Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit provided on April 1, 2021 by an out-of-network (OON) provider.  

You asked the Plan to pay for the OON office visit. You say that you feel that these services have been denied incorrectly as they are covered under Medicare. The Plan denied your request. The Plan says this visit was provided OON without 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 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 office visit provided on April 1, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the complete series x-ray (D0210) and adjunctive pre-diagnostic test (D0431) provided on September 1, 2021.  You asked the Plan to pay for the dental services. You say that you rely on the provider to let you know what is and is not covered. You say that you asked the provider to confirm with your plan as they have the codes that will be used. You also say that you were assured the services would be covered. The Plan denied your request. The Plan says complete series x-ray is not listed as a covered service. The Plan says that adjunctive pre-diagnostic test is not listed as a covered service either.  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 complete series x-ray and adjunctive pre-diagnostic test are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the complete series x-ray (D0210) and adjunctive pre-diagnostic test (D0431) provided on September 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for CxBladder testing (0012M) provided on June 22, 2021.  

You asked the Plan to pay for CxBladder testing. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered.  

The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for CxBladder are non-covered.  

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CxBladder testing have not been met. Therefore, we decided that the Plan does not have to pay for CxBladder testing (0012M) provided on June 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the sunglass lenses (S0504) and frames (S0418) purchased on October 14, 2020.  You asked the Plan to pay for the sunglasses. You say that this claim was submitted and processed incorrectly. The Plan denied your request. The Plan says that they did find that the codes initially submitted on this claim were inaccurate, and they have agreed to cover the eyeglasses purchased following your cataract surgery on this date and provide additional reimbursement. However, you had previously exhausted your supplemental benefit for routine vision services in April of 2019. There is a maximum benefit allowance of $240 every 24 months for supplemental eyewear; therefore, the additional eyewear purchased on this date remains denied.  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 $240 every 24 months.  We looked at the file and the Plan's rules. Documentation shows that the Plan has covered the eyeglasses purchased following your cataract surgery, and that you have used your routine vision benefit allowance in full in April of 2019. Based on this information, we decided that the Plan's rules for coverage of the additional eyewear have not been met. Therefore, we decided that the Plan does not have to pay for the sunglass lenses (S0504) and frames (S0418) purchased on October 14, 2020.
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 September 13, 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 September 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the office visit (99204) provided on  July 23, 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 $45 copayment for each Medicare-covered specialist visit.   

You have been asked to pay a $45 copayment for the Medicare-covered specialist visit 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 office visit (99204) provided on July 23, 2021.   

Your complaint that the physician advised he would be unable to provide treatment for your condition in the office visit provided 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: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ground mileage (A0425) and non-emergent ambulance transport (A0428) provided on August 31, 2021.  You asked the Plan to pay for the ambulance transport and mileage. You say that the enrollee required non-emergent transportation by ambulance back to the nursing facility. You also say that you need payment for this claim. The Plan denied your request. The Plan says the criteria are not met for non-emergency ambulance transportation.  Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules.      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 ambulance transport and mileage. Our reviewer says that the documentation does not support that the ambulance transport on August 31, 2021 was medically reasonable and necessary for the patient. Our physician reviewer found the documentation does not support that other means of transport (such as stretcher van) were contraindicated for this patient on this date of service. Our reviewer also found that the documentation does not support that the patient needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport on August 31, 2021. Oxygenation was normal, she was hemodynamically stable, and did not receive treatment during transport.  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 ambulance transport and mileage have not been met. Therefore, we decided that the Plan does not have to pay for the ground mileage (A0425) and non-emergent ambulance transport (A0428) provided on August 31, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided on July 7, 2021, through July 9, 2021.  You asked the Plan to waive the copayment for the inpatient hospital care. You say that the cost share is wrong. The Plan denied your request. The Plan says the cost share 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 30% coinsurance per visit and the plan will reimburse a maximum of $1,500 for out-of-network (POS) services per calendar year for inpatient hospital care.   You have been asked to pay a 30% coinsurance for the inpatient hospital care. This service falls within the inpatient hospital care 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 inpatient hospital care provided on July 7, 2021, through July 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the core buildups, including any pins when required (D2950) provided September 7, 2021.  You asked the Plan to pay for the core buildups. You say that this service was necessary, you were not told it would not be covered and you cannot afford the cost. The Plan denied your request. The Plan says this service is 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 core buildups, including any pins when required (D2950) provided September 7, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance oxygen and oxygen supplies, life sustaining situation (A0422) provided January 15, 2021.  

You asked the Plan to pay for the oxygen supplies provided during ambulance transport. You say that the claim should be covered. The Plan denied your request. The Plan says this service is not separately payable.  

The Plan must follow Medicare rules. The rules say that the cost of oxygen and its administration in connection with and as part of the ambulance service is covered.  Under the ambulance fee schedule (FS), oxygen and other items and services provided as part of the transport are included in the FS base payment rate and are NOT separately payable. pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules.  

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the oxygen supplies provided during ambulance transport have not been met. Specifically, the record shows the enrollee was provided emergency ambulance transport. The oxygen supplies provided during the ambulance transport are not separately billable. Therefore, we decided that the Plan does not have to pay for the ambulance oxygen and oxygen supplies, life sustaining situation (A0422) provided January 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a specialist office visit provided on January 21, 2021.  You asked the Plan to waive the copayment for the specialist office visit. You say that your appointment was in the doctor's office and not an outpatient facility. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for specialist office visits.   You have been asked to pay a $40 copayment for the specialist office visit. Specialist office visits fall within the Physician/Practitioner Services, Including Doctor's Office Visits benefit category.  This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a specialist office visit provided on January 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for out of network medial services provided to the enrollee on September 8, 2021.  You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee 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 medial services provided to the enrollee on September 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for an eye refraction (92015) provided on July 23, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for an eye refraction. You say that you are requesting reconsideration of the denial charges. The Plan denied your request. The Plan says the service is not a covered benefit. An eye refraction is only covered by the Plan when it is performed as part of a routine screening. 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 contract also says that a refraction is covered when it is performed as part of a routine screening.  We looked at the file and the Plan's rules. The eye refraction was performed as part of a medical vision exam, and therefore is not a covered benefit. Based on this information, we decided that the Plan's rules for coverage of an eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for an eye refraction (92015) provided on July 23, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on August 12, 2021.  You asked the Plan to pay for the dental service. You say that you do not understand what frequency means. The Plan denied your request. The Plan says 1 set of bitewing x-rays are covered per plan year. The Plan also says that the number of allowed bitewing x-rays per year has been exceeded.  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 and bitewing x-rays are listed as covered, the number of bitewing x-rays that are allowed per year has been exceeded.    The record shows that the Plan paid for a set of bitewing x-rays that you received on February 10, 2021. Therefore, we decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on August 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the anesthetic injection rendered on July 9, 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 procedure code 64416 is not separately payable.  The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.     The provider submitted a claim for procedure codes 64416 (anesthetic injection) and 01760 (anesthesia for open or surgical arthroscopic procedures on the elbow). Code 64416 is a column II code with a modifier indicator of 1 when billed with column I code 01760. Code 64416 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the anesthetic injection rendered on July 9, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for infrared therapy (97026) provided on July 22, 2021.  You asked the Plan to pay for infrared therapy (97026). The Plan denied your request. The Plan says infrared therapy is noncovered for all indications.  The Plan must follow Medicare rules. Medicare rules say that infrared therapy is noncovered for all indications.  We looked at the file and Medicare rules. Medicare says infrared therapy is noncovered for all indications. Therefore, we decided that the Plan does not have to pay for infrared therapy (97026) provided on July 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the medical services (99053) provided on July 21, 2021.  You asked the Plan to pay for code 99053. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We looked at the file and Medicare rules. Code 99053 has a status code of "B" under the Medicare Physicians Fee Schedule Database (MPFSDB) and no separate payment is made for this code under the fee schedule as payment is bundled into the payment for the services to which this code is incident to. Therefore, we decided that the Plan does not have to pay for the medical services (99053) provided on July 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on August 12, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the laboratory services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide 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 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 August 12, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level (CPT code 64494) and injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level (CPT code 64493), for the enrollee.  You asked the Plan to pre-approve the service. You say that the enrollee wants to only have injection as these have helped them and the last injection lasted for five (5) months. You state the enrollee is happy with only injections at this point and they are in pain again and would like to have these done again. The Plan denied your request. The Plan says there is no documentation of failed conservative measures, there is no imaging to rule out other causes of pain, and there is no documented deterioration of functional status to support repeat injection.  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 service. Our physician reviewer found there is no documentation of conservative treatments, pain assessments, no images, no documentation of functional status, and no relating information to prior injections and their success or failures in the treatment of the enrollee's pain outside of it working for five (5) months with the last injection. The request does NOT meet with the LCD for therapeutic facet joint injection and is therefore, not medically reasonable or necessary.  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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level (CPT code 64494) and injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level (CPT code 64493), for the enrollee.