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

 We decided that the Plan does not have to pay for the glucose blood testing and the Lidocaine services provided on August 20, 2021 by an out-of-network (OON) provider.  

You asked the Plan to pay for the glucose blood testing and the Lidocaine services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.    

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 glucose blood testing and the Lidocaine services provided on August 20, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for subsequent nursing facility care, per day, for the evaluation and management of a patient (99308) provided on May 14, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for subsequent nursing facility care, per day, for the evaluation and management of a patient. You say that you were asked to see this patient at the request of his admitting/attending physician. You also say that you are obligated, when on call, to see a patient as requested regardless of the authorization status. The Plan denied your request. The Plan says the services were performed by a non-participating provider and were not authorized. The Plan also says that the medical records provided to them do not reveal that the services rendered were medically urgent or emergent.  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 subsequent nursing facility care, per day, for the evaluation and management of a patient (99308) provided on May 14, 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 laboratory services provided on July 9, 2021.  You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.  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.  The laboratory testing at issue in this appeal 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 the laboratory services provided on July 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99308) rendered by the out-of-network (OON) provider on April 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 subsequent nursing facility care, per day (99308) rendered by the out-of-network (OON) provider on April 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an annual exam/office visit (G0439, 99214) provided on August 9, 2021, by an OON provider.  You asked the Plan to pay for an annual exam/office visit. You say that this was an annual checkup and  you do not understand why it was not paid. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not referred by a network provider or rendered in an in-network facility. The Plan also says that they have also determined that these services are not urgent or emergent, nor were they approved in advance.  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 an annual exam/office visit (G0439, 99214) provided on August 9, 2021, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit provided on August 31, 2021 by an out-of-network (OON) provider.  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 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 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 August 31, 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 laboratory services provided on August 31, 2020 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 received were neither emergent nor urgent and prior authorization was not obtained to seek 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 31, 2020 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the surgical trays (A4550) provided on March 4, 2021.  You asked the Plan to pay for the surgical trays. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code A4550 has a status indicator of B.  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 A4550 is not supported in the record. Specifically, CPT code A4550 has a status indicator of B. This means that the payment for CPT code A4550 is always bundled into the payment for another procedure or service. Separate payment is not made.   Based on this information, we decided that Medicare rules for coverage of the surgical trays have not been met. Therefore, we decided that the Plan does not have to pay for the surgical trays (A4550) provided on March 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on June 15, 2021.  You asked the Plan to pay for the laboratory services. 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. Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed.    We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regard to the physician's intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on June 15, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ambulance transportation services (A0427) provided on August 12, 2021.  You asked the Plan to waive the copayment for the ambulance transportation. You say that this service should have been covered in full, and this cost is a financial hardship to you. The Plan denied your request. The Plan says this claim was processed correctly, and your copayment was assessed in accordance with your contract.  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 $275 copayment for ambulance services.   You have been asked to pay a $275 copayment for the ambulance transportation. 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 ambulance transportation services (A0427) provided on August 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an inpatient rehabilitation stay provided by a participating provider on April 22, 2021, to May 4, 2021.  

You asked the Plan to waive the copayment for an inpatient rehabilitation stay. You say that you do not agree with this copayment. The Plan denied your request. The Plan says the correct copayment has been applied to the stay that was 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 $210 per day for days 1-6. There is no copayment for additional days. for an inpatient hospital care.   

You have been asked to pay less than a $210 per day for days 1-6. There is no copayment for additional days. for an inpatient rehabilitation stay. You have been asked to pay $840, which is less than your copayment amount of $1,260 ($210 x 6 days = $1,260). An inpatient rehabilitation stay 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 an inpatient rehabilitation stay provided by a participating provider on April 22, 2021, to May 4, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the emergency room visit (99285) provided on August 30, 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 $120 copayment for emergency care services.   You have been asked to pay a $120 copayment for the emergency care 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 emergency room visit (99285) provided on  August 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for a laminectomy (63267-59) provided on June 9, 2021.  You asked the Plan to pay for a laminectomy. You say that this is separately payable with the billed modifier. The Plan denied your request. The Plan says the records do not support this as a separate service.  The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.    The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural service. Specifically, the records show that this service was performed in the same encounter and at the same site as the primary procedure. Based on this information, we decided that Medicare rules for coverage of services billed with a -59 modifier have not been met. Therefore, we decided that the Plan does not have to pay for a laminectomy (63267-59) provided on June 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).  You asked the Plan to pre-approve a Freestyle Libre CGM. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  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 you do not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the transthoracic echocardiography (C8929) and Perflutren lipid microspheres injection (Q9957) provided on September 30, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the transthoracic echocardiography and Perflutren lipid microspheres injection. You say that you would like this claim to be reconsidered for payment. The Plan denied your request. The Plan says these services were rendered by a non-network provider, and the services were not referred by a network provider or rendered in an in-network facility. The Plan also says that these services were not urgent or emergent, nor were they approved in advance.  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 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 transthoracic echocardiography (C8929) and Perflutren lipid microspheres injection (Q9957) provided on September 30, 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 comprehensive oral evaluation (D0150), and panoramic x-ray (D0330) provided on July 29, 2021. You also asked the Plan to pay an additional amount for the complete lower denture (D5120) provided on August 12, 2021.  You asked the Plan to pay for the dental services. You say that you did not go to the dentist is January 2021. You say that you left your appointment in December 2020 with no teeth. You say that you need dentures. You also say that the services should be covered. The Plan denied your request. The Plan says 1 comprehensive oral evaluation every 3 calendar years. The Plan says that 1 complete series x-ray or panoramic x-ray every 3 calendar years. The Plan says that the frequency limits have been exceeded. The Plan also says that the annual maximum benefit of $2,000 has been exhausted.  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 the services are listed as covered, the frequency limits have been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation and complete series x-ray that you received on September 28, 2020. Additionally, the record shows that the Plan paid up to the annual maximum benefit towards the complete lower denture. The record shows that the Plan paid $430 for services that you received on January 5, 2021, and $1,570 ($1,100 + $470) for services provided on August 12, 2021. $430 + $1,570 = $2,000. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), and panoramic x-ray (D0330) provided on July 29, 2021. You also asked the Plan to pay an additional amount for the complete lower denture (D5120) provided on August 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Meningococcal recombinant protein and outer membrane vesicle vaccine provided on June 23, 2021.  You asked the Plan to pay for the Meningococcal recombinant protein and outer membrane vesicle vaccine. 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.  In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Meningococcal recombinant protein and outer membrane vesicle 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 Meningococcal recombinant protein and outer membrane vesicle vaccine.      Therefore, we decided that the Plan does not have to pay for the Meningococcal recombinant protein and outer membrane vesicle vaccine provided on June 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the comprehensive hearing test (92557) provided on September 10, 2020.  You asked the Plan to waive the copayment for the comprehensive hearing test. You say that you were not aware of a copayment. The Plan denied your request. The Plan says the copayment has processed 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 $40 copayment for Medicare-covered diagnostic hearing exam.       You have been asked to pay a $40 copayment for the comprehensive hearing test. This service falls within the Medicare-covered diagnostic hearing exam 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 comprehensive hearing test (92557) provided on September 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for wound care surgery provided on February 11, 2021.  You asked the Plan to waive the copayment for wound care surgery. You say that the services were not provided in the hospital. The Plan denied your request. The Plan says the claim was processed correctly with the appropriate copayment.  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 $250 copayment for Outpatient hospital surgery.     You have been asked to pay a $250 copayment for wound care surgery. Wound care surgery while being seen at an outpatient hospital falls within the Outpatient hospital 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 wound care surgery provided on February 11, 2021.