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

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) provided on February 9, 2021.

You asked the Plan to pay for the ambulance service. You say that someone called an ambulance for you, and you were not transported. You say that you warmed up in a gas station with hot coffee. You also say that you cannot afford to pay this bill. The Plan denied your request. The Plan says there was no transportation provided. The Plan also says that when there is no transportation provided, the service is not covered.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on February 9, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) provided on February 9, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Botulinum Toxin Type A injection you received on May 4, 2021.
You asked the Plan to waive the coinsurance for the Botulinum Toxin Type A injection. You say that you think this drug should be billed under your pharmacy, and not medical, benefits. You say that if it was under pharmacy, you would be able to afford it. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for Medicare Part B drugs.
You have been asked to pay 20% coinsurance for the Botulinum Toxin Type A injection. The Botulinum Toxin Type A injection falls within the Medicare Part B drugs benefit category because Medicare Part B drugs include drugs that usually aren't self-administered and are injected while you are getting physician 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 coinsurance for the Botulinum Toxin Type A injection you received on May 4, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services (A0428, A0425) provided on May 6, 2021.
You asked the Plan to pay for ambulance services. You say that this is supported in the records. The Plan denied your request. The Plan says this is not separately payable form the enrollee's inpatient stay.
The Plan must follow Medicare rules. Medicare rules say that all items and nonphysician services, including transportation, furnished to inpatients must be furnished directly by the hospital or billed through the hospital under arrangements. We looked at the file and Medicare rules. The records show that enrollee was an inpatient on the date of service at issue, meaning that the hospital is responsible for the payment or billing of this service. Based on this information, we decided that Medicare rules for coverage of ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for ambulance services (A0428, A0425) provided on May 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the progressive lenses (V2781) and deluxe frames (V2025)
provided April 27, 2021.
You asked the Plan to pay for the progressive lenses and deluxe frames. You say that the OON provider has
given you service beyond what you received from an in-network provider. The Plan denied your request. The
Plan says the provider in this case does not participate in your vision plan and therefore the eyewear is not
covered.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers these services up to a $300 benefit when purchased at a network optical provider.
We looked at the file and the Plan's rules. The requested provider in this case is not a network provider with the
Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We
found no exception that would require the Plan to pay for these items/services. Based on this information, we
decided that the Plan's rules for coverage of the progressive lenses and deluxe frames have not been met.
Therefore, we decided that the Plan does not have to pay for the progressive lenses (V2781) and deluxe frames
(V2025) provided April 27, 2021.
Your complaint about which providers are covered under the Plan's benefits and you dissatisfaction with
service provided by an in-network vision provider in the past 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: 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 a review of the current medical literature indicates that this service is considered experimental and investigational.

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.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on June 10, 2021.
You asked the Plan to pay for the dental service. You say that this is the only periodontist in your town. You also say that you do not feel comfortable and safe driving too far. 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 to providers that have 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. 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, the file shows that the provider in this case has opted out of Medicare. The Evidence of Coverage clearly states that if you use a provider that has opted out of Medicare, you will not receive reimbursement. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on June 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the rest home and annual wellness visits rendered on January
7, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services were not billed correctly.
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis
code.
We looked at the file and Medicare rules. The file shows that the claim was billed with mismatched diagnosis
codes. Based on this information, we decided that Medicare rules for coverage of these services have not been
met. Therefore, we decided that the Plan does not have to pay for the rest home and annual wellness visits
rendered on January 7, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on March 13, 2021.
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the charges because of how the enrollee was treated by the ambulance staff. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is being charged the correct 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $200 copayment for ambulance services. The enrollee has been asked to pay a $200 copayment for ambulance services. Ambulance services fall within the ambulance services benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services provided on March 13, 2021.
We note your complaint that the staff did not treat the enrollee well. Your complaint is a grievance that must be answered by the health 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 pre-approve continuous glucose monitor (CGM) supplies.

You asked the Plan to pre-approve the CGM supplies. You say that you take oral medication for your diabetes and are on dialysis. You say that you must check your glucose levels 8 times a day and pricking your finger so frequently is painful. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for coverage of the requested items.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the CGM supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve continuous glucose monitor (CGM) supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided on May 25, 2021.

You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says you did not have prior authorization for out of network care.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must 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 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 out of network physician services provided on May 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you have a foot ulcer and will significantly
benefit orthotics as alternative for surgery. 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 you do not suffer from diabetic foot disease and you do not wear a leg brace. Although
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services (procedure code A0428) provided to the enrollee on May 30, 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 there was no actual transport that happened.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on May 30, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for ambulance services (procedure code A0428) provided to the enrollee on May 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction provided on April 22, 2021.
You asked the Plan to pay for an eye refraction. The Plan denied your request. The Plan says an eye refraction
is not a covered benefit when it is being performed for medical reasons, such type 2 diabetes mellitus without
complications. Eye refractions are only covered by your Plan if performed by a participating provider and
performed as a routine screening.
The Plan must follow Medicare rules. Medicare does not pay for procedures performed in the course of any eye
exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in
connection with otherwise covered diagnosis or treatment of illness or injury.
We looked at the file and the Medicare rules. Medicare does not pay for procedures performed in the course of
any eye exam to determine the refractive state of the eyes. Therefore, we decided that the Plan does not have to
pay for an eye refraction provided on April 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pontic (D6241) and two retainer crowns (D6751 x2).

You asked the Plan to pre-approve the pontic and retainer crowns. You say that your provider recommends
these services and has no alternative options for you. You also say that you believe these services should be
approved for coverage by the Plan. The Plan denied your request. The Plan says these services are 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 (D6241) and two retainer crowns (D6751 x2).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a tetanus, diphtheria toxoids and acellular pertussis (Tdap)
vaccine (90715) and administration (90471) provided on May 18, 2021.
You asked the Plan to pay for a Tdap vaccine and administration. You say that you needed this because you are
a cancer survivor. The Plan denied your request. The Plan says coverage of this vaccine is the responsibility of
your prescription drug plan.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a Tdap vaccine and
administration. The Plan follows the same rules.
Records do not show that you have been injured or directly exposed to any illness related to a Tdap vaccine and
administration. Therefore, we decided that the Plan does not have to pay for a tetanus, diphtheria toxoids and
acellular pertussis (Tdap) vaccine (90715) and administration (90471) provided on May 18, 2021.
Benefits for a Tdap vaccine and administration 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the gauze, non-impregnated, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing (A6219) provided on May 21, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the sterile dressing. You say that the claim should be paid and you request a reconsideration of the denial. 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 gauze, non-impregnated, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing (A6219) provided on May 21, 2021, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services (S9348) provided March 19, 2021 to March 25, 2021.
You asked the Plan to pay for the home health services. You say that the services were medically necessary. The Plan denied your request. The Plan says the code billed is not eligible for Medicare payment.
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 find that CPT code S9348 is not supported in the medical record. Specifically, per the National Physician Fee Schedule, CPT code S9348 has a status of "I" which means it is ineligible for Medicare payment. Based on this information, we decided that Medicare rules for coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to pay for home health services (S9348) provided March 19, 2021 to March 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal scaling and root planing (D4341) provided on June 1, 2021.
You asked the Plan to pay for periodontal scaling and root planing. You say that you are covered for cleanings and deep cleanings and do not understand why this claim is denied. The Plan denied your request. The Plan says this service is not covered by your dental benefit. Your plan covers standard prophylaxis cleanings and periodontal maintenance, which is a deeper cleaning for an individual with a documented history of gum disease. Periodontal scaling and root planing is a different service which is not covered by this 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 periodontal scaling and root planing (D4341) provided on June 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for facet joint injections (64635, 64636) provided April 21, 2021
You asked the Plan to pay for facet joint injections. You say that the services were medically necessary. The Plan denied your request. The Plan says the number of units billed exceeds the allowable amount.
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 64635 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Since CPT code 64635 is not covered, addon code 64636 is not eligible for coverage. Based on this information, we decided that Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan does not have to pay for facet joint injections (64635, 64636) provided April 21, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for tissue examination (88305) provided on April 26, 2021.
You asked the Plan to pay for tissue examination. You say that this is supported in the records. The Plan denied your request. The Plan says this is not separately payable.
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 88305 has a bundled relationship with code 17311 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 tissue examination (88305) provided on April 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you by an out-of-network provider on April 8, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 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 services provided to you by an out-of-network provider on April 8, 2021.