Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for oxygen and oxygen supplies (A0422) provided on November 23, 2020.
You asked the Plan to pay for oxygen and oxygen supplies. You say that you would like the claim to be reviewed again for payment. The Plan denied your request. The Plan says the payment is denied because supplies, materials, and equipment used in conjunction with a major service are considered a necessary part of that service.
The Plan must follow Medicare rules. Medicare rules say that [insert custom text from glossary]. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of oxygen and oxygen supplies have not been met. Specifically, payment for these services is included in the payment rate for the transport. This item/service is not separately covered by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for oxygen and oxygen supplies (A0422) provided on November 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit you had at a foot & ankle center on May 6, 2021.
You asked the Plan to waive the copayment for the foot & ankle center visit. You say that you didn't receive injections on this date, so you want to appeal the claim. 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 $20 copayment for visits with a specialist. You have been asked to pay a $20 copayment for the foot & ankle center visit. This copayment applies regardless of the extent of services you receive during the visit. 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 the office visit you had at a foot & ankle center on May 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the scaling and root planing (D4342 x 2), pre-diagnostic test
(D0431), and periapical x-ray (D0230) provided on June 28, 2021.
You asked the Plan to pay for the dental services. You say that the services should be covered. The Plan denied
your request. The Plan says 1 periapical x-ray is covered per calendar year. The Plan says that the frequency
limit has been exceeded. The Plan says that scaling and root planing are not covered services. The Plan says
that pre-diagnostic test is not listed as a covered service either.
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 and periapical x-ray is listed as
covered, the frequency limit has been exceeded. The record shows that the Plan paid for the initial periapical x-ray
that you received on the date of service in this case. Additionally, periodontal scaling and root planing and
pre-diagnostic test are not among those covered under this benefit. Therefore, we decided that the Plan does not
have to pay for the scaling and root planing (D4342 x 2), pre-diagnostic test (D0431), and periapical x-ray
(D0230) provided on June 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on May 17, 2021.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or proprietary laboratory analysis CPT code.
We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple code. Per Medicare rules, the testing should be reported with one unit of one CPT code. 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 the lab services provided on May 17, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided on April 28, 2021.
You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 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 nurse practitioner services provided on April 28, 2021.
Appeal type: SNF
Decision: Partially Favorable

We decided that the Plan has to reduce the copayment for the SNF care. We decided that the Plan does not have to waive the copayment for the SNF care.
You asked the Plan to waive the copayment for the SNF care. You say that you cannot afford to pay these claims. The Plan says that you have been asked to pay the correct cost-sharing amount.
We decided that the Plan has to reduce the copayment for the SNF care.
The record shows that you paid $15,081 towards out-of-pocket costs. This means you were charged $7,531 over your maximum out-of-pocket amount. The Plan says that you must pay $9,256 for the SNF care. Based on the Plan contract, however, you cannot be asked to pay more than $1,779 for the SNF care. ($9,256 - $7,531 =$1,779). Therefore, we decided that the Plan has to reduce the copayment for the SNF care.
We also decided that the Plan does not have to waive the copayment for the SNF care.
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 $0 copayment per day for days 1-20 for each stay and a $178 copayment per day for days 21-100 for each stay for the SNF care. The record shows that you met your maximum out-of-pocket amount. Therefore, we decided that the Plan does not have to waive the copayment for the SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the reline complete mandibular denture (indirect) (D5751) and unspecified preventive procedure, by report (D1999) provided May 17, 2021.
You asked the Plan to pay for the complete lower denture reline and unspecified preventative procedure. You say that it doesn't make sense for only one denture plate to be relined. The Plan denied your request. The Plan says you have exceeded the frequency limit for the denture reline and the unspecified preventative procedure is not covered under your benefits.
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 complete lower denture reline and unspecified preventative procedure when the services are medically necessary and reasonable.
We looked at the file and Medicare rules. The Plan provided documentation showing that one denture reline was covered on the same date of service. Based on this information, we decided that the Plan's frequency limit for coverage of the complete lower denture reline has been exceeded. Thought the Plan offers dental benefits in excess of Medicare coverage, the unspecified preventative procedure is not among those covered. Therefore, we decided that the Plan does not have to pay for the reline complete mandibular denture (indirect) (D5751) and unspecified preventive procedure, by report (D1999) provided May 17, 2021.
Your complaint about the Plan's policy to only cover an upper or lower denture reline but not both is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept procedure.
You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 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 an Intracept procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Intracept procedure is experimental. More research is needed to show safety and efficacy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the breast biopsy you had at an outpatient hospital facility on June 25, 2020.
You asked the Plan to waive the copayment for the breast biopsy. You say that you think this should be covered because you didn't receive the bill for over a year. 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 $245 copayment for outpatient surgery at an outpatient hospital facility. You have been asked to pay a $245 copayment for the breast biopsy. The breast biopsy falls within the outpatient surgery at an outpatient hospital facility benefit category. This copayment applies regardless of when
you are billed. 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 the breast biopsy you had at an outpatient hospital facility on June 25, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the wound care supplies/surgical dressing provided on April 8, 2021.
You asked the Plan to pay for the surgical dressings. You say that these surgical dressing were ordered by the network surgeon. The Plan denied your request. The Plan says that these are not payable on the Physician Fee Schedule and were provided without authorization.
Please note, although these codes are not payable on the Physician Fee Schedule, they have been provided by a Durable Medical Equipment (DME) supplier. This means that they would be paid on the DME fee schedule.
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. The enrollee was referred for the surgical dressings by a contracted surgeon. The file does not show that the plan provided notice that the surgical dressings would not be covered. Under Medicare rules, this means the surgical dressings is considered approved by the plan. Therefore, we decided that the Plan has to pay for the wound care supplies/surgical dressing provided on April 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Freestyle Libre 14 Day Reader (CPT code K0554), for the enrollee.
You asked the Plan to pre-approve the item. You say that the enrollee has diabetes and are not on insulin. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. We looked at the file and Medicare rules. The documentation indicates that the enrollee is not currently treated with insulin. Based on this information, we decided that Medicare rules for coverage of the item have not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle Libre 14 Day Reader (CPT code K0554), for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Xhance.
You asked the Plan to pre-approve Xhance. You say that the requested drug is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for self-administered drugs have not been met.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Xhance.
Benefits for Xhance 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion (99601) provided on April 30, 2021.
You asked the Plan to pay for the home infusion. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 99601 has a status indicator of I.
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 99601 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code 99601 has a status indicator of I. This means that CPT code 99601 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion (99601) provided on April 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (75716, 75774) provided on April 22, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these are bundled 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. In this case, we have confirmed that codes 75716 and 75774 have a bundled relationship with code 37221 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 the services (75716, 75774) provided on April 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to make additional payment for the periodontal scaling and root planing provided on June 2, 2021.
You asked the Plan to make additional payment for the periodontal services. You say that you believe that you should be reimbursed more. The Plan denied your request. The Plan says the entire maximum dental benefit has been paid.
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, coverage is up to a maximum of $1000 per year. The Plan has paid this maximum and is not obligated to make additional payment. Therefore, we decided that the Plan does not have to make additional payment for the periodontal scaling and root planing provided on June 2, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a CardioPro genetic panel (81291, 81407, 81408, 81439, 81479) provided on November 9, 2020.
You asked the Plan to pay for a CardioPro genetic panel. You say that this was billed correctly. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular (CV) risk assessment panels, except the basic lipid panel, for symptomatic and asymptomatic patients. We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not covered. Based on this information, we decided that Medicare rules for coverage of a CardioPro genetic panel have not been met. Therefore, we decided that the Plan does not have to pay for a CardioPro genetic panel (81291, 81407, 81408, 81439, 81479) provided on November 9, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on March 17, 2021.
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that your boyfriend had called the paramedics because he believed you were starting to seize from your low blood sugar. You also say that this was a life-threatening emergency and you believe being transported to the hospital would have cost more. The Plan denied your request. The Plan says this service is 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 March 17, 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 the ambulance response and treatment with no transport (A0998) provided on March 17, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for genetic testing provided on January 26, 2021.
You asked the Plan to pay for genetic testing. You say that this testing was necessary, and the enrollee meets the criteria. The Plan denied your request. The Plan says that the denial of payment for these services is correct, because these services were already paid under claim 820211090786020 so this claim is redundant.
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. You submitted a claim for payment of these services, which was assigned claim number 820211190383888. The Plan says that these services were already billed on claim 820211090786020 so additional reimbursement is not warranted. However, the Plan did not provide any evidence to support that claim 820211090786020 exists, constitutes the services for which you are requesting payment, and has already been approved for payment by the Plan. Without this information, the Plan has not shown that claim 820211190383888 is redundant and does not warrant reimbursement. The Plan has not provided any other basis or rationale to deny payment for this testing. Therefore, the Plan has not shown that its decision to deny payment for this testing is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for genetic testing provided on January 26, 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 June 2, 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 physician services provided to the enrollee on June 2, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for flow cytometry testing (88188 and 88189) provided on
December 14, 2020.
You asked the Plan to pay for flow cytometry testing. You say that you are appealing with supporting records.
The Plan denied your request. The Plan says the denial of payment for this testing is correct, because these tests
are not covered for screening purposes.
The Plan must follow Medicare rules. Medicare rules say that test codes 88188 and 88189 are only covered for
certain specified diagnoses which do not include diagnosis code D53.9.
We looked at the file and Medicare rules. These tests are not covered for the billed diagnosis code of D53.9.
Based on this information, we decided that Medicare rules for coverage of flow cytometry testing have not
been met. Therefore, we decided that the Plan does not have to pay for flow cytometry testing (88188 and
88189) provided on December 14, 2020.