Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses provided on June 17, 2021.

You asked the Plan to pay for the eyeglasses. You say that you paid out-of-pocket after the provider told you insurance would cover it and you could apply for reimbursement. You say that you are appealing because your glasses were not covered. The Plan denied your request. The Plan says this provider is an out of network provider and prior authorization was not requested.

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 they are received from a participating provider. 

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Specifically, the glasses were not purchased from a participating provider. Therefore, we decided that the Plan does not have to pay for the eyeglasses provided on June 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient office visit (99213) provided August 18, 2021.
You asked the Plan to pay for the office visit. You say that you believe that this claim should be covered by the Plan. Anything to do with the body should be covered. Just because it is for the driver's license it is still medical. The Plan denied your request. The Plan says Medicare does not reimburse evaluations performed solely to assess a beneficiary's ability to drive a vehicle.
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 this information, we decided that Medicare rules for coverage of the office visit have not been met. Therefore, we decided that the Plan does not have to pay for outpatient office visit (99213) provided August 18, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the emergency room services provided on June 23, 2021.  

You asked the Plan to waive the copayment for the emergency room services. You say that you feel the enrollee should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says the enrollee received emergency care services on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per the enrollee's contract with the Plan.  

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that the enrollee must pay a $90 copayment for Emergency care.   

We looked at the file, the Plan's contract and Medicare rules. The file shows that the enrollee received emergency room services on June 23, 2021. The enrollee has been asked to pay a $90 copayment for the emergency room services. The emergency room services fall 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 the emergency room services provided on June 23, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on July 24, 2021.

You asked the Plan to pay for the ambulance response and treatment with no transport. You say that your son called the ambulance because you passed out and were not responding to him. You also say that you refused to be transported to the hospital. The Plan denied your request. The Plan says this service is not a covered benefit by Medicare.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on July 24, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on July 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for progressive lenses provided on February 25, 2021, and  June 23, 2021.  You asked the Plan to pay for the eyeglasses. You say that the eyeglasses should be covered in full, and you should not have to pay anything. The Plan denied your request. The Plan says the Plan could not make payment for progressive lenses because it is not covered. The Plan has reprocessed the claim and refunded you $378.40.  Medicare generally does not cover eyewear services. However, Medicare and the Plan cover one pair of eyeglasses or contact lenses after each cataract surgery that includes insertion of an intraocular lens.  We looked at the file and the Plan's rules. The file shows that progressive lenes are not a covered benefit. Therefore, we decided that the Plan does not have to pay for progressive lenses on February 25, 2021, and  June 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network services provided to the enrollee on August 25, 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 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 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 services provided to the enrollee on August 25, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the diagnostic mammography (77065-26) provided on March 3, 2021.  You asked the Plan to pay for the diagnostic mammography. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says this claim was not billed in accordance with Medicare rules.  The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2.   In this case, the MUE for CPT code 77065-26 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the diagnostic mammography have not been met. Therefore, we decided that the Plan does not have to pay for the diagnostic mammography (77065-26) provided on March 3, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for the emergency room visits provided from June 19, 2021 to June 21, 2021.  

You asked the Plan to waive the copayments for the emergency room visits. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you visited the emergency room on June 19, 2021, June 20, 2021, and June 21, 2021. The Plan says the correct copayments have applied per your contract with the Plan.  

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 $50 copayment for each emergency room visit.    

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received emergency room visits on June 19, 2021, June 20, 2021, and June 21, 2021. You have been asked to pay a $50 copayment for each emergency room visit. The emergency room visits fall within the Emergency Care benefit category. This means that you have been asked to pay the correct amounts 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 copayments for the emergency room visits provided from June 19, 2021 to June 21, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 We decided that the Plan has to hold you harmless for the periodic oral evaluation (D0120), prophylaxis (D1110), and topical application of fluoride varnish (D1206) provided on July 23, 2021.  You asked the Plan to pay for the periodic oral evaluation, prophylaxis, and topical application of fluoride varnish. You say that you got this bill in the mail but used your insurance card. The Plan denied your request. The Plan says that this claim was paid to you on July 30, 2021 in the amount of $125.00. The Plan also says that you need to make payment to the provider for these services.  Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules.  You were referred for the periodic oral evaluation, prophylaxis, and topical application of fluoride varnish by a contract provider. The file does not show that the Plan provided notice that the periodic oral evaluation, prophylaxis, and topical application of fluoride varnish would not be covered. Under Medicare rules, this means the periodic oral evaluation, prophylaxis, and topical application of fluoride varnish is considered approved by the Plan. The record shows that the Plan reimbursed you $125 directly for these services, but the provider is billing a total of $190. Therefore, we decided that the Plan has to hold you harmless for the periodic oral evaluation (D0120), prophylaxis (D1110), and topical application of fluoride varnish (D1206) provided on July 23, 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: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lumbosacral spine x-ray rendered on June 17, 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 72110 is not covered.  The rules say that, if the modifier indicator is 0, the Column 2 code cannot be paid regardless of whether a modifier is used.  The provider submitted a claim for procedure codes 72110 (lumbosacral spine x-ray, minimum of 4 views) and 72120 (lumbosacral spine x-ray, bending views only, 2 or 3 views).   Code 72110 is a column II code with a modifier indicator of 0 when billed with column I code 72120. Code 72110 is not separately payable. Therefore, we decided that the Plan does not have to pay for the lumbosacral spine x-ray rendered on June 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the transportation of portable x-ray equipment rendered on June 29, 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 R0070 is not supported.  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, the CPT Code Manual definition of code R0070 is transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or location, one patient seen.    We find that CPT code R0070 is not supported in the medical record. Specifically, the transport code was not billed with the required set-up code. 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 transportation of portable x-ray equipment rendered on June 29, 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 July 2, 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 physician services provided to the enrollee on July 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the eye exam and refraction provided on July 27, 2021.  You asked the Plan to pay for the eye exam and refraction. You say that you've been with this provider a long time and trust them. You say that you want to keep this provider and have the claim covered. The Plan denied your request. The Plan says this provider is out-of-network and you must use a network provider.  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 they are received from a network provider.  We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the eye exam and refraction have not been met. Specifically, this provider is not a network provider with the vision Plan. Therefore, we decided that the Plan does not have to pay for the eye exam and refraction provided on July 27, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for ALS routine disposable supplies (A0398) provided on May 12, 2021.  You asked the Plan to pay for ALS routine disposable supplies. The Plan denied your request. The Plan says ambulance supplies are included in the payment rate for the ambulance transport.  The Plan must follow Medicare rules. Medicare rules say that payment for items and services are included in the fee schedule payment.      We looked at the file and Medicare rules. Medicare says that payment for items and services are included in the fee schedule payment. Therefore, we decided that the Plan does not have to pay for ALS routine disposable supplies (A0398) provided on May 12, 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 October 4, 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 physician services provided to the enrollee on October 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the periodontal scalings and root planings (D4341) provided on July 29, 2021.  

You asked the Plan to pay for the scalings and planings. You say that you would like these services to be covered. The Plan denied your request. The Plan says your benefit maximum 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, the Plan offers a $1,000 annual dental benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are responsible for the full charges of any additional dental services. The record shows that you met the annual maximum benefit while processing this claim for the July 29, 2021 date of service and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the periodontal scalings and root planings (D4341) provided on July 29, 2021.
Appeal type: ER
Decision: Favorable

 We decided that the Plan has to waive the copayment for an emergency department visit provided from June 19, 2021, to June 20, 2021.  

You asked the Plan to waive the copayment for the emergency room visit. You say that you should only be responsible for one copayment. The Plan denied your request. The Plan says that 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. Your contract with the Plan says that enrollees must pay a $75 copayment for each emergency room visit.   

The Plan says you must pay a $75 copayment for each emergency room visit. Based on the Plan contract, however, you cannot be asked to pay more than one $75 copayment for the emergency room visit. There are no medical records indicating that there were two separate emergency room visits. Therefore, we decided that the Plan has to waive the copayment for an emergency department visit provided from June 19, 2021, to June 20, 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: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for 319 units of ground mileage for ambulance transport provided on January 21, 2021.  

You asked the Plan to pay for 319 units of ground mileage for ambulance transport. 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 the actual number of units provided for each procedure code.  

We find that 319 units of CPT code A0425 are not supported in the medical record. The medical record only supports 250 units of CPT code A0425.    

Based on this information, we decided that Medicare rules for coverage of 319 units of ground mileage for ambulance transport have not been met. Therefore, we decided that the Plan does not have to pay for 319 units of ground mileage for ambulance transport provided on January 21, 2021.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pay for the anesthesia described by code 00938. We decided that the Plan does not have to pay for the services described by code 99100.

You asked the Plan to pay for the anesthesia described by code 00938. You say that this claim should be paid. The Plan says that no decision is made on the main code at this time, but the code 99100 is not separately payable.
We decided that the Plan has to pay for the anesthesia described by code 00938.

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.

Because the Plan neglected to address one of the two appealed codes, we find that there is no valid denial rationale for code 00938. Therefore, we decided that the Plan has to pay for the anesthesia described by code 00938.

We also decided that the Plan does not have to pay for the services described by code 99100.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

Code 99100 has a status indicator of "B" in the Physician Fee Schedule, meaning payment for this is always bundled with other services. No separate payment is made for this. Therefore, we decided that the Plan does not have to pay for the services described by code 99100.

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.