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

We decided that the Plan does not have to pay forthe 2 case presentations (D9450) provided from December 9, 2019 to January 13, 2020.You asked the Plan to pay forthe dental services. You say that you are on Social Security. You say that you do not have the money to pay these bills.The Plan denied your request. The Plan says case presentation is not listed as a covered service for 2019 or 2020.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, case presentation is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe 2 case presentations (D9450) provided from December 9, 2019 to January 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the hearing tests provided on December 3, 2019.You asked the Plan to waive the copayment for the hearing tests. You say that you went for your annual hearing exam. You say that you should be reimbursed.The Plan denied your request. The Plan says the copayment applied 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 $50 copayment for each in-network, Medicare-covered visit.You have been asked to pay a $50 copayment for the hearing tests. The hearing tests falls within the "Hearing services" benefit category. The hearing tests are considered diagnos tictests. 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 hearing tests provided on December 3, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay foran abdomen x-ray (71049) provided on December 3, 2019.You asked the Plan to pay forthe abdomen x-ray. You say that you would like reconsideration as this claim denied as a duplicate in error.The Plan denied your request. The Plan says that procedure code 74019 was denied as the column II code to the column I code 74022 based on the CCI policy.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 74019is supported in the record. Specifically, this service was rendered by a separate provider with a different NPI. Based on this information, we decided that Medicare rules for coverage of the abdomen x-ray have been met.Therefore, we decided that the Plan has to pay foran abdomen x-ray (71049) provided on December 3, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe cystourethroscopy provided from June 3, 2019 to June 5, 2019.You asked the Plan to waive the coinsurance forthe cystourethroscopy. You say that you could have gone toan ambulatory surgical center instead of an outpatient hospital. 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). The enrollee's contract with the Plan clearly says that enrollees must pay 20% coinsurance for each outpatient hospital facility visit, including physician or surgical charges. The enrollee has been asked to pay $941.76 which is 20% of the allowed amount for the cystourethroscopy. The allowed amount is $4,708.78. ($4,708.78 x 20% = $941.76). The cystourethroscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance forthe cystourethroscopy provided from June 3, 2019 to June 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the custom fabricated abutments (D6057) and abutment
supported crowns (D6058) for teeth # 19 and 30.
You asked the Plan to pre-approve the dental services. You say that you cannot afford to pay for these services.
You also say that you have major medical issues. The Plan denied your request. The Plan says custom
fabricated abutments are not a covered service. The Plan also says that abutment supported crowns are not a
covered service.
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 dental services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the
custom fabricated abutments (D6057) and abutment supported crowns (D6058) for teeth # 19 and 30.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve corn starch baby powder.
You asked the Plan to pre-approve corn starch baby powder. You say that the Plan has provided the corn starch baby powder in the past. The Plan denied your request. The Plan says this is a non-covered over-the-counter item.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and baby powder is an OTC item. You do not have a supplemental OTC benefit. Therefore, we decided that the Plan does not have to pre-approve corn starch baby powder.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services provided on November 21, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not covered.
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT code 38500. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the services have not been met. Therefore, we decided that the Plan does not have to pay for the assistant surgeon services provided on November 21, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from September 28, 2019 to October 17, 2019.You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act.The Plan denied your request. The Plan says Skilled Nursing Facility (SNF) care beyond 100 days per benefit period is not covered by Medicare or the Plan.The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that the enrollee received 100 days of SNF care during the benefit period from August 23, 2019 to February 11, 2020. The Plan has covered 100 days of SNF care. Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. the enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row.Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from September 28, 2019 to October 17, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe two guided tissue regenerations (D4266), two bone replacement grafts for ridge preservation (D7953), and occlusal adjustment (D9952) provided on November 12, 2019.You asked the Plan to pay forthe guided tissue regenerations, bone replacement grafts, occlusal adjustment. You say that the provider never told you that these services would not be covered. You also say that the provider was pulling your teeth, but you did not know you were having a surgery.The Plan denied your request. The Plan says these services arenot 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 pay forthe two guided tissue regenerations (D4266), two bone replacement grafts for ridge preservation (D7953), and occlusal adjustment (D9952) provided on November 12, 2019. Your complaint about the provider taking advantage of you 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital visits (99232x3) and s provided on October 15, 2019 to October 17, 2019 by an out of network (OON) provider.You asked the Plan to pay for the subsequent hospital visits. You say that please review and process the claim.The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to services being rendered.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 has network providers available who can provide 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 subsequent hospital visits (99232x3) and s provided on October 15, 2019 to October 17, 2019 by an out of network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for cryoablation(64635 and 64636) provided on August 30, 2019.You asked the Plan to pay for the cryoablation. You say that you would like reconsideration as this service was medically necessary.The Plan denied your request. The Plan says this service is non-covered.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 cryoablation. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the records do not include any recent imaging, indicate that the member has concurrent radicular pain complaints and that the second diagnostic branch block did not achieve 80% pain relief.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 cryoablation have not been met.Therefore, we decided that the Plan does not have to pay forcryoablation (64635 and 64636) provided on August 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for assistant at surgery services provided by provider on October 8, 2019.You asked the Plan to pay for surgical assistant services. You say that the surgical assistant was requested at the surgeon's discretion, and you should be paid in full immediately.The Plan denied your request. The Plan says the denial of payment for this service is correct, because a surgical assistant was not necessary for this procedure.The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT code 64721. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon isnot medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for surgical assistant services have not been met.Therefore, we decided that the Plan does not have to pay for assistant at surgery services provided by provider on October 8, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on October 8, 2019.You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services rendered are not a covered benefit.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The laboratory testing at issue in this appeal 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 the laboratory services provided on October 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic testing services provided on August 15, 2019 by an out of network (OON) provider.You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says the information did not show a prior authorization was obtained.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 forthe diagnostic testing services provided on August 15, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forocclusal adjustment -limited (D9951) provided on January 8, 2020 by an out-of-networkprovider.You asked the Plan to pay forthe dental services. You say that you are appealing for reconsideration of the denied charges.The Plan denied your request. The Plan says the service is not a covered benefit under the plan.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. This service is not listed in your EOC as a covered benefit; therefore, it is not covered.Therefore, we decided that the Plan does not have to pay forocclusal adjustment -limited (D9951) provided on January 8, 2020 by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an ultrasound (76770) provided on July 8, 2019. You asked the Plan to pay for the ultrasound. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this procedure is more commonly billed with indications specific to embolism and thrombosis. 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 76770 is not supported in the record. Specifically, per Local Coverage Article: Billing and Coding: Retroperitoneal Ultrasound (A55336), this diagnosis code does not support medical necessity. There is insufficient documentation to determine whether Medicare criteria for coverage have been met. Based on this information, we decided that Medicare rules for coverage of the ultrasound have not been met. Therefore, we decided that the Plan does not have to pay for an ultrasound (76770) provided on July 8, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for vision services (V2799) trifocal eyeglass lens (V2303) and anti-reflective lens coating (V2750) purchased on October 3, 2019.You asked the Plan to pay for the vision services. You say that you were told on that date that the balance due would be $100. Had you known you would be paying $274 instead of $100 you would have went without the new lenses.The Plan denied your request. The Plan says the plan had approved the $100 eyewear for this date of service and the benefit has been exhausted.The rules say that a Cost plan must disclose in writing all benefits available under the Plan. The health plan contract says that enrollees must pay The plan has a $100 allowance a year to use toward the purchase price of eyewear. If the eyewear you purchase costs more than $100 you pay the difference.You have been asked to pay $174 for the vision services. The vision services fall within the Vision care 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 pay for vision services (V2799) trifocal eyeglass lens (V2303) and anti-reflective lens coating (V2750) purchased on October 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for electrical stimulation (97014) and extra-spinal manipulation (98943) provided on May 23, 2019.You asked the Plan to pay for the electrical stimulation and extra-spinal manipulation. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says manual manipulation of the spine is covered but all other services furnished or ordered by a chiropractor are not covered.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay for electrical stimulation (97014) and extra-spinal manipulation (98943) provided on May 23, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay forthe emergency room (ER) services rendered on September 2, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claim was not billed with an appropriate diagnosis.The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis code.We looked at the file and Medicare rules. The file shows that the claim for procedure code 99284 was not billed with an appropriate primary, first-listed, or principal diagnosis. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe emergency room (ER) services rendered on September 2, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on October 27, 2019.You asked the Plan to waive the copayment for the ambulance transport. You say that you are being charged incorrectly.The Plan denied your request. The Plan says that the claim processed 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 $300 copayment per one-way trip for emergency ambulance services and non-emergency ambulance services. You have been asked to pay a $300 copayment for the ambulance transport. The ambulance transport falls within the one-way trip for emergency ambulance services and non-emergency ambulance 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 copayment for the ambulance transport provided on October 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe wrist/hand orthosis coded L3916 provided on November 18, 2019.You asked the Plan to pay forthe wrist/hand orthosis. 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 L3916is wrist hand orthosis, includes one or more nontorsion joint(s), elastic bands, turnbuckles, may include soft interface, straps, prefabricated, off-the-shelf.We find that CPT code L3916 is not supported in the medical record. Specifically, the documentation submitted did not indicate the provider discussed the need for the billed supply code. Based on this information, we decided that Medicare rules for coverage of the wrist/hand orthosis have not been met.Therefore, we decided that the Plan does nothave to pay forthe wrist/hand orthosis coded L3916 provided on November 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea chiropractic office visit (CPT 99215 and CPT 99245).You asked the Planto pre-approvethe visit. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not a covered benefit.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine.Therefore, we decided that the Plandoes not haveto pre-approvea chiropractic office visit (CPT 99215 and CPT 99245)