Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient observation services provided by
a contracted provider on August 20, 2021.
You asked the Plan to waive the copayment for outpatient observation services. You say that you do not think
you should have to pay for this. The Plan denied your request. The Plan says the correct copayment has 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 $225
copayment for outpatient hospital observation.
You have been asked to pay a $225 copayment for outpatient observation services. The correct copayment has
been applied to the services that were provided. Outpatient observation services fall within the outpatient
hospital observation benefit category. This means that you have been asked to pay the correct amount based on
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for outpatient
observation services provided by a participating provider on August 20, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered by the out-of-network
(OON) provider on July 8, 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 laboratory services rendered by the out-of-network (OON) provider on July 8,
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) (K0553) provided on April 9, 2021.  You asked the Plan to pay for the CGM. 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. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.   The record does not contain a valid physician order or relevant medical records which support medical necessity for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor (CGM) (K0553) provided on April 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Sanexas device therapy and vitamin injections provided
on July 27, 2021 and billed with CPT codes G0283, 97750, 96372, 97112, J3411, J3415, J7999, 97016 and
J3490.
You asked the Plan to pay for the Sanexas device therapy and vitamin injections. You say that you would like
reconsideration based on the records submitted. The Plan denied your request. The Plan says this therapy is not
a Medicare covered benefit.
The Plan must follow Medicare rules. Medicare rules say that Medicare Part B pays for outpatient physical
therapy services only if they are furnished by, or under the direct supervision of a physical therapist in private
practice; or by, or incident to the service of a nurse practitioner (NP) or physician assistant (PA) only when that
NP/PA may perform physical therapy services under State law. The rules also say that in order for physician provided drugs to be covered, the medical records must document the name of the drug administered as well as
the dosage.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the Sanexas device therapy and vitamin injections have not been met. Specifically, after review of
the file and publicly available records, we find that the physical therapy services at issue in this case were
rendered by an NP/PA who is not licensed to provide physical therapy in the State of Oklahoma. Also, payment
for HCPCS/CPT codes J3411, J3415, J7999, 96372 and J3490 are not supported. The record does not contain
documentation of the dosage and type of drug administered in each injection, which is required by Medicare
for these services to be reimbursed. Additionally, the record indicates that these services were not urgent,
emergent or approved in advance. Therefore, we decided that the Plan does not have to pay for the Sanexas
device therapy and vitamin injections provided on July 27, 2021 and billed with CPT codes G0283, 97750,
96372, 97112, J3411, J3415, J7999, 97016 and J3490.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown - porcelain/ceramic (D2740) and core buildup,
including any pins when required (D2950) provided September 16, 2021.
You asked the Plan to pay for the crown and core buildup. You say that you would like these services covered.
The Plan denied your request. The Plan says these services are not covered under your 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 crown
- porcelain/ceramic (D2740) and core buildup, including any pins when required (D2950) provided September
16, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the computed tomographic angiography of the chest (71275) provided on May 26, 2021.  You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service 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 $110 copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in a physician's office or at a free-standing facility (such as a radiology center or medical clinic).   You have been asked to pay a $110 copayment for the Medicare-covered radiological diagnostic service provided. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the computed tomographic angiography of the chest (71275) provided on May 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for imaging services received on September 5, 2021.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the provider did not bill as required by Medicare coding regulations.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70460 is a column II code to column I code 70496. 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 imaging services received on September 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (S1015, S8301) provided on August 4, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not covered.

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 purposes. 

We looked at the file and Medicare rules. Codes S1015 and S8301 are assigned a status indicator of "I" under the Physician Fee Schedule, which means that these codes are not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services. 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 (S1015, S8301) provided on August 4, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the
enrollee from September 16, 2021 to October 12, 2021.
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your
request. The Plan says the enrollee did not require or receive any skilled level medical management or nursing
services.
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 pay for the services. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found based on the medical records provided there is
no documentation that the enrollee required skilled nursing services, i.e., the specialized skill, knowledge and
judgment of a skilled professional nurse were not required to safely and effectively provide medically
necessary and reasonable treatment from 09/16/2021 through 10/12/2021. No treatment with physical therapy
was documented in the records available. Daily skilled services were not required from 09/16/2021 through
10/12/2021. Services in the nursing facility appear custodial in this case (with part time skilled occupational
therapy services provided) from 09/16/2021 through 10/12/2021.
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 pay for skilled nursing facility (SNF) services provided to the enrollee from September 16, 2021 to
October 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for 2 additional extractions (D7210), and alveoloplasty in
conjunction with extractions (D7311) provided on August 19, 2021.
You asked the Plan to pay for the 2 additional extractions and alveoloplasty. You say that you were advised by
the dentist that you would be fully refunded for these services. The Plan denied your request. The Plan says
alveoloplasty in conjunction with extractions 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 alveoloplasty in conjunction with
extractions is not among those covered under this benefit. The record shows that 2 extractions are covered per
year. The record also shows that the Plan paid for 2 extractions that you received on the date of service in this
case. Therefore, we decided that the Plan does not have to pay for 2 additional extractions (D7210), and
alveoloplasty in conjunction with extractions (D7311) provided on August 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on July 8, 2021 by an out-
of-network (OON) provider.
You asked the Plan to pay for the laboratory services. You say that you believe you should not be held
responsible for the billed charges. The Plan denied your request. The Plan says the services received are not a
covered benefit when provided by an OON provider.
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 laboratory services provided on July 8, 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 the ostomy supplies (A5057), provided on July 27, 2021 by
an out-of-network (OON) provider.
You asked the Plan to pay for the ostomy supplies. You say that the items should be covered. The Plan denied
your request. The Plan says prior authorization is required for non-emergent services obtained out-of-network.
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 ostomy supplies (A5057), provided on July 27,
2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on August 23, 2021.
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.
The Plan follows Medicare rules. The rules say that the enrollee's medical record must include an appropriate
testing frequency based on the stage of screening, treatment, or recovery; the rationale for the drugs/drug
classes ordered; and the results must be documented in the medical record and used to direct care.
Review of the file does not support the required frequency relationship criteria. Therefore, we decided that the
Plan does not have to pay for the drug testing provided on August 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), complete series
x-ray (D0210), and prophylaxis (D1110) provided on August 18, 2021.
You asked the Plan to pay for the dental services. You say that when the enrollee's plan was contacted, no one
advised of the specific plan. You also say that you feel it is not fair for the enrollee or the office that this claim
was denied. The Plan denied your request. The Plan says there is no coverage for dental services that are
performed out of network.
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 enrollee's Plan offers a dental benefit in excess of Medicare coverage, dental services performed
out of network are not among those covered under this benefit. Additionally, the record shows that you did not
verify your network status prior to the date of service. Therefore, we decided that the Plan does not have to pay
for the comprehensive oral evaluation (D0150), complete series x-ray (D0210), and prophylaxis (D1110)
provided on August 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and management of an established patient (99337) rendered by the out-of-network (OON) provider on September 9, 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 for the evaluation and management of an established patient (99337) rendered by the out-of-network (OON) provider on September 9, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialty care transport (A0434) and
ground mileage (A0425) provided September 1, 2021.
You asked the Plan to waive the copayment for the specialty care transport. You say that since it was necessary
to transport you to another hospital for treatment, you feel that it is a continuation of service that should be the
hospital's responsibility. The Plan denied your request. The Plan says the copayment was applied 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 for each Medicare-covered service or one-way trip by ground transportation.
You have been asked to pay a $225 copayment for the specialty care transport. The specialty care transport
falls within the Ambulance 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 specialty care transport (A0434) and ground mileage (A0425) provided September 1, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an outpatient colonoscopy provided on September 30, 2021.  You asked the Plan to waive the copayment for a colonoscopy. You say that this service was not a diagnostic procedure, and you received the wrong instruction to prep for the test, so you had to schedule another colonoscopy. The Plan denied your request. The Plan says the provider billed for this service and the proper copayment 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 $325 copayment for Diagnostic Colonoscopy in an Outpatient Hospital.     You have been asked to pay a $325 copayment for an outpatient colonoscopy. An outpatient colonoscopy falls within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an outpatient colonoscopy provided on September 30, 2021.   Your complaint about your experience with this 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral exam (D0140) and bitewing x-rays (D0270)
provided on September 14, 2021.
You asked the Plan to pay for the exam and x-rays. You say that this service was necessary, and you have not
used your whole $1,000 limit for dental care. The Plan denied your request. The Plan says bitewing x-rays and
limited oral exams may only be covered once per year. You had a previous set of bitewing x-rays in April 2021
and a previous limited exam in August 2021. You have exhausted your benefit for these services in 2021, and
those provided on the date in question are 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. The Plan can cover one
limited exam to evaluate a problem per plan year and one set of bitewing x-rays per plan year.
Though the Plan offers a dental benefit in excess of Medicare coverage, the items or services are requested in a
frequency that exceeds what is covered under this benefit. Documentation shows that you had a previous set of
bitewing x-rays and a previous limited exam in 2021, which were covered by the Plan. Therefore, we decided
that the Plan does not have to pay for the limited oral exam (D0140) and bitewing x-rays (D0270) provided on
September 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a limit oral evaluation (D0140), intraoral x-rays (D0220, and D0230), and an unspecified preventative procedure (D1999) provided by an out-of-network provider on March 16, 2021.  You asked the Plan to pay for a limit oral evaluation, intraoral x-rays, and an unspecified preventative procedure. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says the dental services provided are not covered dental 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 a limit oral evaluation (D0140), intraoral x-rays (D0220, and D0230), and an unspecified preventative procedure (D1999) provided by an out-of-network provider on March 16, 2021.