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

We decided that the Plan does not have to pay for the reline of the complete lower denture (D5751) provided on February 24, 2021.

You asked the Plan to pay for the dental service. You say that your dentist is in network. You say that you do not understand why only one of your dentures can be relined. You say that you have a full set of dentures. You also say that your dentures will not fit correctly if you do not have both relined. The Plan denied your request. The Plan says 1 denture reline is covered per calendar year. The Plan also says that the frequency limit has been exceeded.

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 denture reline is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for the reline of the upper denture provided on the date of service in this case. Therefore, we decided that the Plan does not have to pay for the reline of the complete lower denture (D5751) provided on February 24, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on January 28, 2021, by an OON
provider.
You asked the Plan to pay for the OON services. You say that the enrollee's provider took the specimen at their
office and sent them to the lab. The Plan denied your request. The Plan says services rendered by nonparticipating
providers require 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 lab services provided on January 28, 2021, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a partial upper denture (D5213) provided on January 21, 2021.

You asked the Plan to pay for a partial upper denture. You say that you want the Plan to pay for the service. The Plan denied your request. The Plan says the service at issue is not a covered benefit.

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 for a partial upper denture (D5213) provided on January 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the supplies and anesthesia services rendered on December 29, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes. The rules say that CPT codes describing anesthesia services (00100-01999) are required
when billed by an anesthesia practitioner.

We looked at the file and Medicare rules. Billed procedure codes S1015 (IV tubing extension set) and S8301 (infection control supplies) have a status indicator of I and are not valid for Medicare purposes. Billed procedure code 99199 (unlisted special service or report) is not appropriate to bill for anesthesia services. 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 for the supplies and anesthesia services rendered on December 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an alveoloplasty in conjunction with extraction, 4 or more teeth per quadrant, (D7310) for all 4 quadrants.
You asked the Plan to pre-approve the dental services. You say that the services are necessary. The Plan denied your request. The Plan says the requested services are not medically necessary. The Plan also says that the documentation submitted by the provider did not mention or document any justification of the requested procedure.
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 dental services when the services are medically necessary and reasonable. 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 dental services. Our reviewer says that the alveoloplasties are not medically necessary.
Our physician reviewer found the requested code (D7310) is reserved for cases where there are 4 or more teeth in 1 quadrant where bone recontouring is required following the extractions. The reviewer found that there are less than 4 teeth in any 1 quadrant, making the D7310 code inapplicable. Therefore, the reviewer found that there would not be necessity for the requested procedures of 4 quadrants of bony recontouring under code D7310. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does not have to pre-approve an alveoloplasty in conjunction with extraction, 4 or more teeth per quadrant, (D7310) for all 4 quadrants.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for an outpatient surgery provided by a participating provider on October 23, 2020.

You asked the Plan to waive the co-payment for an outpatient surgery. You say that you do not understand why your co-payment is so high. The Plan denied your request. The Plan says the correct co-payment has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $175 co-payment for outpatient surgery.

You have been asked to pay a $175 co-payment for an outpatient surgery. The injection that was provided is considered an outpatient surgery; therefore, the correct co-payment has been applied. An outpatient surgery falls
within the outpatient surgery benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the co-payment for an outpatient surgery provided by a participating provider on October 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on August 5, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was billed incorrectly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results.
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on August 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses (V2781, V2200, V2020) and eye exam (92002) provided on February 10, 2021.
You asked the Plan to pay for the eyeglasses and eye exam. You say that you called the provider to verify your benefits and they said that you had coverage. You trusted them to give you accurate information and feel that an exception should be made for the two days as you were acting in good faith and not trying to exceed the benefit. The Plan denied your request. The Plan says you last used your vision benefits on February 12, 2019, and your benefits had not yet reset on the date of purchase. Routine vision benefits are administered on a rolling calendar year from the last date of service, and you were not two years out from the last date. The Plan also says you did not contact the Plan directly to verify benefits.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services every two years from the last date of service. We looked at the file and the Plan's rules. The Plan administers this benefit on a rolling calendar year, and it had not been exactly two years since your last date of service. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses and eye exam have not been met. Therefore, we decided that the Plan does not have to pay for the eyeglasses (V2781, V2200, V2020) and eye exam (92002) provided on February 10, 2021.
Your complaint about whether or not the Plan can or should make an exception for a two-day difference 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-rays provided on February 2, 2021.
You asked the Plan to waive the copayment for the x-rays. You say that your doctor sent you to Urgent Care to
get further x-rays, so you had no choice but to use the facility. 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 $50
copayment for diagnostic tests at any other location besides a physician's office for Outpatient Diagnostic
Tests. You have been asked to pay a $50 copayment for procedures at an outpatient facility. The x-rays fall within the
Outpatient Diagnostic Tests 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 x-rays
provided on February 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the telephone evaluation provided by an out-of-network provider on August 4, 2021.

You asked the Plan to pay for the telephone evaluation. You say that the patient informed you they were covered under Medicare at the time of service. You say that authorization was impossible with the incorrect insurance information and the claim should be reprocessed for payment. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the service was not approved in advance.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan 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 telephone evaluation provided by an out-of-network provider on August 4, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the train of four testing represented by code 95999 provided
on October 28, 2019.
You asked the Plan to pay for code 95999. You say that you would like the Plan to reconsider their denial of
payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 95999 is Unlisted neurological or neuromuscular
diagnostic procedure.
We find that CPT code 95999 is not supported in the medical record. Specifically, the record shows that train
of four testing was performed, and this is not the appropriate code for this service. Per Medicare guidelines, it
is inappropriate to bill unlisted neurological or neuromuscular diagnostic CPT codes for train of four
monitoring. There is no separate code for train of four monitoring. Based on this information, we decided that
Medicare rules for coverage of code 95999 have not been met. Therefore, we decided that the Plan does not
have to pay for the train of four testing represented by code 95999 provided on October 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services billed to the enrollee for date of service November 6, 2020.
You asked the Plan to pay for psychotherapy services billed to the enrollee. You say that this service should be covered by the Plan. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial for insufficient claim information. The Plan requested a reopen and provided additional information regarding the billing errors preventing payment.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code which includes correct place of service or POS code. In this case, this claim cannot be paid due to the omission of a correct place of service (POS) code. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay for psychotherapy services billed to the enrollee for date of service November 6, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit (99284) provided on February 17, 2021.
You asked the Plan to waive the copayment for an emergency room visit. You say that you disagree with the charges. The Plan denied your request. The Plan says the copayment you are being charged is correct.
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 $90 copayment for emergency care. You have been asked to pay a $90 copayment for an emergency room visit. The EOC confirms that $90 is the required copayment for this service. 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 emergency room visit (99284) provided on February 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray rendered on March 19, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 71045 is not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 71045 (chest x-ray) and 32557 (percutaneous pleural drainage with imaging guidance). Code 71045 is a column II code with a modifier indicator of 1 when billed with column I code 32557. Code 71045 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the chest x-ray rendered on March 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost for the intravenous infusions provided on November 9, 2020.
You asked the Plan to waive the cost for the intravenous infusions. You say that it was just a saline injection and there should not have been a charge. The Plan denied your request. The Plan says the coinsurance 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 $150 copayment for Medicare covered non-surgical services in an outpatient hospital setting. You have been asked to pay $53.75, which is less than the standard $150 copayment for the intravenous infusions. The intravenous infusions fall within the "Outpatient hospital services" benefit category. The intravenous infusions are considered a physician service that were provided in an outpatient hospital setting. 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 for the intravenous infusions provided on November 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the fetal non-stress test (59025) and the office visit (99213) rendered by the OON provider on December 8, 2020.

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 fetal non-stress test (59025) and the office visit (99213) rendered by the OON provider on December 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the mandibular partial denture provided on September 16, 2020.
You asked the Plan to pay more for the mandibular partial denture. You say that you were not advised that you would have to pay anything for the dentures. You also say that you cannot afford to pay any bills. The Plan denied your request. The Plan says a total of $3,000 has been paid by the Plan toward services for the 2020 benefit year.
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 Plan offers a $3,000 combined
allowance for supplemental preventive and comprehensive services every year. The contract says that you are responsible for any amount over and above the allowance amount. The record shows that you met the annual maximum benefit while processing this claim for the September 16, 2020 date of service and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay more for the mandibular partial denture provided on September 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services provided on August 4, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe laboratory services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide 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 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 forthe laboratory services provided on August 4, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the positron emission tomography (PET) with concurrently acquired computed tomography (CT) provided on December 18, 2020.
You asked the Plan to pay for the PET/CT (78815). You say that the Plan should pay this claim. The Plan denied your request. The Plan says a modifier was not submitted on the claim.
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 78815 is Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid-thigh. We find that CPT code 78815 is missing the PI or PS modifier. Based on this information, we decided that Medicare rules for coverage of the PET/CT (78815) have not been met. Therefore, we decided that the Plan does not have to pay for the positron emission tomography (PET) with concurrently acquired computed tomography (CT) provided on December 18, 2020.