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

We decided that the Plan does not have to waive the copayment for the emergency ambulance transportation services (A0427, A0425) provided on March 28, 2021.
You asked the Plan to waive the copayment for the ambulance services. You say that this service was necessary, and you do not understand why you are being billed. The Plan denied your request. The Plan says these services are covered, but you are responsible for your share of the cost. For ambulance services, you must pay a $290 copayment per date of 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). Your contract with the Plan clearly says that you must pay a $290 copayment for ambulance services. You have been asked to pay a $290 copayment 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 the emergency ambulance transportation services (A0427, A0425) provided on March 28, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), bitewing x-rays (D0272), and prophylaxis (D1110) provided on June 15, 2021.

You asked the Plan to pay for the comprehensive oral evaluation, bitewing x-rays, and prophylaxis. You say that you were promised by the Plan and your agent that you would receive two free dental cleanings annually. The Plan denied your request. The Plan says your financial responsibility for the dental cleaning is $25.00.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for a $25 copayment for a preventive dental services visit. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), bitewing x-rays (D0272), and prophylaxis (D1110) provided on June 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic office visit (99212) you had on January 5, 2021.
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the chiropractic office visit (99212) you had on January 5, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a right knee orthosis (L1833) and a suspension sleeve (L2397) November 2, 2020.
You asked the Plan to pay for a knee orthosis and a suspension sleeve. You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met because the request is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for a knee orthosis and a suspension sleeve. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no documentation of recent injury to, or recent surgical procedure on the enrollee's knee, and there is insufficient credible objective documentation of joint laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a knee orthosis and a suspension sleeve have not been met. Therefore, we decided that the Plan does not have to pay for a right knee orthosis (L1833) and a suspension sleeve (L2397) November 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for scanning computerized ophthalmic diagnostic imaging provided on August 18, 2020.
You asked the Plan to pay for scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; optic nerve (92133). You say that the procedure was performed out of medical necessity to evaluate the enrollee due to the reported diagnosis. The Plan denied your request. The Plan says criteria was not met for this procedure.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; optic nerve (92133). Our reviewer says that the service was not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has cataract causing vision loss. The provided records do not indicate the presence of an enumerated indication for posterior segment scanning. The elements of the coverage rule are not satisfied. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; optic nerve (92133) have not been met. Therefore, we decided that the Plan does not have to pay for scanning computerized ophthalmic diagnostic imaging provided on August 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99326) rendered by the out-of-network (OON) provider on March 10, 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 domiciliary or rest home visit (99326) rendered by the out-of-network (OON) provider on March 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99335) provided on September 8, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is included in the surgery payment.

The Plan must follow Medicare rules. Medicare rules say that payment for the listed services is included in the global surgical package. 

We looked at the file and Medicare rules. The requested visit is included in the global surgical package for the surgery performed on the same date of service. Separate payment cannot be made for this visit. 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 pay for the services (99335) provided on September 8, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a computed tomography (CT) scan (70450) provided on May 25, 2021.

You asked the Plan to pay for a CT scan. You say that the enrollee had multiple exams. The Plan denied your request. The Plan says no records have been submitted to support this 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. The rules also say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 

We find that CPT code 70450 is not supported in the medical record. Specifically, medical records documenting this service have not been submitted. Without this information, this code cannot be verified. Based on this information, we decided that Medicare rules for coverage of a CT scan have not been met. Therefore, we decided that the Plan does not have to pay for a computed tomography (CT) scan (70450) provided on May 25, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a computed tomography scan (70450) provided on May 11, 2021.
You asked the Plan to pay for a computed tomography scan. You say that the enrollee had multiple exams. The Plan denied your request. The Plan says this is not separately payable without an additional modifier.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 has a bundled relationship with code 70496 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for a computed tomography scan (70450) provided on May 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says there are not enough studies to show that this device is helpful.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental. More research is needed to show safety and efficacy of the device. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for routine disposable ambulance supplies (A0382) provided on January 25, 2021.
You asked the Plan to pay for routine disposable ambulance supplies. You say that this should be covered. The Plan denied your request. The Plan says this is not payable.
The Plan must follow Medicare rules. Medicare rules say that items and services which include but are not limited to oxygen, drugs, extra attendants, supplies, and night differentials are no longer paid separately for ambulance services. We looked at the file and Medicare rules. The supplies at issue at not paid separately. Based on this information, we decided that Medicare rules for coverage of routine disposable ambulance supplies have not been met. Therefore, we decided that the Plan does not have to pay for routine disposable ambulance supplies (A0382) provided on January 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the two YAG laser capsulotomy procedures you had on April 5, 2021, and April 7, 2021.

You asked the Plan to waive the copayments for the two eye surgeries. You say that you do not agree with being charged a $395 copayment for each date. You said that the original eye surgery you had two years ago was much cheaper. You also said that these procedures only took 20 minutes and you were able to drive home right afterwards. You said that you didn't know that the facility would bill this as surgery. 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 $395 copayment for outpatient surgery.

You have been asked to pay a $395 copayment for the two eye surgeries. Medicare considers YAG laser capsulotomy to be a surgical procedure. 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 copayments for the two YAG laser capsulotomy procedures you had on April 5, 2021, and April 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a lower partial denture (D5214) provided on May 25, 2021.
You asked the Plan to pay for a lower partial denture. You say that the service was necessary. The Plan denied your request. The Plan says the service at issue is not a covered benefit.
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 a lower partial denture (D5214) provided on May 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for wound care provided by a participating provider on April 5, 2021, to April 19, 2021.
You asked the Plan to waive the copayment for wound care. You say that no surgery was performed. The Plan denied your request. The Plan says the correct copayments have been 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 $325 copayment for outpatient surgery/in-network/hospital. You have been asked to pay a $325 copayment for each wound care. The total amount you are being asked to pay is $650 ($325 x 2 surgeries = $650). Wound care is considered an outpatient surgery; therefore, the correct copayments have been applied.
Wound care falls within the outpatient surgery/in-network/hospital 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 wound care provided by a participating provider on April 5, 2021, to April 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup procedure (D2950) provided on April 16, 2021.
You asked the Plan to pay for the core buildup. You say that this was a necessary service that should be covered. The Plan denied your request. The Plan says this service is not covered by your dental benefit.
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 core buildup procedure (D2950) provided on April 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) rendered by the out-of-network (OON) provider on April 5, 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 domiciliary or rest home visit (99336) rendered by the out-of-network (OON) provider on April 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the periodontal maintenance (D4910) provided on May 5, 2021.
You asked the Plan to reimburse you for the dental service. You say that you are aware that the Evidence of Coverage states that the plan does not reimburse for a provider who has opted out of Medicare. You also say that you have been going to this provider for the last 25 years. You say that this service has been covered in the past. You also say that The Plan denied your request. The Plan says the provider in this case has opted out of
Medicare. The Plan also says that payment cannot be made for dental services that you receive from a provider that has opted out of Medicare.
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 dental service when the services are medically necessary and reasonable. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental service have not been met. Specifically, payment cannot be made for dental services that you received from a provider that has opted out of Medicare. Therefore, we decided that the Plan does not have to reimburse you for the periodontal maintenance (D4910) provided on May 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a segmental pneumatic compression device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation of a trial and failure of the basic pump.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found according to the physician medical progress notes, the enrollee does not have lymphedema of the chest, trunk, or abdomen. There are no unique characteristics that would indicate the segmented pump over a standard pump in the submitted documentation. The documentation does not reveal a four week trial of the standard pump. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve a segmental pneumatic compression device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit you had with a cardiology nurse practitioner on April 21, 2021.
You asked the Plan to waive the copayment for the specialty office visit. You say that you were told there would be no charge for this office visit because you already had a test on that day for which you were charged a $75 copayment. 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 $15 copayment for visits or consultations with a specialist. You have been asked to pay a $15 copayment for the specialty office visit. There is no provision in your contract that says you don't owe an office visit copayment if you have a test on the same day. 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 office visit you had with a cardiology nurse practitioner on April 21, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on March 20, 2021.
You asked the Plan to waive the copayment for the ER visit. You say that you feel as though you left the hospital too early on March 18, 2021, requiring you to return two days later. You do not feel as though you should have to pay a second ER copayment. 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 $110 copayment for each emergency room visit. You have been asked to pay a $110 copayment for the ER visit. This copayment applies for each visit to the
ER, regardless of the reason for the visit. 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) visit you had on March 20, 2021.