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

We decided that the Plan does not have to pay for the standby service provided on May 5, 2021.
You asked the Plan to pay for standby service (99360). You say that the service was medically necessary because you did not want to go home without a defibrillator device. The Plan denied your request. The Plan says this service is not covered by Medicare.
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 99360 is standby service, requiring prolonged attendance, each 30 minutes. We find that CPT code 99360 is not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of standby service (99360) have not been met. Therefore, we decided that the Plan does not have to pay for the standby service provided on May 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on May 11, 2021 by an out-of-network provider.
You asked the Plan to pay for the office visit. You say that you were out of town and needed to see a doctor at an outpatient clinic. The Plan denied your request. The Plan says the non-urgent services were not approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. The service was not urgent or pre-approved. We found no exception that would require the Plan to pay for the service. Therefore, we decided that the Plan does not have to pay for the office visit provided on May 11, 2021 by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wheelchair lift for the vehicle.
You asked the Plan to pre-approve the lift. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a wheelchair lift for the vehicle.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on December 11, 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 the services are not covered.
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 84443 is 4. The MAI value for this code is 2. You billed 8 units of this code, exceeding the MUE. 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 laboratory services rendered on December 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wheelchair ramp (A9270).
You asked the Plan to pre-approve the wheelchair ramp. You say that the wheelchair ramp is required to get the wheelchair in and out of the house. The Plan denied your request. The Plan says the request for a Wheelchair Ramp is considered not reasonable and necessary, according to the standards of original Medicare.
The Plan must follow Medicare rules. Medicare rules say that a wheelchair ramp is not a covered benefit of the plan or Medicare. We looked at the file and Medicare rules. Based on this information, we decided that the Plan was correct to uphold their decision to not approve the wheelchair ramp. Therefore, we decided that the Plan does not have to pre-approve a wheelchair ramp (A9270).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mandibular partial denture - cast metal framework
with resin denture bases (including retentive/clasping materials, rests and teeth) (D5214).
You asked the Plan to pre-approve a lower partial denture. You say that you would like the service covered
because you are having difficulty eating properly. The Plan denied your request. The Plan says you have
reached the total amount that your plan will pay in a year.
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 Plan pays up to $,1000
per year for comprehensive dental services.
We looked at the file and Medicare rules. The Plan provided documentation showing that Plan has already
provided the full $1,000 dental benefit towards your comprehensive dental services in 2021. Therefore, we
decided that the Plan does not have to pre-approve a mandibular partial denture - cast metal framework with
resin denture bases (including retentive/clasping materials, rests and teeth) (D5214).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on March 23, 2021.
You asked the Plan to pay for ambulance response and treatment, no transport. You say that you would have no way of knowing that the ambulance service would not be covered. The Plan denied your request. The Plan says per Medicare guidelines, the ambulance benefit is a transport benefit. If there is no transport, then there is no Medicare-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 March 23, 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 ambulance response and treatment, no transport (A0998) provided on March 23, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0483) provided on November 30, 2020.
You asked the Plan to pay for drug testing. You say that this is supported in the records. The Plan denied your request. The Plan says this was billed with an incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place
where the sample was taken is reported as the Place of Service (POS).
We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent
laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we
decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan
does not have to pay for drug testing (G0483) provided on November 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral x-rays, comprehensive oral evaluation and palliative treatment provided on May 3, 2021.
You asked the Plan to pay for the palliative treatment. You say that it was confirmed that the dentist's status is in-network. You say that you would have asked for another dentist if you knew the doctor was not in-network, and you should be reimbursed the difference. The Plan denied your request. The Plan says the intraoral x-rays and comprehensive oral evaluation will be reprocessed at the in-network benefit level. The Plan also says the palliative treatment 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 palliative treatment is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the intraoral x-rays, comprehensive oral evaluation and palliative treatment provided on May 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional intraoral x-ray provided on April 21, 2021.
You asked the Plan to pay for the additional intraoral x-ray. You say that this was the first set of x-rays taken since 2018 and were requested by the dentist to update the x-rays that were three years out of date. You say that the claim should be reviewed, and you should be sent a check for $33. The Plan denied your request. The Plan says reimbursement has already been issued for one intraoral x-ray.
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, you also have a maximum benefit of one intraoral x-ray per calendar year. The Plan paid for one intraoral x-ray provided on April 21, 2021, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the additional intraoral x-ray provided on April 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on March 1, 2021 by a non-network provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-network provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The referring provider is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on March 1, 2021 by a non-network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services (A0429-QL) provided on March 5, 2021.
You asked the Plan to pay for ambulance services. You say that this was billed correctly. The Plan denied your
request. The Plan says this was billed with an incorrect code.
The Plan must follow Medicare rules. Medicare rules say that in the case where the beneficiary was
pronounced dead after the ambulance is called but before the ambulance arrives at the scene, providers report
the A0428 code with report modifier QL.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the ambulance services (A0429-QL) have not been met.
Specifically, code A0429 is not the appropriate code for billing Medicare when the enrollee is pronounced dead
after the ambulance is called. Medicare requires the reporting of A0428 for services provided under these
circumstances. Based on this information, we decided that Medicare rules for coverage of ambulance services
have not been met. Therefore, we decided that the Plan does not have to pay for ambulance services (A0429-
QL) provided on March 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a full mouth debridement (D4355).
You asked the Plan to pre-approve the full mouth debridement. You say that you would like to appeal this service. The Plan denied your request. The Plan says this service is not a covered benefit under your plan.
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. Therefore, we decided that the Plan does not have to pre-approve a full mouth debridement (D4355).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and panoramic x-ray (D0330) provided on May 26, 2021 by an OON provider
You asked the Plan to pay for the problem focused limited oral evaluation and panoramic x-ray. You say that you went to the dentist that your daughter goes to because you thought that the Plan would cover all of your dental services. You also say that you gave them your insurance card, they took x-rays, and then told you that their dentist does not accept your insurance. The Plan denied your request. The Plan says services performed by an OON provider are not covered because your healthcare plan does not have OON benefits. The Plan also says that you did not contact the Plan prior to this date of service to verify benefits and provider eligibility.
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, you are responsible for 100% of the cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and panoramic x-ray (D0330) provided on May 26, 2021 by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport provided on February 15, 2021.
You asked the Plan to pay for ambulance response and treatment, no transport. You say you did not refuse transport to the hospital. The Plan denied your request. The Plan says the ambulance benefit is a transport benefit as noted on the 2021 Evidence of Coverage. Since it was your decision to refuse the transport, the determination is to uphold the denial of coverage of claim number 21068E08543.
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 February 15, 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 ambulance response and treatment, no transport provided on February 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the cardiac device monitoring services you received from a cardiologist on May 28, 2020.
You asked the Plan to reduce the copayment for the cardiology services. You say that you believe the copayment for this service should be $25 since that is what you paid in February of 2020. 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 services with a specialist. You have been asked to pay a $40 copayment for the cardiology services. The cardiology services fall within the services with a specialist 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 reduce the copayment for the cardiac device monitoring services you received from a cardiologist on May 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection(s), of diagnostic or therapeutic substance(s) not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral; with imaging guidance (62323) rendered by the out-of-network (OON) provider on April 12, 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 injection(s), of diagnostic or therapeutic substance(s) not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral; with imaging guidance (62323) rendered by the out-of-network (OON) provider on April 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a bronchoscopy provided on April 13, 2021.
You asked the Plan to waive the copayment for a bronchoscopy. You say that the tube placed during a previous procedure was too long which caused complications that required a second surgery. You feel that for this reason the enrollee should not be responsible to pay the second copayment. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is being charged the correct 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $250 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. The enrollee has been asked to pay a $250 copayment for a bronchoscopy. A bronchoscopy falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category.
This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a bronchoscopy provided on April 13, 2021.
We note your complaint that the tube placed during the initial surgery was too long and caused complications. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture, without electrical stimulation, initial 15 minutes (97810) acupuncture, without electrical stimulation, each additional 15 minutes (97811) provided on October 15, 2020.
You asked the Plan to pay for the acupuncture services. You say that please see all other dates of service. They have been paid including the same CPT and ICD-10 codes. The Plan denied your request. The Plan says the provider is a non-covered provider type.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the person providing the acupuncture must be a physician licensed to perform the service. In this case, the provider is a licensed acupuncturist, not a physician. This provider is not supervised by any physician, PA, NP/CNS. Therefore the provider is a non-covered provider type. Therefore, we decided that the Plan does not have to pay for acupuncture, without electrical stimulation, initial 15 minutes (97810) acupuncture, without electrical stimulation, each additional 15 minutes (97811) provided on October 15, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce the cost share charged for out of network physician services provided on April 8, 2021.
You asked the Plan to waive or reduce this cost share. You say that where you live there are limited in network providers. The Plan denied your request. The Plan says the Plan contract is clear that if you choose to use out of network provider you will pay Original Medicare rates.
The Plan must follow Medicare rules. The rules say that Plans can expect enrollees to use network providers. The Plan contract is clear that the cost for out of network services will be higher. Therefore, we decided that the Plan does not have to waive or reduce the cost share charged for out of network physician services provided on April 8, 2021.