Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the extraction, erupted tooth requiring
removal of bone and/or sectioning of tooth (D7210) received November 30, 2020.
You asked the Plan to waive the coinsurance for the extraction. You say that the Plan should pay more for the
extraction. The Plan denied your request. The Plan says the correct cost share applied to the claim.
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 50%
coinsurance for Non-Medicare covered preventive or comprehensive dental services.
You have been asked to pay 50% coinsurance for the extraction (50% of $303 = $151.50). The extraction falls
within the Non-Medicare covered preventive or comprehensive dental services benefit category. This means
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan
does not have to waive the coinsurance for the extraction, erupted tooth requiring removal of bone and/or
sectioning of tooth (D7210) received November 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam (D0150) and the complete series x-ray
(D0210) provided on October 23, 2019.

You asked the Plan to pay for the dental services. You say that you did not know that you owed any money for
these services. You say that you never received a bill until January 2021. You also say that you need help. The
Plan denied your request. The Plan says claims received more than 12 months after the date of service are not
covered. The Plan says that had the claim been submitted timely, it would still have denied for frequency limit.
The Plan says that 2 exams and 1 full mouth or panoramic x-ray are covered per year. The Plan also says that
reimbursement for these services has been paid previously.

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 dental services was not filed until January 13, 2021. This means that
more than one calendar year from the date of service had passed before a claim was filed. The record shows
that the services would not have been covered regardless of when the claim was submitted due to frequency
limitations. Therefore, we decided that the Plan does not have to pay for the oral exam (D0150) and the
complete series x-ray (D0210) provided on October 23, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on October 15, 2020.

You asked the Plan to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device. You say that the treatment was medically necessary and should be covered. The Plan denied your request. The Plan says the record does not support that the procedures were performed 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, the HCPCS/CPT Code Manual definition of code 97016 is application of blood vessel compression or decompression device to 1 or more areas. The HCPCS/CPT Code Manual definition of code 97032 is application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes. The HCPCS/CPT Code Manual definition of code 97150 is therapeutic procedure(s), group (2 or more individuals). The HCPCS/CPT Code Manual definition of code 96372 is therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular. The HCPCS/CPT Code Manual definition of code J3490 is unclassified drug injection. The HCPCS/CPT Code Manual definition of code J3411 is injection, thiamine hcl, 100 mg. The HCPCS/CPT Code Manual definition of code J3415 is injection, pyridoxine hcl, 100 mg.

We find that HCPCS/CPT codes 97016, 97032, and 97150 are not supported in the medical record. Specifically, the record does not support that a blood vessel compression device was applied. The manufacturer of the Sanexas device describes it as an electric cell signaling energy wave device, which does not meet the criteria to report CPT code 97016. The record also does not support that manual electrical stimulation was applied to any area for any amount of time. The record states that the Sanexas device was applied using standard programs. This does not support constant direct patient contact, which is required to report CPT code 97032. The record also does not support that therapeutic procedures in a group of 2 or more was performed. The record does not mention any therapeutic procedures, or the presence of any other patients receiving therapy at the same time; the criteria for reporting CPT code 97150 has not been met.

Payment for HCPCS/CPT codes 96372, J3490, J3411, and J3415 are not supported. Specifically, the record does not contain documentation of the dosage and type of drug administered in each injection, which is required by Medicare for these services to be reimbursed.

Based on this information, we decided that Medicare rules for coverage of the nutria-pharmaceutical injections and treatment with a Sanexas device have not been met. Therefore, we decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on October 15, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for diagnostic radiology services provided by a participating provider on January 26, 2021.
You asked the Plan to waive the copayment for diagnostic radiology service. You say that you did not know you would have this copayment. The Plan denied your request. The Plan says the correct copayment has been applied.
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 $150 copayment for outpatient diagnostic tests/in-network/diagnostic radiology. You have been asked to pay a $150 copayment for diagnostic radiology service. The correct copayment has been applied to the services that were provided. Diagnostic radiology service falls within the outpatient
diagnostic tests/in-network/diagnostic radiology 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 diagnostic radiology services provided by a participating provider on January 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two periodic oral evaluations, two prophylaxes, two topical applications of fluoride varnish, and bitewing x-rays provided on February 24, 2020, and November 25, 2020 by a Medicare opt out provider.

You asked the Plan to pay for the periodic oral evaluations, prophylaxes, topical applications of fluoride varnish, and bitewing x-rays. You say that the Plan has no approved dental providers where you live. The Plan denied your request. The Plan says the treating provider opted out of Medicare effective May 18, 2015, to May 18, 2021.

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 covered when they are rendered by a provider who has opted out of Medicare. Therefore, we decided that the Plan does not have to pay for the two periodic oral evaluations, two prophylaxes, two topical applications of fluoride varnish, and bitewing x-rays provided on February 24, 2020, and November 25, 2020 by a Medicare opt out provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI provided on January 8, 2021.

You asked the Plan to waive the copayment for an MRI. You say that you feel that you should only owe a $40 copayment. 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 a $275 copayment for diagnostic radiology. 

You have been asked to pay a $275 copayment for an MRI. An MRI falls within the outpatient diagnostic tests and therapeutic services and 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 copayment for an MRI provided on January 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for test for detecting genes associated with heart disease, genomic sequence analysis panel, at least 9 genes (CPT code 81410) and test for detecting genes associated with heart disease, duplication/deletion analysis panel (CPT code 81411) provided to the enrollee on December 18, 2020, by a non-participating provider.

You asked the Plan to pay for the diagnostic pathology. You say that the claim should be paid. The Plan denied your request. The Plan says the services are considered experimental and investigational.

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 pay for the diagnostic pathology. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that that specific genetic testing may be appropriate in patients with a known or suspected diagnosis of unexplained arrhythmia, cardiomyopathy, sudden and unexplained cardiac arrest, conditions that affect the aorta, hypercholesterolemia, pulmonary hypertension, congenital heart disease, or a family member with one of the above conditions whose genetic cause is already known. The review indicates that there was no specific clinical rationale for the obtained tests. The items/services at issue in this case were not medically reasonable or necessary.

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 diagnostic pathology have not been met. Therefore, we decided that the Plan does not have to pay for test for detecting genes associated with heart disease, genomic sequence analysis panel, at least 9 genes (CPT code 81410) and test for detecting genes associated with heart disease, duplication/deletion analysis panel (CPT code 81411) provided to the enrollee on December 18, 2020, by a non-participating provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services coded 73130 and 73565 provided on July 1, 2020.
You asked the Plan to pay for the x-ray services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 73130 is radiologic examination, hand; minimum of 3 views. The CPT Code Manual definition of code 73565 is radiologic examination, knee; both knees, standing, anteroposterior.
We find that CPT code 73130 and 73565 is not supported in the medical record. Specifically, the documentation only indicates that two views of the left (LT) and two views of the right (RT) hand x-ray services were performed. Therefore, code 73130-RT and 73130-LT XU cannot be verified. The documentation indicates that anteroposterior and lateral views of the bilateral knees were performed. This means that code 73565 cannot be verified. Based on this information, we decided that Medicare rules for coverage of the x-ray services have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray services coded 73130 and 73565 provided on July 1, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on October 26, 2020.

You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered service.

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 pay for the testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no medical history provided other than listed diagnoses. Cardiac gene variant testing has limited clinical application at present and is occasionally useful in more rare familial inherited cardiac conditions. Current AHA/ACC guidelines recommend using clinical risk factor profiles and occasionally radiologic studies (CT calcium scores) for assessing cardiovascular risk and determining individual patient risk factor modification, use of lipid lowering therapies, etc. Cardiac gene variant testing is not currently recommended for general risk stratification, and therefore would not be considered medically reasonable or necessary in this case. 

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 testing have not been met. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on October 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you by an out-of-network provider on November 23, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 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 services provided to you by an out-of-network provider on November 23, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the physical therapy services (CPT code(s): 97110, 91763) to be performed by an out-of-network provider.

You asked the Plan to pre-approve the physical therapy services. You say that you already go to this facility for your neck therapy and you do not see why you are not able to get your leg therapy at the same place. The Plan denied your request. The Plan says there are in-network providers that can perform the services and the in-network provider states they can treat lower extremity edema.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the physical therapy services (CPT code(s): 97110, 91763) to be performed by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the core buildup, custom fabricated abutment, abutment supported crown, pontic and retainer crowns.

You asked the Plan to pre-approve the core buildup, custom fabricated abutment, abutment supported crown, pontic and retainer crowns. You say that your doctor faxed the supporting documents for the need of two implants. You say that you will not be able to pay for the cost of this procedure. The Plan denied your request. The Plan says the services are not covered 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. 

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 the core buildup, custom fabricated abutment, abutment supported crown, pontic and retainer crowns.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a participating provider on January 7, 2021.

You asked the Plan to waive the copayment for a specialist office visit. You say that you shouldn't have to pay for this because the doctor did not do anything, and you had to come back. The Plan denied your request. The Plan says the correct copayment has been applied.

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 $45 copayment for physician/practitioner services/specialist.

You have been asked to pay a $45 copayment for a specialist office visit. Since a specialist office visit did take place, the correct copayment has been applied. A specialist office visit falls within the physician/practitioner services/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 waive the copayment for a specialist office visit provided by a participating provider on January 7, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional seven (7) PT visits.

You asked the Plan to pre-approve additional PT visits. The Plan denied your request. The Plan says an additional seven (7) PT visits are not reasonable and necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.

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 additional seven (7) PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health Plan. The enrollee has had prior therapy of 24 outpatient visits and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist beyond what was approved by the Plan. The enrollee has been authorized additional therapy to review instruction in a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. 

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 additional seven (7) PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional seven (7) PT visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair glide.

You asked the Plan to pre-approve a stair glide. You say that this equipment is medically necessary. The Plan denied your request. The Plan says this is not a covered service.

The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. 

While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a stair glide.