Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Gastrointestinal pathogen (0097U) provided on August 4, 2021.

You asked the Plan to pay for code 0097U. 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 as billed.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. 

In this case, the MUE for CPT code 0097U is 1. The MAI value for this code is 2. Two units of this code were billed on the same date of service exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of code 0097U have not been met. Therefore, we decided that the Plan does not have to pay for the Gastrointestinal pathogen (0097U) provided on August 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on July 2, 2021.

You asked the Plan to pay for the laboratory 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 as billed.

The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on July 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for medical supplies provided on June 28,
2021.
You asked the Plan to waive the coinsurance for the medical supplies. You say that they should have billed the
supplies properly. The Plan denied your request. The Plan says the proper coinsurance was applied.
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%
coinsurance for prosthetic devices and medical supplies. The total amount was $223.60, and the coinsurance
was $44.72 ($223.60 total amount x 20% coinsurance).
You have been asked to pay a 20% coinsurance for medical supplies. The medical supplies fall within the
Prosthetic devices 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 medical supplies provided on June 28, 2021.
Your complaint about the quality of service from the provider 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the automatic external defibrillator, with integrated
electrocardiogram analysis, garment type (K0606) provided on May 30, 2021 by an out-of-network (OON)
provider.
You asked the Plan to pay for automatic external defibrillator. You say that the medical records provided
support the necessity of the services in dispute. 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 the automatic external defibrillator, with
integrated electrocardiogram analysis, garment type (K0606) provided on May 30, 2021 by an out-of-network
(OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140)
provided August 18, 2021.
You asked the Plan to pay for the limited oral exam. You say that you don't feel the service should be denied
because you pay premiums. The Plan denied your request. The Plan says you have exceeded the frequency
limit for this 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. The Plan covers the limited
oral exam once per plan year.
We looked at the file and Medicare rules. The Plan provided documentation showing that a limited oral exam
was previously covered on March 12, 2021. Based on this information, we decided that the Plan's frequency
limit for coverage of the limited oral exam has been exceeded. Therefore, we decided that the Plan does not
have to pay for the limited oral evaluation - problem focused (D0140) provided August 18, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the CxBladder test (0012M) provided on March 3, 2021.

You asked the Plan to pay for code 0012M. 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 CPT codes 0012M and 0013M for CxBladder are non-covered. 

We looked at the file and Medicare rules. The service at issue is non-covered. Therefore, we decided that the Plan does not have to pay for the CxBladder test (0012M) provided on March 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the Magnetic resonance angiography (70544) provided on June 10, 2021.

You asked the Plan to pay for code 70544. 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 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, we have confirmed that code 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 the Magnetic resonance angiography (70544) provided on June 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical placement of implant body (D6010) and bone
graft (D6104) provided on October 19, 2021.
You asked the Plan to pay for the surgical placement of implant body (D6010) and bone graft (D6104). You
say that the bridge became loose and would no longer support your bridge. You say that two implants were
needed to replace the two missing teeth. The Plan denied your request. The Plan says the services 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 the
surgical placement of implant body (D6010) and bone graft (D6104) provided on October 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for an onabotulinumtoxina injection (J0585)
and surgical services (64612, 64616) provided on August 20, 2021.
You asked the Plan to waive the cost-sharing for the onabotulinumtoxina injection and surgical services. You
say that the services should be covered as they would cause you a financial hardship The Plan denied your
request. The Plan says the cost-sharing applied correctly based on the services provided.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20%
coinsurance for Medicare Part B prescription drugs and a $15 copayment for Physician/Practitioner services,
including doctor's office visits.
You have been asked to pay a 20% coinsurance an onabotulinumtoxina injection (allowed amount is $954.80 x
20% = $190.96) and a $15 copayment for surgical services. Onabotulinumtoxina injections fall within the
Medicare Part B prescription drugs benefit category and surgical services fall within the Physician/Practitioner
services, including doctor's office visits 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 cost-sharing
for an onabotulinumtoxina injection (J0585) and surgical services (64612, 64616) provided on August 20,
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided on June 23, 2021.
You asked the Plan to waive the copayment for the specialist office visit. You say that you were unaware that you would have a copayment for the follow-up appointment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for each specialist visit. You have been asked to pay a $50 copayment for the specialist office visit. The specialist office visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits 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 specialist office visit provided on June 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the trigger point injections (20552) rendered by the out-of-
network (OON) provider on March 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 trigger point injections (20552) rendered by the out-of-network (OON)
provider on March 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on September 20, 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 office visit (99214) rendered by the out-of-network (OON) provider on
September 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pontic (D6245).

You asked the Plan to pre-approve the pontic. You say that you would like your tooth replaced so you can eat correctly. The Plan denied your request. The Plan says this service is not covered under your benefit plan.

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 pre-approve a pontic (D6245).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the new patient domiciliary or rest home visit (99326) provided on June 23, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for domiciliary or rest home visit. You say that your physician provided medically necessary services to the enrollee in good faith. In consideration for the services rendered, your doctor is seeking reimbursement. 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 the new patient domiciliary or rest home visit (99326) provided on June 23, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot insert (L3170).
You asked the Plan to pay for foot orthotics. You say that the item is medically necessary. The Plan denied
your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace.
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pay for foot insert
(L3170).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the infection control supplies and IV tubing equipment (S1015, S8301) provided on August 11, 2021.

You asked the Plan to pay for the medical equipment. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says this claim has not been billed in accordance with 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. 

We looked at the file and Medicare rules. Specifically, these codes both have a Status Code of "I" under the Physician Fee Schedule. This indicates that these codes are not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the medical equipment have not been met. Therefore, we decided that the Plan does not have to pay for the infection control supplies and IV tubing equipment (S1015, S8301) provided on August 11, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health infusion services (99601) provided on August 12, 2021.
You asked the Plan to pay for the home health infusion services. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says this claim has not been billed 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. In this case, the CPT Code Manual definition of code 99601 is home infusion/specialty drug administration, per visit (up to 2 hours). We looked at the file and Medicare rules. Specifically, code 99601 has a Status Code of "I" under the Physician Fee Schedule. This means that this code is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home health infusion services have not been met. Therefore, we decided that the Plan does not have to pay for the home health infusion services (99601) provided on August 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your
request. The Plan says the criteria is not met.
The Plan must follow Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and
necessary for enrollees with diabetes who meet the criteria referenced 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 the monitor. Our reviewer says that the
requested monitor is not medically reasonable or necessary. Our physician reviewer found based on the
medical records provided, there is no documentation that the enrollee is insulin treated with three or more daily
administrations of insulin or a Medicare-covered continuous subcutaneous insulin infusion pump. There is no
documentation that the enrollee's insulin treatment regimen requires frequent adjustment by the enrollee on the
basis of BGM or CGM testing results.
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 monitor have been met. Therefore, we decided that the Plan does not have to
pre-approve a continuous glucose monitor for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to fully pay for the dental services provided from July 1, 2021, through July 19, 2021.
You asked the Plan to fully pay for the dental services. You say that member services gave false information about the dentist being in-network. You say that you need help with the bill as it is now in default. The Plan denied your request. The Plan says the claim processed correctly toward your out-of-network 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 Plan is only obligated to pay the allowed amount for the dental services provided. You are responsible for any amount greater than what the Plan pays to the out-of-network provider. Therefore, we decided that the Plan does not have to fully pay for the dental services provided from July 1, 2021, through July 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the duplex scan of lower extremity arteries or arterial bypass grafts, complete bilateral study (93925) provided on August 12, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the diagnostic service. You say that the medical records provided will show proof of medical necessity. 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 the duplex scan of lower extremity arteries or arterial bypass grafts, complete bilateral study (93925) provided on August 12, 2021 by an out-of-network (OON) provider.