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

We decided that the Plan does not have to pay for infrared therapy (97026) provided from March 30, 2021 to April 27, 2021.
You asked the Plan to pay for infrared therapy. You say that you were advised that the services were a covered benefit. The Plan denied your request. The Plan says the services are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that the use of infrared and/or near-infrared light and/or heat, including monochromatic infrared energy, is non-covered for the treatment, including the symptoms such as pain arising from these conditions, of diabetic and/or non-diabetic peripheral sensory neuropathy, wounds and/or ulcers of the skin and/or subcutaneous tissues. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of infrared therapy have not been met. Therefore, we decided that the Plan does not have to pay for infrared therapy (97026) provided from March 30, 2021 to April 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Coronavirus vaccine provided on April 8, 2021.
You asked the Plan to pay for the Coronavirus vaccine. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the provider needs to submit their claim for payment to Original Medicare.
The Coronavirus vaccine is to be billed directly to Original Medicare by the rendering pharmacy or physician's office. The Plan follows the same rules. The Plan has contacted the provider and counseled them on retracting this claim and billing it correctly to Original Medicare. Therefore, we decided that the Plan does not have to pay for the Coronavirus vaccine provided on April 8, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation of portable x-ray equipment represented by code R0070 provided on April 30, 2021.
You asked the Plan to pay for code R0070. 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 services correctly. We looked at the file and Medicare rules. In this case, the review shows that the medical records provided represent professional charges; however, procedure code R0070 was provided in a facility with a place of service code of 31. Procedure code R0070 has a PC/TC Modifier Status of 3, which specifies a Technical Component only code. Therefore, we decided that the Plan does not have to pay for the transportation of portable x-ray equipment represented by code R0070 provided on April 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided on May 5, 2021.

You asked the Plan to pay for these services. You say that this claim should be paid by the Plan. The Plan denied your request. The Plan says you 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 physician services provided on May 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion (99601) provided on April 29, 2021.
You asked the Plan to pay for home infusion. You say that the services were billed correctly. The Plan denied your request. The Plan says the code billed has a status code of "I" which is not valid for Medicare coverage.
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 99601 is home infusion. We find that CPT code 99601 is not supported in the medical record. Specifically, the code billed is not valid for Medicare payment purposes. Based on this information, we decided that Medicare rules for coverage of home infusion have not been met. Therefore, we decided that the Plan does not have to pay for home infusion (99601) provided on April 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a chest x-ray (71045) provided on April 23, 2021.
You asked the Plan to pay for the chest x-ray. You say that the services were billed correctly. The Plan denied your request. The Plan says the enrollee was inpatient status at the time of service.
The Plan must follow Medicare rules. Medicare rules say that as a general policy, the POS code assigned by the physician/practitioner for the PC of a diagnostic service shall be the setting in which the beneficiary received the TC service. We looked at the file and Medicare rules. The records show that the claim for the services in dispute was billed with a POS code of 22. The record indicates that the member was inpatient on the billed date of service. There is a more appropriate POS code for the billed service.
Based on this information, we decided that Medicare rules for coverage of the chest x-ray have not been met. Therefore, we decided that the Plan does not have to pay for a chest x-ray (71045) provided on April 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skin lesion destruction procedure you had at your dermatologist's office on May 20, 2021.
You asked the Plan to waive the copayment for the dermatology services. You say that you saw the dermatologist on May 13, 2021. You said that due to other commitments, you had to return to the dermatologist a week later to complete the treatment. You also said that there was an agreement that you would only be charged one office visit. The Plan denied your request. The Plan says you were charged this copayment 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 physician specialist services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic activities (97530) provided on February 26, 2021. You asked the Plan to pay for therapeutic activities. You say that the services were provided, and payment should be rendered. The Plan denied your request. The Plan says procedure code 97530 is considered a column II procedure code and is not eligible for reimbursement when billed with 92526 a column I procedure code. These procedure codes were reported together, therefore Medicare billing criteria has not been met.
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 972530 has a bundled relationship with code 92526 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for therapeutic activities (97530) provided on February 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the reline of the complete upper denture (D5750) provided on May 17, 2021.
You asked the Plan to pre-approve the reline of the complete upper denture. You say that you are only responsible for a 50% copayment based on your plan details. The Plan denied your request. The Plan says the requested service is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Specifically, the Platinum Dental Rider was not active at the time of service. Therefore, we decided that the Plan does not have to pre-approve the reline of the complete upper denture (D5750) provided on May 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a health club membership (S9970) for the 2020 benefit allowance.
You asked the Plan to pay for a health club membership. You say that you tried to get the paperwork, but the gym was closed and that is the reason for submitting the request late. The Plan denied your request. The Plan says your reimbursement request was submitted past the March 31st deadline.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan reimburses you up to $150 each calendar year towards your cost for membership in a qualified health club or fitness facility. Reimbursement requests must be received by the Plan no later than March 31st of the following year. rsement request on June 18, 2021. The EOC confirms all reimbursement request must be received by the Plan no later than March 31st of the following year. Therefore, we decided that the Plan does not have to pay for a health club membership (S9970) for the 2020 benefit allowance.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided on May 20, 2021.
You asked the Plan to pay for these services. You say that while you were told this provider is not in network you were not told you could not go there. The Plan denied your request. The Plan says you did not have prior authorization to use an out of network provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The 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.
You were given notice that this provider and facility were not in network. 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 on May 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Prolia drug provided on April 14, 2021.

You asked the Plan to waive the coinsurance for the Prolia drug. You say that in 2020 you had the same shot with no copayment. The Plan denied your request. The Plan says you have been asked to pay 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 2021 contract with the Plan clearly says that you must pay 20% coinsurance for drugs covered under Medicare Part B.

You have been asked to pay $241.13, which is 20% of the allowed amount for the Prolia drug ($1,205.64 allowed amount x 20% coinsurance = $241.13). The Prolia drug 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 coinsurance for the Prolia drug provided on April 14, 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 March 29, 2021.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have 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 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 March 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 on January 15, 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 physician services provided on January 15, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on May 20, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the physician 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 provided were neither emergent nor urgent and prior authorization was not obtained to provide 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 physician services provided on May 20, 2021
by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a fit-bit for your 2020 Wellness Allowance Benefit.
You asked the Plan to reimburse you for a fit-bit. You say that you submitted your forms on time but when the Plan scanned the documents in, the Plan was not able to see the items purchased. The Plan denied your request. The Plan says this item is not a covered benefit.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan reimburses you up to $300 each calendar year towards your cost for membership in a qualified health club or fitness facility. The Plan's rules for coverage of gym benefits have not been met because a fit-bit is not a covered item under your wellness allowance benefit or the temporary exercise reimbursement benefit. Therefore, we decided that the Plan does not have to reimburse you for a fit-bit for your 2020 Wellness Allowance Benefit.
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 December 16, 2020.
You asked the Plan to pay for the ambulance response. You say that you would like the service covered. The Plan denied your request. The Plan says since there was no transport, the ambulance response is not a covered service.
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 December 16, 2020. 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 the enrollee refused transport to the hospital 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 December 16, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for the visit with an audiologist you had on June 15, 2021.
You asked the Plan to waive the copayment for the audiology visit. You say that you went to the audiologist to have a hearing and balance exam to in order to see an ear, nose and throat (ENT) specialist. You said that when you saw the ENT, they asked why you had the hearing exam. The Plan denied your request. The Plan says that you were charged the $50 copayment for a specialist visit correctly
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 $0 copayment for hearing and balance exams by an audiologist. The Plan says you must pay a $50 copayment for the audiology visit. Based on the Plan contract, however, you cannot be asked to pay more than a $0 copayment for the audiology visit. The medical records explicitly state that the services you received were for a hearing and balance test. Your Evidence of Coverage states "diagnostic hearing and balance evaluations performed by your provider to determine if you need medical treatment" are to be provided at no charge. The Plan has failed to provide any claims or Explanations of Benefits showing what specific codes were billed for the services you received, so we can only assume that the billing reflects that you received a hearing and balance evaluation for which no cost sharing is owed. Therefore, we decided that the Plan has to waive the copayment for the visit with an audiologist you had on June 15, 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 sq cm or 1% of body area of infants and children (CPT code 15004, adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm (CPT code 14301), and adjacent tissue transfer or rearrangement, any area; each additional 30.0 sq cm, or part thereof (List separately in addition to code for primary procedure) (CPT code 14302 X 4) provided to the enrollee on February 12, 2021.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records.
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 asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer found the record indicates that the enrollee underwent a procedure. When a lesion is removed, debridement to complete the procedure is not separately billable. Therefore, CPT code 15004 is not covered. An advancement flap is a complex tissue repair, not a tissue transfer, or rearrangement. Therefore, CPT code 14301 is not covered. Because the primary CPT code 14301 is not covered, CPT code 14302 is not covered for additional area. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for CPT code 15004, CPT code 14301, and CPT code 14302 X 4, provided to the enrollee on February 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services represented by codes 44500 and 30999 provided on April 27, 2021.
You asked the Plan to pay for codes 44500 and 30999. 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 providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 44500 is Introduction of long gastrointestinal tube (eg, Miller-Abbott) (separate procedure). The definition of code 30999 is Unlisted procedure, nose. We find that CPT codes 44500 and 30999 are not supported in the medical record. Specifically, code 44500, the medical records provided do not include sufficient documentation to validate that an Introduction of long gastrointestinal tube (eg, Miller-Abbott) (separate procedure) was performed on April 27, 2021, therefore this procedure cannot be verified. For code 30999, this code was billed by the provider to represent a septal strap to keep the nasogastric (NG) tube in place. However, the code billed by the provider (44500) to represent the tube placed, also does not meet criteria for reimbursement consideration, as the provider placed a Corpak instead of a Miller-Abbott. As a result, 30999 is not eligible for separate reimbursement consideration as it would already be included in the hospital reimbursement for placing an NG tube (Corpak). Based on this information, we decided that Medicare rules for coverage of codes 44500 and 30999 have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services represented by codes 44500 and 30999 provided on April 27, 2021.