Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for oxygen equipment (E1390) provided June 14, 2021.
You asked the Plan to pay for the oxygen equipment. You say that you were told the equipment would be covered. The Plan denied your request. The Plan says only rental oxygen equipment is covered.
The Plan must follow Medicare rules. Medicare rules say that purchased oxygen equipment is statutorily non-covered. We looked at the file and Medicare rules. The oxygen equipment was purchased. Oxygen equipment is only covered for rental. Based on this information, we decided that Medicare rules for coverage of the oxygen equipment have not been met. Therefore, we decided that the Plan does not have to pay for oxygen equipment (E1390) provided June 14, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services provided from January 18, 2021,
to January 20, 2021.
You asked the Plan to pay for outpatient hospital services. You say that this claim was billed correctly, and you
have submitted supporting records. The Plan denied your request. The Plan says the denial of payment for these
services is correct, because code 93352 has a Status Indicator of M which is not payable and the other codes
billed on this claim are not payable until this Integrated Outpatient Code Editor (I/OCE) edit error has been
corrected.
The Plan must follow Medicare rules. Medicare rules say that code 93352 has a Status Indicator of M and is not
payable under the Outpatient Prospective Payment System. Medicare rules state that a code with Status
Indicator M results in an I/OCE edit of 72, meaning that the whole claim will be rejected and returned to the
provider until the error is corrected.
We looked at the file and Medicare rules. Code 93352 has a Status Indicator of M and is not payable. We
reviewed the I/OCE Specifications file for this date of service. OCE Edit 72 is invoked when a code has a
Status Indicator of M. The required disposition for a claim with this edit is Return To Provider. This means the
whole claim is returned to the provider. The provider can resubmit the claim once the problem is corrected.
Based on this information, we decided that Medicare rules for coverage of outpatient hospital services have not
been met. Therefore, we decided that the Plan does not have to pay for outpatient hospital services provided
from January 18, 2021, to January 20, 2021
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pay for the anesthesia coded 00142. We decided that the Plan does not have to pay for the additional services coded 99100.
You asked the Plan to pay for the anesthesia coded 00142. You say that it is felt payment should be made based on the records. The Plan says that 99100 is not a payable code. The Plan decided to provide a separate response for the decision on code 00142.
We decided that the Plan has to pay for the anesthesia coded 00142.
The Plan follows Medicare rules. Medicare rules say that plans must make reasonable and diligent efforts to gather and forward information to the Independent Review Entity (IRE). The Plan made no effort to forward information regarding its decision of the non-payment of code 00142. The records included support that this was provided. Without a valid argument, we find the denial is not supported. Therefore, we decided that the Plan has to pay for the anesthesia coded 00142.
We also decided that the Plan does not have to pay for the additional services coded 99100.
The Plan follows Medicare rules. Medicare rules say that providers must report services correctly. Procedures should be reported with the Current Procedural Terminology (CPT) code that describes the services performed. Code 99100 has a status indicator of "B" in the Physician Fee Schedule. This means that payment for this is always bundled in payment for other services. Therefore, we decided that the Plan does not have to pay for the additional services coded 99100.
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 May 24, 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 May 24, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the blood count; complete (CBC), automated (85027) provided April 20, 2021.
You asked the Plan to pay for the CBC laboratory services. You say that the services should be paid. The Plan denied your request. The Plan says there is no additional documentation supporting additional studies which were billed and remain denied.
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 asked our coder 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 CBC laboratory services. Our reviewer says that the billing of blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) (85027) is not supported. Our reviewer found that laboratory report documents a CBC with differential was performed, with no additional testing to confirm more than 1 unit of service should be paid in addition to 1 unit of service already paid. Therefore, any additional units would not be covered.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CBC laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the blood count; complete (CBC), automated (85027) provided April 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the out of network cost share for the oral exam (D0120), prophylaxis (D1110), and bitewing x-rays (D0274) provided on April 28, 2021.
You asked the Plan to waive the out of network cost share for the dental services. You say that you have a preferred provider organization (PPO) plan. You say that you were advised that if you submit a claim, you will get paid up to $1,000. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also says you will be responsible for any difference in amount charged by a non-participating dentist and MAC per procedure.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Specifically, dental services performed out of network may have a higher cost share amount. This is a contractual obligation you agreed to when you enrolled in the Plan's dental coverage. Therefore, we decided that the Plan does not have to waive the out of network cost share for the oral exam (D0120), prophylaxis (D1110), and bitewing x-rays (D0274) provided on April 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on October 6, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 drug testing provided on October 6, 2020 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 full mouth debridement (D4355) provided on June 3,
2021.
You asked the Plan to pay for the full mouth debridement. You say that you went in for a cleaning and were
told it may take two appointments because of extensive work that was needed. You also say that you were not
advised that the cleaning process would become a debridement which your plan does not cover. The Plan
denied your request. The Plan says this procedure is not a benefit under your dental 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 pay for the full
mouth debridement (D4355) provided on June 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the upper and lower dentures provided on February 4, 2021.
You asked the Plan to pay for the upper and lower dentures. You say that you never received upper dentures and the lower ones you received are worthless. You believe that you should not owe anything. The Plan denied your request. The Plan says payment was made for upper and lower dentures for date of service August 10, 2020. As you had dentures covered in the last five years, the new dentures provided in February 2021 were correctly denied.
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, dentures are covered only once every five years. Therefore, we decided that the Plan does not have to pay for the upper and lower dentures provided on February 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $35 copayment charged for specialist services provided on May 14, 2021.

You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The Plan denied your request. The Plan says this copayment was charged based on the service provided and your Plan contract agreement.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan clearly says that you must pay $35 copayment for specialist services. 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 $35 copayment charged for specialist services provided on May 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the problem focused limited oral evaluation (D0140)
and first intraoral periapical x-ray (D0220) provided on April 29, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay more for the problem focused limited oral evaluation and first intraoral periapical xray.
You say that you asked the representative when you signed up for this plan if you could continue seeing
the same dentist you have been seeing for the past 25 years and were told yes. The Plan denied your request.
The Plan says this claim was processed correctly. The Plan also says that no dental benefits or dental providers
were mentioned during your call with the 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, you are responsible for the difference
between the billed amount and allowed amount for dental services received OON. Therefore, we decided that
the Plan does not have to pay more for the problem focused limited oral evaluation (D0140) and first intraoral
periapical x-ray (D0220) provided on April 29, 2021 by an out-of-network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entyvio (J3380).
You asked the Plan to pre-approve Entyvio. You say that this requested drug is medically reasonable for the enrollee's condition. The Plan denied your request. The Plan says step therapy criteria have not been met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Entyvio. Our reviewer says that the requested drug is not medically reasonable and necessary. Our physician reviewer found The Plan requires a trial of Stelara before they will approve the requested drug. In this case, the patient has not tried and failed the required drug(s). There is no documentation provided indicating that the Plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Entyvio have not been met. Therefore, we decided that the Plan does not have to pre-approve Entyvio (J3380).
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for genetic testing (Decision Dx-SCC test) provided on June 8, 2021.
You asked the Plan to pay for genetic testing. You say that this testing is a Medicare covered benefit and was ordered by the enrollee's treating physician with the intent to use the results to inform treatment decisions. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because the enrollee did not meet the coverage criteria for this test.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules. This testing was ordered by an in-network provider. The file does not show that the plan provided notice that genetic testing would not be covered. Under Medicare rules, this means genetic testing is considered approved by the plan. Therefore, we decided that the Plan has to pay for genetic testing (Decision Dx-SCC test) provided on June 8, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral - complete series of radiographic images (D0210) provided August 3, 2021.
You asked the Plan to pay for the complete series of x-rays. You say that you would like the Plan to cover the x-rays because you did not have any performed in 2020. 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 complete series of x-rays once every 36 months. We looked at the file, and Medicare rules. The Plan provided documentation showing that a complete series of x-rays was previously covered on May 28, 2019. Based on this information, we decided that the Plan's frequency limit for coverage of the complete series of x-rays has been exceeded. Therefore, we decided that the Plan does not have to pay for the intraoral - complete series of radiographic images (D0210) provided August 3, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Buprenorphine tablet.
You asked the Plan to pre-approve Buprenorphine. You say that the requested drug is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for self-administered drugs have not been met.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Buprenorphine tablet.
Benefits for Buprenorphine may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for laser prostate surgery provided on February 5, 2021, by an out-of-network provider at an in-network level.
You asked the Plan to pay for laser enucleation of the prostate with morcellation (52649) at in-network benefit level. You say that you are requesting in-network benefits. The Plan denied your request. The Plan says they will approve the claim at the out-of-network level.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the costs to the enrollee will be higher if services are provided by an out-of-network provider. 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 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 at the in-network level. Therefore, we decided that the Plan does not have to pay for laser prostate surgery provided on February 5, 2021, by an out-of-network provider at an in-network level.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pulp vitality test (D0460), treatment of a root canal obstruction (D3331) and retreatment of a previous root canal (D3347) provided on August 14, 2020, through September 11, 2020.
You asked the Plan to pay for the pump vitality test, treatment of a root canal and retreatment of a previous root canal. You say that you would like reconsideration for the dental services. The Plan denied your request. The Plan says the services billed are 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 the pulp vitality test (D0460), treatment of a root canal obstruction (D3331) and retreatment of a previous root canal (D3347) provided on August 14, 2020, through September 11, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from May 22, 2021,
through May 24, 2021.
You asked the Plan to pay for the self-administered drugs. You say that you did not know there was a problem
until you received a denial and you know you have insurance to cover the bills. The Plan denied your request.
The Plan says Medicare Part B does not cover self-administered drugs.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs
provided from May 22, 2021, through May 24, 2021.
Benefits for the self-administered drugs 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 pay for the services (99380) provided on March 31, 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 a status indicator of "B" under the Physician Fee Schedule indicates that payment for covered services are always bundled into payment for other services not specified. We looked at the file and Medicare rules. Code 99380 is assigned a status indicator of "B" under the Physician Fee Schedule, which means that this is a bundled service. Payment for this service is bundled into payment for other services. No separate payment can be made for this service. 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 (99380) provided on March 31, 2021.