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

We decided that the Plan does not have to pay for subsequent nursing facility care (99309) provided on May 5, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the nursing facility care. You say that you have attached the medical records for the date of service. You are requesting review of the documents and processing of the claim towards 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) provided on May 5, 2021 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 therapy services (97530) provided on April 14, 2021.
You asked the Plan to pay for the therapy services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that the services of a OTA shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of occupational therapy have not been met. Specifically, the billing provider is a physician's assistant, and not a licensed therapist. As such, OTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for the therapy services (97530) provided on April 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for domiciliary or rest home visit provided on April 20, 2021 by an out-of-network provider.

You asked the Plan to pay for domiciliary or rest home visit for the evaluation and management of an established patient (99335). You say that the services were medically necessary at the facility where the enrollee resides. The Plan denied your request. The Plan says the provider did not request prior authorization as required.

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 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 the service. Therefore, we decided that the Plan does not have to pay for domiciliary or rest home visit provided on April 20, 2021 by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Countour next test strips.
You asked the Plan to pre-approve the strips. You say that Accu-chek is currently on recall. You state the enrollee is unable to get the supplies to test sugars. The Plan denied your request. The Plan says your appeal said you that you were unable to get the ACCU-CHEK strips. The Plan states the pharmacy records show that the enrollee was able to get them filled on September 14, 2021.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at this physician's review, the file, and Medicare rules. The pharmacy records show that the enrollee was able to get them filled on September 14, 2021. Therefore, we decided that the Plan does not have to pre-approve the Countour next test strips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extraction (D7210) provided on March 15, 2021.
You asked the Plan to pay for the surgical extraction. You say that you pay for the extra dental coverage and would like to know why this service was not covered. The Plan denied your request. The Plan says this service is not covered under your dental plan benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. You received a surgical extraction, and the only type of extractions covered under your plan are simple extractions. Therefore, we decided that the Plan does not have to pay for the surgical extraction (D7210) provided on March 15, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the endoscopy procedure with specimen
collection (43235) provided on June 17, 2021.
You asked the Plan to reduce the copayment for the endoscopy procedure. You say that you were told this
service would only have a $105 copayment because no incision was made, and it is not surgery. You say this
was an outpatient diagnostic exam and the lesser copayment should apply. The Plan denied your request. The
Plan says this claim was processed correctly, and your copayment was assessed in accordance with your
contract.
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 $275
copayment for outpatient surgery performed in an ambulatory surgical center.
You have been asked to pay a $275 copayment for the endoscopy procedure. The endoscopy service in this
case is classified as a surgical procedure and was provided in an ambulatory surgical center. 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 reduce the copayment for the endoscopy procedure with specimen collection (43235) provided
on June 17, 2021.
Your complaint about potential misinformation from a Plan-contracted provider or Plan representative 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab testing services (88305, 88312) provided on June 9, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the lab testing. You say that the enrollee does not show up to the lab on their own, and instead specimens are sent/referred by participating providers. The provider failed to send a pre-authorization form for approval, and you should not be liable for these services. The Plan denied your request. The Plan says out-of-network care is only covered in limited circumstances. The referring provider in this case is not contracted with the Plan, and therefore Plan directed care does not apply. These services were not urgent or emergent, nor were they pre-approved.

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 referring provider is also 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 lab testing services (88305, 88312) provided on June 9, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on May 27,
2021, to June 2, 2021.

You asked the Plan to waive the copayment for inpatient hospital care. You say that you should not pay a
copayment because you had Coronavirus. The Plan denied your request. The Plan says the copayment you are
being charged is correct.

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 $285
copayment per day, for days 1 to 7 for inpatient hospital care. Your contract with the Plan also clearly says that
you pay a $0 copayment per day, for days 8-90 for inpatient hospital care.

You have been asked to pay a $285 copayment per day for inpatient hospital care. The records show that you
had inpatient hospital care for six days ($285 x 6 days = $1,710). Your total cost share is $1,710. The EOC
confirms $285 is the required copayment per day, for this service. 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 inpatient hospital care provided on May 27, 2021, to June 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyewear enhancements provided on May 13, 2021.

You asked the Plan to pay for eyewear enhancements. The Plan denied your request. The Plan says lens enhancements are not covered under the member's vision plan but are available at discounted rates as an extra benefit for having vision insurance.

Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

We looked at the file and the Plan's rules. The file shows that lens enhancements are not covered through the eyewear allowance. Therefore, we decided that the Plan does not have to pay for eyewear enhancements provided on May 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2740) and core build up (D2950) provided on May 10, 2021.
You asked the Plan to pay for the dental services. You say that you had pain in your tooth. You say that your policy was decreased, and you were not aware of it. You also say that you would like the services to be paid per your previous dental plan. The Plan denied your request. The Plan says the claim was processed correctly. The Plan says that you have had the same dental coverage since 2020. The Plan says that the crown is not listed as a covered service. The Plan says that core build up is not listed as a covered service either. The Plan also says that you did not contact the Plan prior to the date of service to verify benefits and 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 crown and core build up are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the crown (D2740) and core build up (D2950) provided on May 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the periodic oral evaluation (D0120), panoramic x-ray (D0330), and prophylaxis (D1110) provided on May 14, 2021 by an OON provider.
You asked the Plan to pay more for the periodic oral evaluation, panoramic x-ray, and prophylaxis. You say that the dental rider states that there is a $0 copay for exams, cleanings, x-rays, and fluoride. You also say that you were led to believe these preventive services would be covered. The Plan denied your request. The Plan says the cost share was applied correctly per your plan benefits. Our reviewer also found that cost-sharing is a contractual obligation of the Plan and cannot be waived.
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, you are responsible for the difference between the billed amount and allowed amount for services received OON. Therefore, we decided that the Plan does not have to pay more for the periodic oral evaluation (D0120), panoramic x-ray (D0330), and prophylaxis (D1110) provided on May 14, 2021 by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a computed tomography (CT) scan (70450) provided on April 24, 2021.
You asked the Plan to pay for a CT scan. You say that this is supported in the records. The Plan denied your request. The Plan says this is not separately payable without a modifier.
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, we have confirmed that code 70450 has a bundled relationship with code 70496 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for a computed tomography (CT) scan (70450) provided on April 24, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to waive the copayment for the laboratory services rendered on May 12, 2021.

You asked the Plan to waive the copayment for these services. You say that you never had laboratory services. The Plan denied your request. The Plan says that the copayment was applied correctly.

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 states that the copayment was applied correctly because you had laboratory services on the date of service at issue. There are no medical records to support that you had laboratory services performed on this date. It is noted that the Plan attempted to obtain records from the network provider; however, without records, it cannot be supported that you had laboratory services performed for which a copayment can be assessed. Therefore, we decided that the Plan has to waive the copayment for the laboratory services rendered on May 12, 2021.

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the FoundationOne CDx Panel provided on April 28, 2021.
You asked the Plan to pay for the FoundationOneCDx. You say that you would like reconsideration because this testing is medically necessary. The Plan denied your request. The Plan says there are currently no clinical indications for this technology.
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 pay for the FoundationOneCDx.
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found testing of multiple genes in this panel are considered experimental and investigational. 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 FoundationOneCDx have not been met. Therefore, we decided that the Plan does not have to pay for the FoundationOne CDx Panel provided on April 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the prophylaxis (D1110) provided on
February 12, 2021.

You asked the Plan to pay an additional amount for the dental service. You say that it was your understanding
that the plan would pay 80% of the billed amount. The Plan denied your request. The Plan says nonparticipating
providers do not agree to accept the Dental Plan's allowed amount as payment in full. The Plan
also says that you can incur additional cost with out of network dentists.

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 and the service is listed as covered,
dental services received by a non-participating dentist may cost more. The Schedule of Dental Benefits clearly
states that if you receive services from a dentist that does not participate in the Dental Plan's network, you will
be responsible for the difference between what the Dental Plan pays to you and the amount charged by the nonparticipating
dentist. Therefore, we decided that the Plan does not have to pay an additional amount for the
prophylaxis (D1110) provided on February 12, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for testosterone pellets (S0189) provided on March 9, 2021.
You asked the Plan to pay for testosterone pellets. You say that this was medically necessary. The Plan denied your request. The Plan says this was not billed with a valid code.
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 S0189 is not supported in the medical record. Specifically, this code has a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of testosterone pellets have not been met. Therefore, we decided that the Plan does not have to pay for testosterone pellets (S0189) provided on March 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing facility care (99308) provided on February 18, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for OON nursing facility care. You say that this was a medically necessary service provided in good faith. The Plan denied your request. The Plan says this was not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan 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 nursing facility care (99308) provided on February 18, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5214) provided May 4, 2021.
You asked the Plan to reduce the copayment for the lower partial denture. You say that you are not working due to the pandemic and would like the copayment lowered. The Plan denied your request. The Plan says the copayment 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). Your contract with the Plan clearly says that you must pay a $150 copayment for covered complete/partial dentures, once per arch, per 60 months. You have been asked to pay a $150 copayment for the lower partial denture. The lower partial denture falls within the dental 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 reduce the copayment for the mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5214) provided May 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (87486, 87496, 87498, 87541, 87581, 87640, 87798, 87532) provided September 3, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.
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 87486, 87496, 87498, 87541, 87581, 87640, 87798 and 87532 is not supported in the medical record. Specifically, the place of service on the claim form (81, laboratory) does not match the place of service detailed in the records (11, laboratory). Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (87486, 87496, 87498, 87541, 87581, 87640, 87798, 87532) provided September 3, 2020.