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

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the orbit, sella, or
posterior fossa or outer, middle, or inner ear rendered on September 24, 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 are 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 70480 (CT orbit, sella, or posterior fossa or outer, middle,
or inner ear) and 70450 (CT head or brain). Code 70480 is a column II code with a modifier indicator of 1
when billed with column I code 70450. Code 70480 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 computed tomography (CT)
scan of the orbit, sella, or posterior fossa or outer, middle, or inner ear rendered on September 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on April 19, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says the rendering provider is an out-of-network 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 physician services provided on April 19, 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 dental services provided by a participating provider on
September 16, 2021.
You asked the Plan to pay for dental services. You say that you would like the Plan to pay for this. The Plan
denied your request. The Plan says a dental rider was not selected.
Medicare generally does not cover dental services. The Plan follows the same rule.
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid
for by Medicare. Therefore, we decided that the Plan does not have to pay for dental services provided by a
participating provider on September 16, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the CxBladder testing provided on August 3, 2021.
You asked the Plan to pay for the testing services. You say that the testing is clinically validated. The Plan
denied your request. The Plan says this is not an approved test.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We looked at the file and the rules. We find that the testing at issue is not supported in the medical record.
Specifically, there are insufficient medical records to show how the results will be used to assist in the
management of the enrollee. The records do not show that the testing was ordered to treat a specific medical
problem. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore,
we decided that the Plan does not have to pay for the CxBladder testing provided on August 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for segmental pneumatic compression device (E0651) segmental pneumatic appliance (E0667) provided August 18, 2021.

You asked the Plan to pay for pneumatic compression device and appliance. You say that you have attached all the supporting documentation. Please reprocess the claim. The Plan denied your request. The Plan says this request is not medically necessary because the records do not show that there an appropriate face to face encounter documented in the records to substantiate the need for this item.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file and Medicare rules. Based on the records provided, the enrollee did not meet the criteria needed for the orthoses provided. Based on this information, we decided that Medicare rules for coverage of pneumatic compression device and appliance have not been met. Therefore, we decided that the Plan does not have to pay for segmental pneumatic compression device (E0651) segmental pneumatic appliance (E0667) provided August 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on August 17, 2021.

You asked the Plan to pay for out of network 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 physician services provided to the enrollee on August 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the implant removal (D6100), guided tissue regeneration
(D4266) and biologic materials to aid in soft and osseous tissue regeneration (D4265) provided on June 9,
2021.
You asked the Plan to pay for the dental services. You say that these services were necessary, and you feel that
the Plan's description of benefits is misleading. The Plan denied your request. The Plan says they have agreed
to pay for the implant placement and bone graft; however, the remaining services are not covered by your
dental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
implant removal (D6100), guided tissue regeneration (D4266) and biologic materials to aid in soft and osseous
tissue regeneration (D4265) provided on June 9, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to pay for the electrocardiogram (EKG) interpretation and report and emergency room (ER) services rendered on April 15, 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 claim is a duplicate.  The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied.  We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the Plan on a separate claim for the same date of service. 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 electrocardiogram (EKG) interpretation and report and emergency room (ER) services rendered on April 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the cost sharing for the continuous glucose monitor testing services you received from an endocrinologist on November 14, 2020, and the injections you received on November 14, 2020, November 16, 2020, and November 23, 2020.  You asked the Plan to waive the cost sharing for the continuous glucose monitor testing services and the injections. You say that you were never told that you would owe anything.  You said that you are elderly and cannot afford this bill. The Plan denied your request. The Plan says you were charged this cost sharing correctly. The Plan says that for the continuous glucose monitor testing, since the allowed amount for this service ($39.71) is less than your copayment obligation, you are responsible for the full allowed amount for this service.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for diagnostic procedures and tests in an office setting and 20% coinsurance for Medicare Part B drugs and administration.   You have been asked to pay a $40 copayment for the continuous glucose monitor testing services and 20% coinsurance for the injections. The continuous glucose monitor testing services fall within the diagnostic procedures and tests in an office setting benefit category and the injections fall with the Medicare Part B drugs and administration 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 cost sharing for the continuous glucose monitor testing services you received from an endocrinologist on November 14, 2020, and the injections you received on November 14, 2020, November 16, 2020, and November 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for eyeglasses provided on September 20, 2021.

You asked the Plan to reimburse you for the eyeglasses. You say that you went to the eye doctor whose office is connected to this provider thinking this provider was in the network. The Plan denied your request. The Plan says there are no benefits for out of network services.

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 when received through the Plan's vision network provider. 

We looked at the file and the Plan's rules. The file shows that the eyeglasses were not provided through the Plan's vision network provider.

Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to reimburse you for eyeglasses provided on September 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tetanus, diphtheria toxoids and acellular pertussis
vaccine (Tdap) vaccine (90715) provided on October 12, 2021.

You asked the Plan to pay for the Tdap vaccine. You say that you would like reconsideration because you were
advised by your doctor to receive this vaccine. The Plan denied your request. The Plan says this vaccine is not
covered under Medicare Part B.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Tdap vaccine.
The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any
illness related to the Tdap vaccine. Therefore, we decided that the Plan does not have to pay for the Tetanus,
diphtheria toxoids and acellular pertussis vaccine (Tdap) vaccine (90715) provided on October 12, 2021.

Benefits for the Tdap vaccine 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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on September 17, 2021.  You asked the Plan to waive the copayment for the outpatient surgery. You say that the copayment for this service is too high. The Plan denied your request. The Plan says the proper copayment was applied for this service.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $550 copayment for outpatient surgery in an Outpatient Hospital Facility.     You have been asked to pay a $550 copayment for the outpatient surgery. The outpatient surgery falls within the Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 surgery provided on September 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on April 22, 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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a
physician who has furnished a consultation or treats an enrollee for a specific medical problem.
We looked at the file and Medicare rules. The file does not contain documentation of an established
relationship between the enrollee and the ordering provider. Without a record showing that this provider is
treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the
Plan does not have to pay for the laboratory services rendered on April 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the oral hygiene instructions (D1330) and periodic oral evaluation - established patient (D0120) provided September 17, 2021.  You asked the Plan to pay for the oral hygiene instructions and periodic oral exam. You say that you feel the provider was dishonest and you should not have any cost for the services. The Plan denied your request. The Plan says you have exceeded the frequency limit for the periodic oral exam and the oral hygiene instructions are not 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. The Plan covers the oral hygiene instructions and periodic oral exam twice per calendar year.   We looked at the file and Medicare rules. The Plan has previously covered two exams in 2021. Based on this information, we decided that the Plan's frequency limit for coverage of the periodic oral exam has been exceeded. Though the Plan offers dental benefits in excess of Medicare coverage, the oral hygiene instructions are not among those covered services. Therefore, we decided that the Plan does not have to pay for the oral hygiene instructions (D1330) and periodic oral evaluation - established patient (D0120) provided September 17, 2021.   Your complaint about the network provider potentially providing incorrect information 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: Drugs
Decision: Favorable

 We decided that the Plan has to pre-approve use of Supartz or Visco-3.  You asked the Plan to pre-approve Supartz/Visco-3. You say that you no longer use Orthovisc. The Plan denied your request. The Plan says that the denial of authorization for this drug is correct, because the enrollee does not meet the exception criteria for use of a non-preferred drug and had no previous adverse reactions to the Plan's preferred drug of Orthovisc.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 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; however, viscosupplementation drugs are not included in the types of drugs subject to the Plan's Part B step therapy.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan says that viscosupplementation is likely to be of benefit, but that it will not approve a non-preferred drug simply because your practice no longer uses the preferred drug of Orthovisc. However, the enrollee's contract with the Plan does not clearly impose Part B drug step therapy requirements on viscosupplementation drugs. Therefore, the Plan has not shown that the enrollee is contractually obligated to use the Plan's preferred drug of Orthovisc instead of a non-preferred drug such as Supartz or Visco-3. Therefore, we decided that the Plan has to pre-approve use of Supartz or Visco-3.   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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Fluorescence in situ Hybridization (FISH)testing (coded as 88120) provided to the enrollee on July 8, 2021.

You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your request. The Plan says this test is not covered as a screening.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. This testing was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for Fluorescence in situ Hybridization (FISH)testing (coded as 88120) provided to the enrollee on July 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for inpatient hospital services you received
from August 18, 2021, to August 20, 2021.
You asked the Plan to waive the coinsurance for the inpatient hospital services. You say that you are appealing
these charged but you did not provide any explanation as to why in your appeal request. 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 inpatient hospital care.
You have been asked to pay 20% coinsurance for the inpatient hospital 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 inpatient hospital services you received from August 18, 2021, to August 20,
2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Cxbladder testing rendered on August 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 the testing is not covered.

The Plan must follow Medicare rules. The rules say that the Cxbladder testing is non-covered. 

We looked at the file and Medicare rules. The test at issue is Cxbladder. This test is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the Cxbladder testing rendered on August 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on August 6, 2021.  

You asked the Plan to pay for out of network 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 physician services provided to the enrollee on August 6, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an emergency room visit provided on October 11, 2021.  You asked the Plan to waive the copayment for an emergency room visit. You say that the emergency room did not treat you and you left to another hospital. The Plan denied your request. The Plan says medical records received show the enrollee was seen by this provider. The quality-of-care concerns of the enrollee were also addressed. The proper copayment was applied for this service.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copayment for each emergency care visit.     You have been asked to pay a $90 copayment for an emergency room visit. An emergency room visit falls within the Emergency 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 an emergency room visit provided on October 11, 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.