Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral function therapy (92526) and speech/hearing therapy 
(92507) provided from July 23, 2021, to August 2, 2021 by an out-of-network (OON) provider
.
You asked the Plan to pay for the oral function therapy and speech/hearing therapy. The Plan denied your 
request. The Plan says these services were rendered by an OON provider which requires authorization and 
there is not one on file.

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 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 oral function therapy (92526) and 
speech/hearing therapy (92507) provided from July 23, 2021, to August 2, 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 the comprehensive oral evaluation (D0150) and complete
series of intraoral x-rays (D0210) provided on October 11, 2021.
You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral x-rays. You
say that you cannot afford to pay these charges. The Plan denied your request. The Plan says these services
exceed the maximum allowed per period.
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, comprehensive oral evaluation
(D0150) and complete series of intraoral x-rays (D0210) are each limited to one procedure every three plan
years. The record shows that you received a comprehensive oral evaluation (D0150) and complete series of
intraoral x-rays (D0210) on March 7, 2019 and your comprehensive oral evaluation (D0150) and complete
series of intraoral x-rays (D0210) benefits have been exhausted. Therefore, we decided that the Plan does not
have to pay for the comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210)
provided on October 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete lower denture (D5120) provided on June 21,
2021.
You asked the Plan to pay for the denture. You say that you went to an in-network provider, and you do not
understand why the Plan is not covering the full cost of the denture. The Plan denied your request. The Plan
says you met and exceeded your $1,000 annual dental allowance on the date in question, and you are
responsible for the cost that exceeds this allowance.
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 can cover up to
$1,000 per year for covered supplemental dental services.
Though the Plan offers a dental benefit in excess of Medicare coverage, the cost of the dentures provided
exceeded your annual dental allowance. Documentation shows that the Plan has paid $1,000 in 2021 for your
dental care, and your benefit allowance has been exhausted. You are responsible for any costs that exceed this
allowance. Therefore, we decided that the Plan does not have to pay any additional amount for the complete
lower denture (D5120) provided on June 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a shingles vaccine (90471, 90750) provided October 6, 2021.
You asked the Plan to pay for the shingles vaccine. You say that the immunization should be covered. The Plan
denied your request. The Plan says this vaccine is not eligible for coverage under the Part B medical benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine.
The Plan follows the same rules.
Records do not show that you have been injured or directly exposed to any illness related to the shingles
vaccine. Therefore, we decided that the Plan does not have to pay for a shingles vaccine (90471, 90750)
provided October 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically necessary.    The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found based on the documentation provided the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Favorable

 We decided that the Plan has to pay for the repair of cardiac wound (33300) provided on April 15, 2021.  You asked the Plan to pay for the repair of cardiac wound (33300). The Plan denied your request. The Plan says that procedure code 33300 has a conflict with CPT code 33310-59; it would be considered inclusive and consequently be denied.  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 33300 is repair of cardiac wound; without bypass.  We find that CPT code 33300 is supported in the medical record. Specifically, the Plan has denied these services stating that CPT code 33300 is inclusive to CPT code 33310-59. An edit does not exist showing that CPT code 33300 is a column II code. There is no rule to suggest that this code is inclusive to CPT code 33310. It is the burden of the Health Plan to substantiate their denial with evidence. In this case, the denial has not been substantiated so we must find in your favor. Based on this information, we decided that Medicare rules for coverage of the repair of cardiac wound (33300) have been met. Therefore, we decided that the Plan has to pay for the repair of cardiac wound (33300) provided on April 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an outpatient hospital clinic visit (G0463) provided on
August 31, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for an outpatient hospital clinic visit. You say that you say that you are appealing
with supporting records. The Plan denied your request. The Plan says this provider is not a network provider
with the Plan and the services were not referred by a network provider or rendered in an in-network facility.
The Plan also says that they have also determined that these services were not urgent or emergent, nor were
they 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 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 an outpatient hospital clinic visit (G0463)
provided on August 31, 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 the hearing aids purchased on July 12, 2021.  You asked the Plan to pay for the hearing aids. You say that you chose this provider because they were able to provide inexpensive hearing aids. These services are necessary and should be covered. The Plan denied your request. The Plan says hearing aids are only covered when they are purchased through the Plan's specified hearing vendor network. The provider in question does not participate with this network; therefore, the hearing aids are denied.  Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays only for the Advanced or Premium hearing aids offered by the specified hearing vendor network. Other models or hearing aids purchased from other providers are not covered.    We looked at the file and the Plan's rules. The provider in this case is not part of the Plan's specified routine hearing vendor network. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids purchased on July 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the Magnetic resonance angiography (70544) provided on September 13, 2021.
You asked the Plan to pay for code 70544. 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. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70544 is a column II code to column I code 70551. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the Magnetic resonance angiography (70544) provided on September 13, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram, routine ECG with at least 12 leads; interpretation and report only (CPT code 93010) provided to the enrollee on March 30, 2021.
You asked the Plan to pay for the electrocardiogram. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not covered as billed.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the electrocardiogram have not been met. Our records indicate a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 93010 and 25630. This PTP edit has a modifier indicator of 1, which indicates modifiers associated with NCCI are allowed, however, an appropriate NCCI modifier was not billed with this PTP code edit. Therefore, we decided that the Plan does not have to pay for the electrocardiogram, routine ECG with at least 12 leads; interpretation and report only (CPT code 93010) provided to the enrollee on March 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME provided on June 15, 2021.
You asked the Plan to waive the coinsurance for DME. You say that you were told that you would not owe anything for the equipment. The Plan denied your request. The Plan says the claims were processed correctly and you are 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). Your contract with the Plan clearly says that you must pay 30% coinsurance for out-of-network DME and related supplies. You received DME from an out-of-network provider on June 15, 2021. Therefore, you are responsible to pay your share of the out-of-network cost-sharing charges. The total allowed amount is $269.63 and 30% of that is $80.89. You have been asked to pay the total coinsurance amount of $80.89 for DME. DME falls within the DME and related supplies 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 DME provided on June 15, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on June 19, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the claim was not filed timely per Medicare guidelines.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for the laboratory services was not filed until October 14, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on June 19, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services (P9603, 80048, 85025, G0471) provided on October 18, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for laboratory services. You say that when the patient was switching over from traditional Medicare, they were expecting to receive the same level of coverage with this insurance. You also say that you are an out-of-network laboratory, you see that the patient has no out-of-network benefits, but all current procedural terminology (CPT) codes are Medicare approved codes. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and based on the documentation submitted, the Plan has determined that the services rendered to the member are not urgent or emergent, nor were they approved in advance by a 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 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 laboratory services (P9603, 80048, 85025, G0471) provided on October 18, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction services provided on October 21, 2021.
You asked the Plan to pay for the eye refraction services. You say that you believe this service should be
covered. The Plan denied your request. The Plan says this service is not covered by Medicare or the Plan in this
case.
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 provided during a routine vision exam.
We looked at the file and the Plan's rules. In this case, you received these services during a medical eye exam
and not a routine vision exam. Based on this information, we decided that the Plan's rules for coverage of the
eye refraction services have not been met. Therefore, we decided that the Plan does not have to pay for the eye
refraction services provided on October 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for wound care services provided on June 1, 2021.  You asked the Plan to waive the copayment for the wound care services. You say that you believe that the procedure was coded incorrectly. 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 $225 copayment for outpatient surgery in a hospital facility.   Please note that wound care services are considered surgical procedures. Therefore, you have been asked to pay a $225 copayment for the wound care services. Wound care services fall within the Outpatient Surgery 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 wound care services provided on June 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve promethazine tablets.  You asked the Plan to pre-approve self-administered drug. You say that the enrollee has been on this medication and it is effective. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve promethazine tablets.   Benefits for self-administered drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management (99238) provided on July 23, 2021.
You asked the Plan to pay for the hospital discharge day management. You say that the services that were provided were medically reasonable and necessary. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the hospital discharge day management (99238) provided on July 23, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (87496, 87498, 87631, 87798, 87486, 87541,
87581, 87640) provided November 12, 2020.
You asked the Plan to pay for the lab services. You say that the lab services were medically necessary. The
Plan denied your request. The Plan says the documentation does not support the billed services.
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 87496, 87498, 87631, 87798, 87486, 87541, 87581, & 87640 is not supported in the
medical record. Specifically, the place of service on the claim form (81, laboratory) does not match the place of
service detailed in the records (13, assisted living facility).
Based on this information, we decided that Medicare rules for coverage of the lab services have not been met.
Therefore, we decided that the Plan does not have to pay for lab services (87496, 87498, 87631, 87798, 87486,
87541, 87581, 87640) provided November 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for lead wires (A4557) provided August 13, 2021.  You asked the Plan to pay for the lead wires. You say that the items were medically necessary. The Plan denied your request. The Plan says payment for the code billed is always bundled with payment for another service.  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 A4557 is not supported in the medical record. Specifically, per the National Physician Fee Schedule, this code has a status of "B" and payment is always bundled with payment for another service. Based on this information, we decided that Medicare rules for coverage of the lead wires have not been met. Therefore, we decided that the Plan does not have to pay for lead wires (A4557) provided August 13, 2021.