Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for the localized delivery of anti-microbial agents (D4381 x 3). We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180).
You asked the Plan to pay for the dental services. You say that a plan representative advised you were covered for 3 cleanings per year. You say that you were not advised the difference between a cleaning and a deep root cleaning. You also say that you feel the services should be covered as you did not have the necessary information at the time to make an informed decision. The Plan denied your request. The Plan says the comprehensive periodontal evaluation is not listed as a covered service.
We decided that the Plan has to pay for the localized delivery of anti-microbial agents.
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. We find that the Plan did not provide a decision for the localized delivery of anti-microbial agents that were provided under a different case number. Therefore, we decided that the Plan has to pay for the localized delivery of anti-microbial agents.
We also decided that the Plan does not have to pay for the comprehensive periodontal evaluation.
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 comprehensive periodontal evaluation is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive periodontal evaluation.
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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on November 19, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says due to the enrollee's hospice status at the time of service, this claim must be submitted to Original Medicare first for review.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for medical services provided to the enrollee on November 19, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to reimburse you for the continuous glucose monitor sensor kit refill provided on February 2, 2021.
You asked the Plan to reimburse you for the continuous glucose monitor sensor kit refill. You say that the Plan should reimburse you. The Plan denied your request. The Plan says that the claim was processed previously by another insurance provider.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has not met its obligation with regards to coordination of benefits. Specifically, the Plan has not coordinated your benefits for you. Therefore, we decided that the Plan has to reimburse you for the continuous glucose monitor sensor kit refill provided on February 2, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a hospital observation stay provided from May 6, 2021, to May 7, 2021.

You asked the Plan to waive the copayment for hospital observation. You say that your doctor advised you that you needed to go back to the hospital before you went to a rehabilitation center. The Plan denied your request. The Plan says the copayment amount 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 $325 copayment for hospital observation stay.

You have been asked to pay $325 copayment for hospital observation. Hospital observation falls within the Outpatient Hospital Observation 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 hospital observation stay provided from May 6, 2021, to May 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the diagnostic mammography with breast tomosynthesis you had on June 8, 2021.
You asked the Plan to waive the deductible for the diagnostic mammography. You say that in previous years, you have only paid $16.53 for this service, even if you had not met your deductible in prior years. The Plan denied your request. The Plan says you were charged this deductible correctly. The Plan says that in previous years, mammograms were excluded from the deductible. However, that is in the case in 2021.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $300 deductible which applies to outpatient diagnostic tests. The diagnostic mammogram you had falls within the benefit category for outpatient diagnostic tests. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $300 deductible which applies to outpatient diagnostic tests. This cost sharing is a contractual obligation that had not been met at the time the diagnostic mammography was received on June 8, 2021.
Therefore, we decided that the Plan does not have to waive the deductible for the diagnostic mammography with breast tomosynthesis you had on June 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (74018) provided on June 19, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 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, we have confirmed that code 74018 is a column II code to column I code 74250. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the services (74018) provided on June 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the
chest you had on July 21, 2021.
You asked the Plan to waive the copayment for the CT scan. You say that you think this is a lot of money for a
quick scan. You stated that you are retired and on a fixed income. 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 $300
copayment for diagnostic imaging services.
You have been asked to pay a $300 copayment for the CT scan. The CT scan falls within the diagnostic
imaging 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 computed tomography (CT) scan of the chest you had on
July 21, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound of the heart provided on June 9, 2021.

You asked the Plan to waive the copayment for an ultrasound of the heart. You say that you have never been charged this much in the past and disagree with 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 a $160 copayment for ultrasounds. 

You have been asked to pay a $160 copayment for an ultrasound of the heart. An ultrasound of the heart falls within the outpatient diagnostic tests and therapeutic services and 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 copayment for an ultrasound of the heart provided on June 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for tetanus, diphtheria toxoids, and acellular pertussis (TDAP) immunization provided on June 2, 2021.

You asked the Plan to pay for TDAP immunization. You say that according to your doctor, this shot should be given every 10 years. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this immunization is not covered by Medicare Part B and should be covered through your Medicare Part D benefits instead.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide TDAP immunization. The Plan follows the same rules. 

Records do not show that you have been injured or directly exposed to any illness related to TDAP immunization. Therefore, we decided that the Plan does not have to pay for tetanus, diphtheria toxoids, and acellular pertussis (TDAP) immunization provided on June 2, 2021.

Benefits for TDAP immunization 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0675).

You asked the Plan to pay for a pneumatic compression device. You say that the item is medically necessary. The Plan denied your request. The Plan says this item is not covered.

The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan.

PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory service (81528) rendered by the out-of-network (OON) provider on June 30, 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 laboratory service (81528) rendered by the out-of-network (OON) provider on June 30, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services you received on May
27, 2021.

You asked the Plan to waive the copayment for the ambulance services. You say that the hospital told your
wife that the ambulance would not cost anything. 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 $250
copayment for ambulance services.

You have been asked to pay a $250 copayment for the ambulance services. This copayment applies for every
transport, regardless of the reason. 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 ambulance services
you received on May 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from
June 22, 2021, to June 28, 2021.

You asked the Plan to waive the copayment for the inpatient hospital services. You say that this bill should be
covered in full because these services were medically necessary. The Plan denied your request. The Plan says
these services were not denied. Rather, the enrollee was charged the correct cost sharing for this service.

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 $295 copayment per day for days 1-7 for inpatient hospital care.

Records show that the enrollee was in the hospital for 6 days. The enrollee was charged a $295 copayment per
day, for a total of $1770. 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 inpatient hospital
services provided from June 22, 2021, to June 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for magnetic resonance angiography (MRA) (70544) provided on May 19, 2021.

You asked the Plan to pay for MRA 70544. You say that you are appealing with records to support the code billed. The Plan denied your request. The Plan says the denial of payment for this service is correct, because code 70544 has a procedure-to-procedure (PTP) edit with code 70551 which means this code is not separately payable without an appropriate 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 MRA 70544 is a column II code to column I code 70551. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for magnetic resonance angiography (MRA) (70544) provided on May 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the synthetic secretin injection you received on May 7, 2021.
You asked the Plan to waive the coinsurance for the synthetic secretin. You say that this injection was part of your magnetic resonance imaging (MRI), and you have never been charged coinsurance for the contrast material before. The Plan denied your request. The Plan says 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 medical supplies. Your contract says that supplies for which an appropriate separate charge is made by providers (such as chemical agents used in certain diagnostic procedures), are subject to separate cost sharing. You have been asked to pay 20% coinsurance for the synthetic secretin. 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 synthetic secretin injection you received on May 7, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the direct skilled nursing services provided on February 22, 2021.
You asked the Plan to pay for the direct skilled nursing services. You say that the claim denied incorrectly. You say that per your contract you are to use CMS 1500 claim form and the claim should be approved. The Plan denied your request. The Plan says the provider did not bill as required by Medicare coding regulations.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Medicare rules also say that institutional providers, including home health agencies, use one of two institutional claim formats to bill Original Medicare. In this case, the CPT Code Manual definition of code G0299 is direct skilled nursing services of a registered nurse (rn) in the home health or hospice setting, each 15 minutes. We find that CPT code G0299 is not supported in the medical record. Specifically, these services were not submitted on the appropriate institutional claim for the services billed. Based on this information, we decided that Medicare rules for coverage of the direct skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the direct skilled nursing services provided on February 22, 2021
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the laboratory services coded 88361 and 88305 provided on February 22, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the services billed are not payable.
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 code 88361 was denied due to Medicare medically unlikely edits (MUE) being exceeded. However, the Plan documentation does not show what the MUE was in this case. The documentation does not show why payment for all of the units of service were recouped by the Plan. The Plan states that code 88305 is a possible duplicate claim or claim line. No documentation was submitted to show why this was considered a possible duplicate claim or claim line. The Plan did not substantiate their denial. Therefore, we decided that the Plan has to pay for the laboratory services coded 88361 and 88305 provided on February 22, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia for cardiac electrophysiologic procedures coded as 00537 provided on January 4, 2021.
You asked the Plan to pay for the anesthesia services. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says the documentation does not support the services as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 00537 is anesthesia for cardiac electrophysiologic procedures including radiofrequency ablation.
We find that CPT code 00537 is not supported in the medical record. Specifically, the medical records that document the anesthesia services provided are illegible. Notably, the Plan reached out several times for a better copy of the records, but this was not received. Without a legible copy, we cannot corroborate the services as received. 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 for cardiac electrophysiologic procedures coded as 00537 provided on January 4, 2021.