Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Favorable

 We decided that the Plan has to provide reimbursement for the liquid oxygen refills provided from January 5, 2021, through June 21, 2021.  

You asked the Plan to provide reimbursement for the liquid oxygen refills. You say that you feel that this should be covered as this is the main treatment for your cluster headaches. The Plan denied your request. The Plan says that only rental of oxygen equipment is covered. Since you own your equipment, reimbursement cannot be approved.  

The Plan must follow Medicare rules. Medicare rules say that when enrollees enter Medicare with oxygen equipment that they own, oxygen contents are separately payable for use with this equipment.  In this case, you have received oxygen contents for refilling a oxygen device which you own. This is covered by Medicare per the rules cited. Therefore, we decided that the Plan has to provide reimbursement for the liquid oxygen refills provided from January 5, 2021, through June 21, 2021.   

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: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for psychotherapy services (90834) provided on April 22, 2021.  

You asked the Plan to pay for psychotherapy services. You say that the medically necessary services at issue were provided to the enrollee in good faith. The Plan denied your request. The Plan says rules for payment have not been met.  

The Plan must follow Medicare rules. Medicare rules say that the CP will attempt to consult with the enrollee's attending or primary care physician.  

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of psychotherapy services have not been met. Specifically, the provided records do not document an attempt to consult with, nor a referral from, the enrollee's attending or primary care physician. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90834) provided on April 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee appears to be more stable but requires short-term additional acute care services that can be safely administered at the current facility in order to further stabilize. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to a lower level of care may be considered when treatment has completed and the enrollee is more stable.   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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing (CPT code G0483) provided to the enrollee on October 19, 2020.  You asked the Plan to pay for the drug testing. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not supported by the records.  The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Healthcare Common Procedure Coding System (HCPPCS) code G0483 (1 unit) remains not supported. The plan of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11. Also, the laboratory results submitted indicate the specimen was collected on October 19, 2020, and received by the lab on October 20, 2020. Of note, the patient resides in Alabama and the billing laboratory is located in Florida; therefore, the billed code cannot be verified. Therefore, we decided that the Plan does not have to pay for the drug testing (CPT code G0483) provided to the enrollee on October 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay an additional amount of $150.00 for the frames and Trivex PR lenses provided on May 4, 2021.  You asked the Plan to pay an additional amount for the eyeglasses. The Plan denied your request. The Plan says eyeglasses are a covered benefit, but the enrollee has exceeded limits set in the subscriber agreement. For the Trivex PR, the service or item in question is not covered under the member's contract under any normal circumstances.  Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.   We looked at the file and the Plan's rules. The file shows that the Plan says eyeglasses are a covered benefit, but the enrollee has exceeded limits set in the subscriber agreement. Trivex PR is not covered under the member's contract under any normal circumstances. Therefore, we decided that the Plan does not have to pay an additional amount of $150.00 for the frames and Trivex PR lenses provided on May 4, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ambulance service (A0427) and mileage (A0425), provided on September 4, 2020.  

You asked the Plan to waive the copayment for the ambulance service. You say that the service should be covered. 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 $325 copayment for ambulance services.   

You have been asked to pay a $325 copayment for the ambulance service. This service falls within the ambulance services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance service (A0427) and mileage (A0425), provided on September 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and management of a new patient (99328) rendered by the out-of-network (OON) provider on August 26, 2021.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and management of a new patient (99328) rendered by the out-of-network (OON) provider on August 26, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for psychotherapy services (90834, 90837) provided on April 10, 2020, to August 26, 2021.  You asked the Plan to pay for psychotherapy services. You say that you confirmed with the Plan's customer service in 2019 that the provider of the services at issue is in-network. The Plan denied your request. The Plan says rules for payment have not been met because the provider of the services at issue is not enrolled in the Medicare program. The Plan also says that rules for payment for dates of service May 15 to August 6, 2020, have not been met because the request was not filed timely.  The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. The rules also say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. The record also shows that a claim for dates of service May 15 to August 6, 2020, was not filed until August 27, 2021. This means that more than one calendar year from the dates of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90834, 90837) provided on April 10, 2020, to August 26, 2021.   Your complaint about receiving erroneous or incomplete information about your provider network from a representative of the Plan 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: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the psychotherapy (90837) rendered by an out-of-network (OON) provider on June 1, 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.  

You are 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 psychotherapy (90837) rendered by an out-of-network (OON) provider on June 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the bilateral Visco supplementation with Monovisc 88mg/4 ml syn injections (J7327), provided on May 13, 2021.  

You asked the Plan to waive the copayment for the injections. You say that you did not know there would be a insurance. 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 %20 coinsurance for Medicare Part B prescription drugs.   

You have been asked to pay a %20 coinsurance for the injections. This service falls within the Medicare Part B prescription drugs 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 bilateral Visco supplementation with Monovisc 88mg/4 ml syn injections (J7327), provided on May 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for contact lenses provided on July 23, 2021.  You asked the Plan to pay for contact lenses. The Plan denied your request. The Plan says contact lenses are only covered after cataract surgery.  The Plan contract only covers contact lenses after each cataract surgery.    We looked at the file and the Plan's rules. The file shows that contact lenses are only covered by the Plan after cataract surgery. Therefore, we decided that the Plan does not have to pay for contact lenses provide on July 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit and therapeutic services provided on April 7, 2021 by an out-of-network (OON) provider.  

You asked the Plan to pay for the OON medical services. You say that this was medically necessary care and should be paid. The Plan denied your request. The Plan says the services were non-emergent and provided out of network 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 and therapeutic services provided on April 7, 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 (CPT code(s): 82784, 84165, and 86334) provided to the enrollee on January 13, 2021, by an out-of-network provider.  You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not supported by the records.  The Plan must follow Medicare rules. We cannot determine if a physician's order was given, how the enrollee came to you, the referring provider, and/or whether the services are necessary. All providers are required to furnish necessary information to the health plan when requested. The provider's staff is responsible for submitting information to the health plan for review and determination. After multiple attempts to obtain information, none was received as of this date. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code(s): 82784, 84165, and 86334) provided to the enrollee on January 13, 2021, by an out-of-network provider.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for an abdominal ultrasound (76705) provided on August 9, 2021.  You asked the Plan to pay for ultrasound 76705. You say that you are appealing with records to support this level of service. The Plan denied your request. The Plan says the denial of payment for this service is correct, because code 76705 has a procedure-to-procedure (PTP) edit of 1 with code 93976 so is not separately payable without an appropriate modifier. 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 76705 is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for an abdominal ultrasound (76705) provided on August 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for foot orthotics provided on September 29, 2021.  You asked the Plan to pay for foot orthotics. You say that your physician assured you this was a covered benefit. 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 pay for foot orthotics provided on September 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on July 26, 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 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 test 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 rendered on July 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for additional supplies, materials, and clinical staff time (99072) provided on March 26, 2021.  You asked the Plan to pay for additional supplies, materials, and staff time. You say that your services were requested by the treating physician. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this code has a Status Code of B so is always bundled for payment.  The Plan must follow Medicare rules. Medicare rules say that code 99072 is always bundled for payment, and if this service is covered the payment for it is subsumed by the payment for the services to which it is incident.   We looked at the file and Medicare rules. This code is always bundled for payment and is not separately payable. Based on this information, we decided that Medicare rules for coverage of additional supplies, materials, and staff time have not been met. Therefore, we decided that the Plan does not have to pay for additional supplies, materials, and clinical staff time (99072) provided on March 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the supplies rendered on July 19, 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 covered.  The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of P are bundled/excluded codes.  We looked at the file and Medicare rules. Billed procedure codes A4340 (indwelling catheter, special) and A4357 (bedside drainage bag) have a status indicator and no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for the supplies rendered on July 19, 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 July 30, 2021.  

You asked the Plan to waive the copayment for the specialist office visit. You say that you do not believe that you should be charged the copayment because the doctor has not released you from his care. 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 $35 copayment for each specialist visit.   

You have been asked to pay a $35 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 July 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and interpretation (D0364), pulp vitality tests (D0460), and additional intraoral periapical x-ray (D0230) provided on June 9, 2021  You asked the Plan to pay for the cone beam CT capture and interpretation, pulp vitality tests, and additional intraoral periapical x-ray. You say that these services should be covered under the terms and conditions of your insurance. The Plan denied your request. The Plan says the cone beam CT capture and interpretation and pulp vitality tests are not covered expenses under your dental plan. The Plan says that your benefits for the additional intraoral periapical x-ray had been satisfied and the frequency limitation had been exceeded. The Plan also says that both you and your provider contacted the Plan to verify benefits prior to this date of service and were advised that your plan has code specific coverage.  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 cone beam CT capture and interpretation (D0364) and pulp vitality tests (D0460) are not among those covered under this benefit. The contract says that intraoral x-rays are limited to one procedure code per calendar year. The record shows that you received a first intraoral periapical x-ray (D0220) on June 9, 2021 and your intraoral x-rays benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and interpretation (D0364), pulp vitality tests (D0460), and additional intraoral periapical x-ray (D0230) provided on June 9, 2021