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

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series x-ray (D0210) provided on July 8, 2021.
You asked the Plan to pay for the dental services. You say that the services should be covered. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 3 plan years. The Plan says 1 complete series x-ray is covered every 3 plan years. The Plan also says that the frequency limits have 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 and the services are listed as covered, the frequency limits have been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation and complete series x-ray that you received on December 19, 2019. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series x-ray (D0210) provided on July 8, 2021.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to waive the cost sharing for the drugs you received at an outpatient hospital facility on January 11, 2021.
You asked the Plan to waive the cost sharing for the drugs. You say that you already paid your copayment for the CT scan, so you don't know why you are getting this bill. You are not appealing the cost sharing for the CT scan, only the additional charges for the drugs. The Plan denied your request. The Plan says that there is a $125 copayment for the CT and there is a $190 copayment for the drugs you received.
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 Plan has failed to provide documentation showing why they are charging you $190 for drugs you received. First, there is no explanation as to what kind of drugs you received. Cost sharing can vary depending on the specific drug received and without knowing the specific items, we cannot accurately calculate the cost sharing. The Plan has not explained what types of drugs these are or what benefit category these drugs would fall into. In addition, it appears as though the Plan is charging you the full allowed amount of $190 for these drugs without any explanation as to why. The burden is on the Plan to explain their assessment of cost sharing. We find that the Plan failed to do so in this case. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the cost sharing for drugs you received at an outpatient hospital facility on January 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the office visit you had with an orthopedic
surgeon and back brace you received on February 19, 2021.
You asked the Plan to waive the cost sharing for the specialist visit and the back brace. You say that you went
to this doctor and they prescribed a brace that was very expensive. You are now receiving a bill. The Plan
denied your request. The Plan says you were charged this cost sharing correctly. The Plan says that these
services were not denied- the amount you are being billed is your 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 a $20
copayment for visits with a specialist and 20% coinsurance for prosthetics (including braces).
You have been asked to pay a $20 copayment for the visit with an orthopedic surgeon and 20% coinsurance for the back brace. The orthopedic surgery visit falls in the visits with a specialist benefit category. The back brace falls within the prosthetics benefit category. This means that you have been asked to pay the correct amounts 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 cost sharing for the office visit you had with an orthopedic surgeon and back brace you received on February 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the trigger point injection rendered on October 14, 2020.
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 procedure code 20552 is not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.
The provider submitted a claim for procedure codes 20552 (trigger point injections, 1 or 2 muscles) and 20610 (arthrocentesis). Code 20552 is a column II code with a modifier indicator of 1 when billed with column I code 20610. Code 20552 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the trigger point injection rendered on October 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on February 25, 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.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on February 25, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve six (6) direct skilled nursing (SN) services of a registered nurse (RN) in the home health (HH) or hospice setting, each 15 minutes (CPT code G0299).
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the services are not necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 physician reviewer found the health plan's denial should be upheld. You do not have documented skilled nursing needs (i.e.: intravenous (IVs), complex wound care, new ostomy). As such, the requested, ongoing, HH SN services are not medically necessary or reasonable. 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 six (6) direct skilled nursing (SN) services of a registered nurse (RN) in the home health (HH) or hospice setting, each 15 minutes (CPT code G0299).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from August 24, 2020, through August 28, 2020, billed with code KAGE1.
You asked the Plan to pay for the SNF services as billed. You say that this claim was billed correctly based on the medical documentation. The Plan denied your request. The Plan says the documentation does not support the Patient Driven Patient Model (PDPM) score billed.
The Plan follows Medicare rules. Medicare rules say that SNF services are billed using a HIPPS code which has four digits for four case-mix groups 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 pay for the SNF services as billed. Our reviewer says that the documentation provided does not support the services as billed. Our physician reviewer found the enrollee is a 91-year-old man who was hospitalized on August 19, 2020, with an obstructive kidney stone with hydronephrosis. The enrollee underwent lithotripsy and placement of a left ureteral stent. In this case, the documentation is insufficient to support that parenteral fluids were administered for nutrition or hydration. The limited documentation available does not support the services as billed. 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 SNF services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from August 24, 2020, through August 28, 2020, billed with code KAGE1.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core build up (D2950) provided from July 28, 2021.
You asked the Plan to pay for the dental services. You say that the provider is listed as in network in the provider directory. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that dental services received out of network are not covered.
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, core build up is not among those covered under this benefit regardless of the provider's network status. Therefore, we decided that the Plan does not have to pay for the core build up (D2950) provided from July 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the echocardiography services (93306) provided on May 12, 2021.
You asked the Plan to waive the copayment for the echocardiography services. You say that you believe that your cost shares should be waived as you disagree with the charges. The Plan denied your request. The Plan says although they have reduced your cost share, the diagnostic study processed 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 $5 copayment for outpatient diagnostic tests and
therapeutic services and supplies.
You have been asked to pay a $5 copayment for the echocardiography services. These services fall 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 the echocardiography services (93306) provided on May 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the electrocardiogram (ECG) you had on June 2, 2021.
You asked the Plan to waive the copayment for the ECG. You say that you are under a cardiologist's care for previous heart skipped beat problems. You stated that this was a follow-up visit to see how your heart was doing and he required this test. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for this service ($13.12) is less than your copayment obligation, you are responsible for the full allowed 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 $20 copayment for non-radiological diagnostic services. You have been asked to pay a $20 copayment for the ECG. The ECG falls within the non-radiological diagnostic 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 electrocardiogram (ECG) you had on
June 2, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for occupational therapy services (97530) provided on
May 13, 2020.
You asked the Plan to pay for occupational therapy 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 coverage of services incident to the professional services of a physician or non-physician practitioner (NPP) is limited to situations in which there is direct supervision of auxiliary personnel. Direct supervision in the office setting means the physician must be present in the office suite and immediately available and able to provide assistance and direction throughout the time the service is performed. We looked at the file and Medicare rules. The record does not show that the billing practitioner was present at the time the service at issue was provided. Based on this information, we decided that Medicare rules for coverage of occupational therapy services have not been met. Therefore, we decided that the Plan does not have to pay for occupational therapy services (97530) provided on May 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the shingles vaccine rendered on February 1, 2019 to
May 6, 2019.
You asked the Plan to pay for these services. You say that you disagree with the charges. 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 shingles vaccine rendered on February 1, 2019
to May 6, 2019.
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: 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 you are not able to take your medications on your own. The Plan denied your request. The Plan says further daily therapies are not medically necessary.
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 physician reviewer found from a nursing perspective, you received oral medications, had stable vital signs, and were treated for a urinary tract infection. There are no identifiable skilled nursing service needs. Regarding rehabilitation services, you were at supervision to touch assist level with functional mobility. You required varying assist with activities of daily living. Although there are identifiable skilled therapy service needs, you do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services you received on
June 25, 2021, and June 29, 2021.
You asked the Plan to waive the copayment for the ambulance services. You say that you cannot afford these copayments. The Plan denied your request. The Plan says you were charged these copayments 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 $225 copayment per trip for ambulance services. You have been asked to pay a $225 copayment per trip for the 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 copayment for ambulance services you received on
June 25, 2021, and June 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation (D9310) provided on July 2, 2021.
You asked the Plan to pay for the dental service. You say that you were referred to this specialist for tooth pain. You also say that you cannot afford to pay this bill. The Plan denied your request. The Plan says the consultation is not listed as a covered service.
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 consultation is not among those covered under this benefit. Therefore
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the personal emergency response system (S5161) rendered by the out-of-network (OON) provider on July 31, 2021.
You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the item 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 item at issue in this appeal. The Plan did not pre-approve the item at issue. We found no exception that would require the Plan to pay for this item. Therefore, we decided that the Plan does not have to pay for the personal emergency response system (S5161) rendered by the out-of-network (OON) provider on July 31, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services you received on July 16, 2021.
You asked the Plan to waive the copayment for the ambulance services. You say that this copayment should be waived. You stated that you were receiving care at home and received Lasix. You had a reaction and got dizzy and fell. Your home care called 911 and you were taken to the hospital by ambulance. 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 $150 copayment for ambulance services. You have been asked to pay a $150 copayment for the ambulance services. This copayment applies regardless of the reason for the transport. 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 July 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation (90791) provided on March 23, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for a psychiatric diagnostic evaluation. You say that the service was provided in good faith by the provider, and you are requesting payment for this claim. The Plan denied your request. The Plan says services were provided by an OON 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 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. The records provided for review do not show that the services at issue were urgent or
emergent. 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 a psychiatric diagnostic evaluation (90791) provided on
March 23, 2021, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergency transportation services (T2005, A0380) provided on March 10, 2021.
You asked the Plan to pay for the non-emergency transportation services. You say that you would like these claims reprocessed and approved for payment. The Plan denied your request. The Plan says these claims are statutorily non covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee Schedule indicates that the code in question is not valid for Medicare purpose. We looked at the file and Medicare rules. In this case, both the codes billed (T2005 and A0380) have a status indicator of "I" under the Physician Fee Schedule and are not eligible for payment.
Based on this information, we decided that Medicare rules for coverage of the non-emergency transportation services have not been met. Therefore, we decided that the Plan does not have to pay for the non-emergency transportation services (T2005, A0380) provided on March 10, 2021.