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

We decided that the Plan does not have to waive the cost share for the aminolevulinic acid hcl for topical
administration (J7308) and the photodynamic therapy by external application of light to destroy premalignant
lesions of the skin (96567) provided on October 26, 2021.
You asked the Plan to waive the cost share. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the cost share has been applied correctly to the
item/service provided.
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 20% of
the total cost for Medicare-covered Part B prescription drugs, including chemotherapy drugs. Additionally, you
must pay a $35 copayment for each specialist visit.
You have been asked to pay $190.37. This amount includes the Plan allowed amount of $776.84 x 20%
coinsurance=$155.37 for the Medicare-covered Part B prescription drug and a $35 copayment for the specialist
visit provided. 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 cost share for the aminolevulinic acid hcl for topical
administration (J7308) and the photodynamic therapy by external application of light to destroy premalignant
lesions of the skin (96567) provided on October 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for out of network physician services provided on October 18, 2021.
You asked the Plan to pay for these services. You say that you had a referral, and these services should be
covered. The Plan denied your request. The Plan says it was confirmed that you were not referred for these
services by a Plan contract provider and 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 Plan contract says that physician and specialist services may
require prior authorization.
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
October 18, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services.
You asked the Plan to pay for inpatient hospital services. You say that you would like to be kept at the hospital
because there is no one at your house to help after your surgery. The Plan denied your request. The Plan says
that the right total hip arthroplasty may be performed at an observation level of care.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
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 pay for inpatient hospital services. Our reviewer
says that inpatient hospital services are not medically reasonable and necessary. The documentation does not
reveal that you have a personal medical history to warrant a prolonged hospital stay. There was insufficient
support provided to suggest you would require hospital services that would likely cross 2 midnights. A lower
level of care may be considered for post-op care. Our physician reviewer found that your condition does not
meet criteria for coverage for inpatient hospital services.
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 hospital services have not been met. Therefore, we decided that the
Plan does not have to pay for inpatient hospital services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Clemastine for the enrollee.

You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.

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 Clemastine for the enrollee.

Benefits for this 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220), bitewings - four radiographic images (D0274) and prophylaxis - adult (D1110) provided January 7, 2021.

You asked the Plan to pay for the periapical x-ray, bitewing x-rays and dental cleaning. You say that you expected your dental services to be paid according to your in-network benefits. The Plan denied your request. The Plan says you have exhausted your dental 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 covers the periapical x-ray, bitewing x-rays and dental cleaning up to a $1,000 annual maximum. 

We looked at the file and Medicare rules. The Plan provided documentation showing that your full $1,000 annual maximum was applied to your dental services provided on January 7, 2021, and March 12, 2021. Based on this information, we decided that the Plan's annual maximum for dental benefits has been exceeded. Therefore, we decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220), bitewings - four radiographic images (D0274) and prophylaxis - adult (D1110) provided January 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for Fluorescence in situ Hybridization (FISH) testing provided to the enrollee on March 19, 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 this testing was done as a screening without confirmed presence of disease, which is not covered by Medicare. The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The Fluorescence in situ Hybridization (FISH) was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for Fluorescence in situ Hybridization (FISH) testing provided to the enrollee on March 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided the Plan does not have to pay for out of network practitioner services provided on July 6, 2021.   You asked the Plan to pay for out of network providers. You say that you were not aware that this provider was out of network. 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. Enrollees are responsible for making sure the providers they chose to see are in network. 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 services provided on July 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on February 25,
2022 and billed under code 99232.
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 their records show there is a National Correct Coding Initiatives (NCCI) Procedure to
Procedure (PTP) edit exists between 99238 and 99232.
This PTP edit has a modifier indicator of 0, which indicates there are no modifiers that are allowed with this
PTP code pair.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate code. CPT code. In this case, this claim cannot be paid as
billed due to the errors noted. Therefore, we decided that the Plan does not have to pay for physician services
provided to the enrollee on February 25, 2022, and billed under code 99232.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the automatic external defibrillator (K0606) provided on October 19, 2021.

You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to the item provided.

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 20% coinsurance for durable medical equipment and related supplies. 

You have been asked to pay $633.73 (Plan allowed amount of $3,168.69 x 20% coinsurance) for the durable medical equipment provided.

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 automatic external defibrillator (K0606) provided on October 19, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90853) provided on September 1,
2021.
You asked the Plan to pay for psychotherapy services. You say that the services at issue were a medical
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. Medicare rules say that the CP will attempt to consult with the enrollee's
attending or primary care physician.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of psychotherapy services have not been met. Specifically, the provided records do not document an
attempt to consult with, nor a referral from, the enrollee's attending or primary care physician. Therefore, we
decided that the Plan does not have to pay for psychotherapy services (90853) provided on September 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an external bone growth stimulator.
You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says the
enrollee does not have a covered indication.
The Plan follows Medicare rules. Medicare rules say that osteogenesis stimulators are only covered under
certain medical indications.
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 the requested device. Our physician
reviewer found that the enrollee recently had C2 fracture surgery in January 2022. Not enough time has passed
since the surgery to develop surgical nonunion diagnosis. Therefore, the requested device is not considered
medically reasonable or necessary at this time.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the requested device have not been met. Therefore, we decided that the Plan
does not have to pre-approve an external bone growth stimulator.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the oral exam (D0120) and prophylaxis (D1110) provided on November 11, 2021.

You asked the Plan to pay for the dental services. You say that your dental limit is $778. You say that submitted charges were $569. You also say that $209 should have been enough to cover the $136 claim. The Plan denied your request. The Plan says that 2 periodic oral exams are covered per calendar year. The Plan says that 2 cleanings are covered per calendar year. The Plan also says that the frequency limits for these services have been exceeded.

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. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the file does not show that the Plan has paid for 2 oral exams and 2 prophylaxes in 2021. The file shows that the Plan has only paid for 1 oral exam and 1 prophylaxis that you received on July 7, 2021. The file does not support the Plan's claim that the frequency limits have been exceeded. Therefore, we decided that the Plan has to pay for the oral exam (D0120) and prophylaxis (D1110) provided on November 11, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a lens processing fee for eyewear provided on
June 22, 2021.
You asked the Plan to reimburse you for a lens processing fee. The Plan denied your request. The Plan says a
lens processing fee is not a covered benefit.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
We looked at the file and the Plan's rules. The file shows that the Plan does not cover lens processing fees.
Based on this information, we decided that the Plan's rules for coverage of a lens processing fee have not been
met. Therefore, we decided that the Plan does not have to reimburse you for a lens processing fee for eyewear
provided on June 22, 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 September 21, 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 September 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the transcatheter aortic valve replacement (33361) provided on October 4, 2021.

You asked the Plan to pay for the transcatheter aortic valve replacement (33361). You say that the additional medical records identify medical necessity, and the claim should be reprocessed. The Plan denied your request. The Plan says procedure code 33361 must be submitted with a clinical trial diagnosis code.

The Plan must follow Medicare rules. Medicare rules say that for claims processed after September 28, 2009, with dates of service on or after January 1, 2008, claims submitted with modifier Q1 shall be returned as unprocessable if ICD-9-CM code V70.7 (if ICD-9 is applicable) or ICD-10-CM code Z00.6 (if ICD-10-CM is applicable) is not submitted on the claim.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the transcatheter aortic valve replacement (33361) have not been met. Specifically, while Z00.6 is listed on the claim, it is not associated to CPT code 33361 via the diagnosis pointer. Therefore, we decided that the Plan does not have to pay for the transcatheter aortic valve replacement (33361) provided on October 4, 2021.
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 August 18, 2021.  You asked the Plan to pay for ambulance response and treatment, no transport. The Plan denied your request. The Plan says since there was no transport, ambulance charges are not covered.  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 August 18, 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 August 18, 2021.
Appeal type: Lab
Decision: Favorable

 We decided that the Plan has to pay for the laboratory services provided on June 7, 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 that the services were rendered by an out of network provider, without prior authorization.  Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules.  You were referred for these services by a contract provider. The file does not show that the Plan provided notice that these services would not be covered. Under Medicare rules, this means that the services are considered approved by the Plan. Therefore, we decided that the Plan has to pay for the laboratory services provided on June 7, 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 the Hyaluronan injection (J7318 and 20611) provided on August 26, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the Hyaluronan injection. You say that you would like reconsideration because this was an emergency as you could not walk. The Plan denied your request. The Plan says this service was rendered out-of-network 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 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 Hyaluronan injection (J7318 and 20611) provided on August 26, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the insertion of new or replacement of a permanent pacemaker with transvenous electrode(s) (33208) rendered by the out-of-network (OON) provider on September 24, 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 insertion of new or replacement of a permanent pacemaker with transvenous electrode(s) (33208) rendered by the out-of-network (OON) provider on September 24, 2021.