the services should be covered. The Plan denied your request. The Plan says pulpal debridement is not a 
covered service and you have met your maximum benefit allowed for a resin-based composite and endodontic 
therapy. 
 
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. Specifically, records show you have already met your benefit 
maximum of $2,000 for your supplemental dental coverage. This means the services are not covered. 
Therefore, we decided that the Plan does not have to pay for pulpal debridement, primary and permanent teeth 
(D3211), resin-based composite - one surface, anterior (D2330) and endodontic therapy, anterior tooth 
(D3310) provided on July 6, 2020, August 10, 2020 and August 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the extraction (D7210), the panoramic x-ray (D0330), and the limited oral evaluation (D0140).

You asked the Plan to reimburse you for the dental services. You say that you were not aware that the provider was not in the Medicare network. You say that it was difficult to find a dental surgeon that was open at the beginning of the pandemic. You say that you were in considerable pain and did not have the choice of going somewhere else. The Plan denied your request. The Plan says the provider int his case has opted out of Medicare. The Plan also says that payment cannot be made to providers who have opted out of Medicare.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to reimburse you for the extraction (D7210), the panoramic x-ray (D0330), and the limited oral evaluation (D0140).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a gel mattress overlay (E0185). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there was no documentation showing that you are bed confined, completely immobile, 
or has pressure sores and are unable to reposition yourself. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the documentation does not indicate that you are completely immobile, has limited mobility, or has a 
pressure ulcer. A gel mattress overlay is not medically necessary. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a gel mattress overlay (E0185).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit received by a non-Medicare certified provider.

You asked the Plan to pay for the office visit received by a non-Medicare certified provider. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.

Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the office visit received by a non-Medicare certified provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (81408, 81432, 81479) provided on June 
28, 2020. 
 
You asked the Plan to pay for laboratory services. You say that this was medically necessary. The Plan denied 
your request. The Plan says this was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. To report a CGP service, test providers should 
use CPT code 81479 at this time, in addition to the approved DEX Z-CodeTM for the test. 
 
We find that CPT codes 81408, 81432, and 81479 are not supported in the medical record. Specifically, the 
record shows that the services at issue were a CGP service and should be reported with a single 81479 code. 
Based on this information, we decided that Medicare rules for coverage of laboratory services have not been 
met. Therefore, we decided that the Plan does not have to pay for laboratory services (81408, 81432, 81479) 
provided on June 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to issue additional reimbursement for the eyeglass lenses (V2100) 
provided on September 27, 2020. 
 
You asked the Plan to issue additional reimbursement. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says you have exceeded the maximum 
benefit allowance for this calendar year. 
 
We looked at the file and the Plan's rules.  Based on this information, we decided that the Plan's rules for 
additional reimbursement of the eyeglass lenses have not been met. Specifically, the Plan issued reimbursement 
to you in the amount of $74.99, which is the Plan allowed amount for the first pair of eyeglass lenses 
purchased.  
You purchased a second pair of lenses on this day; however, the Plan contract states that only one pair of lenses 
are payable every calendar year. Therefore, we decided that the Plan does not have to issue additional 
reimbursement for the eyeglass lenses (V2100) provided on September 27, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment for the ultrasounds provided on September 16, 
2020. 
 
You asked the Plan to adjust the copayment for the transrectal ultrasound, retroperitoneal ultrasound and pelvic 
ultrasound. You say that these were not radiological procedures. The Plan denied your request. The Plan says 
you were charged less than your copayment because the allowable amount was less than your copayment. 
 
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 $155 
copayment for each Medicare covered radiological diagnostic service for Other Outpatient Diagnostic Tests.  
 
You have been asked to pay less than your $155 copayment for each Medicare covered radiological diagnostic 
service for the transrectal ultrasound, retroperitoneal ultrasound and pelvic ultrasound. The transrectal 
ultrasound, retroperitoneal ultrasound and pelvic ultrasound fall within the Other Outpatient Diagnostic Tests 
benefit category. The EOC states diagnostic radiology services examples include ultrasounds. 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 adjust the copayment for the ultrasounds provided on September 16, 2020.