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

 We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and a panoramic radiographic image (D0330) provided on June 29, 2021.  You asked the Plan to pay for a comprehensive oral evaluation, and a panoramic radiographic image. You say that the provider didn't do anything to your teeth and no radiographic image was done. The Plan denied your request. The Plan says the services are covered benefits, but you have exceeded the frequency limit of one every 3 Plan years.  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.   We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation, and a panoramic radiographic image have not been met. Specifically, the record shows that you had exceeded the frequency limit prior to these services on February 10, 2020. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and a panoramic radiographic image (D0330) provided on June 29, 2021.   Your complaint about the provider not doing anything to your teeth and no radiographic image being done 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 tetanus, diphtheria, and acellular pertussis (TDaP) vaccine rendered on July 27, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.  In the absence of injury or direct exposure to illness, Medicare does not pay for or provide these services. The Plan follows the same rules.   Records do not show that you have been injured or directly exposed to any illness related to these services. Therefore, we decided that the Plan does not have to pay for the tetanus, diphtheria, and acellular pertussis (TDaP) vaccine rendered on July 27, 2021.   Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99309) rendered by the out-of-network (OON) provider on May 26, 2021.  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 prior authorization.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The 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 (99309) rendered by the out-of-network (OON) provider on May 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for a Renasight gene panel (81242, 81250, 81363, 81364, 81400, 81401, 81403, 81404, 81405, 81406, 81407, 81408) provided on March 18, 2021.  You asked the Plan to pay for a Renasight gene panel. You say that this is supported in the records. The Plan denied your request. The Plan says this is not a covered benefit.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. If a laboratory assays 2 or more genes in a patient in parallel, then those 2 or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so 1 code must be submitted for the panel. MolDX will also deny panels of tests that include the FANCC gene.  We find that CPT codes 81242, 81250, 81363, 81364, 81400, 81401, 81403, 81404, 81405, 81406, 81407, 81408 are not supported in the medical record. Specifically, these codes were used to report a panel, which should be billed with one code. Furthermore, the panel at issue includes the FANCC gene, which is not covered. Based on this information, we decided that Medicare rules for coverage of a Renasight gene panel have not been met. Therefore, we decided that the Plan does not have to pay for a Renasight gene panel (81242, 81250, 81363, 81364, 81400, 81401, 81403, 81404, 81405, 81406, 81407, 81408) provided on March 18, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the emergency ambulance transportation services (A0427, A0425) provided on March 26, 2021.  You asked the Plan to waive the coinsurance for the ambulance transportation. You say that you feel the cost of this transportation should be covered in full because it was medically necessary due to a reaction to the vaccine. The Plan denied your request. The Plan says this claim was processed correctly, and your cost-share 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 35% coinsurance for out-of-network ambulance services.    You have been asked to pay 35% coinsurance on the Plan's allowed amount for out-of-network ambulance services. 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 emergency ambulance transportation services (A0427, A0425) provided on March 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (80307, 83789, G0480) rendered by the out-of-network (OON) provider on June 11, 2021.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The 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 drug testing services (80307, 83789, G0480) rendered by the out-of-network (OON) provider on June 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99212), the x-ray exam of the ankle (73610), and the x-ray exam of the foot (73630) rendered by the out-of-network (OON) provider on July 12, 2021.  You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The 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 office visit (99212), the x-ray exam of the ankle (73610), and the x-ray exam of the foot (73630) rendered by the out-of-network (OON) provider on July 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the continuous positive airway pressure (CPAP) device and related supplies you rented from January 23, 2021, to June 23, 2021.  You asked the Plan to waive the coinsurance for the CPAP devices and supplies. You say that this device has been recalled and you don't think you should be billed for a machine you cannot use. The Plan denied your request. The Plan says they confirmed with the provider that this CPAP device was not recalled until June 15, 2021.  Because of that, you were charged this coinsurance 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 20% coinsurance for durable medical equipment and related supplies.   You have been asked to pay 20% coinsurance for the CPAP devices and supplies. The CPAP devices and supplies falls within the durable medical equipment 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 continuous positive airway pressure (CPAP) device and related supplies you rented from January 23, 2021, to June 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for an apicoectomy (D3425), a retrograde filling (D3430), and inhalation of nitrous oxide (D9230) provided on July 14, 2021.  You asked the Plan to pay for an apicoectomy, a retrograde filling, and inhalation of nitrous oxide. You say that the services were necessary. The Plan denied your request. The Plan says the services at issue are not covered 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. Therefore, we decided that the Plan does not have to pay for an apicoectomy (D3425), a retrograde filling (D3430), and inhalation of nitrous oxide (D9230) provided on July 14, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the Pembrolizumab injection you received on June 15, 2021.  You asked the Plan to waive the coinsurance for the Pembrolizumab injection. You say that you paid less when you received an injection of this medication on May 25, 2021. The Plan denied your request. The Plan says you were charged this coinsurance correctly. The Plan says that for the May 25, 2021, date of service, the provider billed with a -JG modifier, meaning that at that time, the drug was part of a drug pricing discount program.  The provider did not append the same modifier to the claim for date of service June 15, 2021, so the allowed amount for the drug is different.  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 drugs.  You have been asked to pay 20% coinsurance for the Pembrolizumab injection. The Pembrolizumab injection falls within the Medicare Part B drugs benefit category. The allowed amount for this drug can vary based on how the drug is billed and the dosage provided each time. 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 Pembrolizumab injection you received on June 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the injection procedure you had at an outpatient hospital facility on August 11, 2021.  You asked the Plan to waive the copayment for the injection procedure. You say that this shot was given in a primary care clinic.  You said that you have been getting these shots for years and have only had to pay a $20 copayment.  You said that you should not have to pay a $375 copayment for primary care. The Plan denied your request. The Plan says you were charged this copayment 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 $375 copayment for outpatient hospital surgery services.   You have been asked to pay a $375 copayment for the injection procedure. We confirmed that the clinic where you received this service bills as an outpatient hospital because it is affiliated with a hospital. In addition, Medicare considers the injection procedure you had to be a surgical procedure. That is why the injection procedure falls within the outpatient hospital surgery services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the injection procedure you had at an outpatient hospital facility on August 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the personal care services provided from October 5, 2020, through November 17, 2020.  You asked the Plan to pay for the personal care services. You say that it is felt that these services are medically necessary, and you were told that the plan would cover them with 20% coinsurance. The Plan denied your request. The Plan says these services are not covered by Medicare as they are custodial in nature.  The Plan must follow Medicare rules. Medicare rules say that custodial care is not covered by Medicare. The contract indicates that homemaker services including basic household assistance are not covered.  In this case, the services provided are not skilled nurse/therapy services from a home health agency but companion/personal care services that are considered custodial in nature. Neither Medicare nor the Plan provides coverage for these services. Therefore, we decided that the Plan does not have to pay for the personal care services provided from October 5, 2020, through November 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy duty shower chair.

You asked the Plan to pre-approve a heavy duty shower chair. You say that the member needs the chair to
avoid falling and to prevent another hospital stay. The Plan denied your request. The Plan says that this is
considered a convenience item and is not primarily medical in nature.

The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are
not primarily medical in nature.

While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this
item. Therefore, we decided that the Plan does not have to pre-approve a heavy duty shower chair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from  April 22, 2021, through April 25, 2021.  You asked the Plan to waive the copayment for inpatient hospital care. You say that you should not have to pay for the services. 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 $325 copayment per day, days 1-5 for inpatient hospital care.  You have been asked to pay a $650 ($325 x2 = $650) copayment for inpatient hospital care. The services at issue fall within the inpatient hospital 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 inpatient hospital care provided from April 22, 2021, through April 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.  You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that you do not require intensive rehabilitation to return to preadmission baseline.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for mitral valve replacement and pulmonary edema. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the emergency room (ER) services you received on May 22, 2021.  You asked the Plan to waive the copayment for the ER services. You say that the claim shows labs and imaging that you did not have.  You said that you just had your temperature and blood pressure taken and you waited over four hours.  You said that you called your doctor and he told you to go home and take pain pills instead. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that they confirmed with the hospital that you did have a urinalysis and ultrasound done, but you left prior to receiving the results.  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 copayment per visit for emergency room services.   You have been asked to pay a $50 copayment per visit for the ER services. This copayment applies each time you visit the ER, regardless of the extent of services you receive. 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 emergency room (ER) services you received on May 22, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the skills of a physical therapist are not necessary on a daily basis.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laparoscopy (57425) provided on May 25, 2021.  You asked the Plan to pay for the laparoscopy. You say that these services were necessary and were billed correctly. The Plan denied your request. The Plan says the provider in this case is not eligible to order the service billed according to Medicare rules.  The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS.  In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for the laparoscopy (57425) provided on May 25, 2021.