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

We decided that the Plan does not have to pay for cast supplies (A4580) provided on October 1, 2020.
You asked the Plan to pay for the cast supplies. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code A4580 has a status indicator of I and is not valid for Medicare purposes.
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 A4580 is not supported in the medical record. Specifically, per the Physician Fee Schedule, CPT code A4580 has a status indicator of I. This means that CPT code A4580 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the cast supplies have not been met. Therefore, we decided that the Plan does not have to pay for cast supplies (A4580) provided on October 1, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department care rendered on December 6, 2020.
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 99285 is not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 99285 (emergency department care) and 99220 (initial observation care). Code 99285 is a column II code with a modifier indicator of 1 when billed with column I
code 99220. Code 99285 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 emergency department care rendered on December 6,
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an orthosis (L0180) provided February 1, 2021.
You asked the Plan to pay for the orthosis. You say that the item was medically necessary. The Plan denied your request. The Plan says the item was provided as a result of an unsolicited telehealth service. Coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances. We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item.
The record does not show that contact was initiated regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the past 15 months. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met. Therefore, we decided that the Plan does not have to pay for an orthosis (L0180) provided February 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve durable medical equipment to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve a pneumatic compressor. You say that you would like this equipment approved. The Plan denied your request. The Plan says there are in-network providers available for these services.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve durable medical equipment to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for genetic testing provided on October 10, 2020.
You asked the Plan to pay for genetic testing. You say that this testing was ordered by the enrollee's treating physician to help determine the course of treatment for the enrollee. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because this testing was not medically necessary.
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 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 has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not specify whether the ordering physician was in-network or out-of-network with the Plan. The documentation submitted does not include prior notice that this testing would not be covered. Without this information, we cannot determine whether the lab order made constituted plan-directed care. Therefore, the Plan has not shown that its decision to deny payment is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for genetic testing provided on October 10, 2020.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on May 19, 2021.  
You asked the Plan to pay for the dental services. You say that the provider never told you they were out-of-
network. The Plan denied your request. The Plan says the claim was processed correctly.  
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 file shows that you received an oral exam and x-rays. We looked at the file, and Medicare rules. The Plan 
paid the allowed amount for the services provided. You have been charged the difference between the billed 
amount and the allowed amount. Based on this information, we decided that the Plan's rules for coverage have 
not been met. Therefore, we decided that the Plan does not have to further pay for the dental services provided 
on May 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injections and electrical stimulation provided to the enrollee
on January 28, 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 these services are not covered by Medicare.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not
manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for injections and
electrical stimulation provided to the enrollee on January 28, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sleep study (95810, 95811) to be provided by an OON
provider.
You asked the Plan to pre-approve a sleep study. You say that you do not feel secure going to one of the innetwork
providers available with the Plan. You also say you prefer to go to any other place besides the
redirected facility. The Plan denied your request. The Plan says there are in-network providers available for
these services.
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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
a sleep study (95810, 95811) to be provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99203) provided on January 27, 2021 
 
You asked the Plan to pay for an office visit. You say that this was coded correctly. The Plan denied your 
request. The Plan says this was not billed with the most appropriate diagnosis codes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Some  
International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes indicate  
laterality, specifying whether the condition occurs on the left, right or is bilateral. We looked at the file and Medicare rules. The service at issue was billed with diagnosis codes M17.11, 
unilateral primary osteoarthritis of the right knee and M17.12, unilateral primary osteoarthritis of the left knee. 
As the condition is present on both sides, it is inappropriate to report unilateral codes. There is a more 
appropriate bilateral code for the enrollee's condition. Based on this information, we decided that Medicare 
rules for coverage of an office visit have not been met. Therefore, we decided that the Plan does not have to 
pay for an office visit (99203) provided on January 27, 2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric treatment. 
 
You asked the Plan to pre-approve inpatient psychiatric treatment. 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. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric treatment. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found based upon review 
of the records provided, you do not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of September 9, 2021, forward. You could have been treated in a lesser restrictive 
setting as you were not showing any suicidal or homicidal ideation, auditory or visual hallucinations and was 
not showing any aggressive behaviors. You were being cooperative and compliant. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric treatment have not been met. Therefore, we decided that 
the Plan does not have to pre-approve inpatient psychiatric treatment.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injections and stimulation services provided to the enrollee on February 8, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says these services are not covered by Medicare when rendered by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for injections and stimulation services provided to the enrollee on February 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on January 20, 2021 by an out-ofnetwork
(OON) provider.
You asked the Plan to pay for the OON services. You say that the records show medical necessity. The Plan
denied your request. The Plan says services rendered by non-participating providers require 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 file shows that the enrollee was seen for a new patient visit. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the office visit provided on January 20, 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 an eye refraction (92015) provided on May 11, 2021.
You asked the Plan to pay for an eye refraction. You say that you do not understand why the refraction was denied when you cannot have an eye exam without a refraction being performed. The Plan denied your request. The Plan says the service at issue is not a covered benefit since it was a medical vision check.
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 it is performed as a routine screening by a participating provider. We looked at the file and the Plan's rules. The records show the eye refraction was performed as part of a medical vision exam, and therefore, is not a covered benefit. Based on this information, we decided that the Plan's rules for coverage of an eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for an eye refraction (92015) provided on May 11, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered by the out-of-network (OON) provider on February 25, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal.
The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered by the out-of-network (OON) provider on February 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic shoes and associated costs provided on April 7, 2021.
You asked the Plan to pay for the diabetic shoes and associated costs. You say that this is the only provider you can get these shoes from. The Plan denied your request. The Plan says that this provider is not certified for Medicare.
The Plan must follow Medicare rules. The rules state that Medicare payment cannot be made to a supplier who is not enrolled in the Medicare Program. The purchase was not made with a supplier who is enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the diabetic shoes and associated costs provided on April 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), the unspecified 
adjunctive procedure (D9999), the home/extended care facility call (D9410), and the complete upper denture 
(D5110) provided on April 5, 2021. 
 
You asked the Plan to pay for the dental services. You say that you lost your dentures during a stay at a skilled 
nursing facility (SNF). You say that you needed them to be replaced. You say that you are homebound. You 
also say that you tried calling the Plan to find an in-network provider but were unable to find one for you. The 
Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that dental 
services obtained from vendors outside of the plan's network are not covered. 
 
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, dental services obtained from vendors 
outside of the plan's network are not among those covered under this benefit. The record shows that the Plan 
provided in network dentists, one of which made visits to nursing homes/facilities. Therefore, we decided that 
the Plan does not have to pay for the comprehensive oral evaluation (D0150), the unspecified adjunctive 
procedure (D9999), the home/extended care facility call (D9410), and the complete upper denture (D5110) 
provided on April 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pathology services provided on March 31, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that the provider sends the specimen for processing. 
The Plan denied your request. The Plan says the services were not urgent, emergent, or 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 rendering and referring providers in this case are not a network providers with the Plan. The Plan had 
network providers available who could have provided the services at issue in this appeal. The Plan did not pre-
approve the services at issue. We found no exception that would require the Plan to pay for these services. 
Therefore, we decided that the Plan does not have to pay for the pathology services provided on March 31, 
2021 by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 15 physical therapy visits with an out-of-network
provider.
You asked the Plan to pre-approve out-of-network physical therapy. You say that you were referred by your
urologist for core pelvic care and there is nobody in-network available with the training. You say that your care
should be approved out-of-network and you are appealing the denial. The Plan denied your request. The Plan
says an in-network provider is available.
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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
15 physical therapy visits with an out-of-network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) provided June 16, 2021.

You asked the Plan to pay for ambulance response. You say that you don't believe you should be responsible for this payment. The Plan denied your request. The Plan says the ambulance services are not covered because there was no transport.

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 June 16, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. The trip report in this case shows that you refused transport to the hospital because you said it was not necessary and thus the wavier criteria is not met. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) provided June 16, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a laryngoscopy provided on April 15, 2021.
You asked the Plan to waive the copayment for a laryngoscopy. You say that you were hospitalized due to the
Coronavirus (Covid-19). You say the bills are all due to Covid-19 and that you already paid the hospital $95.
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 $395
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including
but not limited to hospital or other facility charges and physician or surgical charges.
You have been asked to pay a $395 copayment for a laryngoscopy. A laryngoscopy falls within the Outpatient
Surgery and Other Medical 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 a laryngoscopy provided
on April 15, 2021.