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

We decided that the Plan does not have to pay for the testing rendered on November 22, 2019.
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 testing was not medically necessary.
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 these services. Our reviewer says that the
testing was not medically necessary. Our physician reviewer found the enrollee has a history of breast cancer.
There are no provider records submitted for review. There is no evidence to support that the testing was
medically necessary and reasonable to diagnose, treat or otherwise manage the enrollee's condition(s).
We looked at this physician's review, the file, and Medicare rules. 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 testing rendered on November 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe eye exam rendered on July 13, 2020.You asked the Plan to waive the copayment forthese services. You say that the services were a glaucoma screening and should have no copayment.The Plan denied your request. The Plan says the copayment was applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles andcoinsurance). Your contract with the Plan clearly says that you must pay a $25 copayment for Medicare-covered exams to diagnose and treat diseases and conditions of the eye. Review of the file shows that you received an eye exam on July 13, 2020. You have been asked to pay a $25 copayment for these services. These services fall within the Medicare-covered exams to diagnose and treat diseases and conditions of the eye 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. The file shows that you previously had a glaucoma screening on July 1, 2020 for which the Plan approved and paid. The Plan covers one glaucoma screening per year. The services rendered on July 13, 2020 were performed less than one year after your previously covered glaucoma screening.Therefore, we decided that the Plan does not have to waive the copayment forthe eye exam rendered on July 13, 2020
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on August 10, 2020.
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on August 10, 2020. 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 services provided on August 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay fortrain of four testing (CPT 95999) provided to the enrollee on March 6, 2020.You asked the Plan to pay forthe testing. You say that this should be paid for.The Plan denied your request. The Plan says this item or service is considered a bundled procedure as the cost is included in the cost of the primary procedure.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 asked our coding 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 services at issue in this case were not supported by the medical records. Our coding reviewer found there is no separate CPT code to report for (TOF)Train of Four testing. TOF testing in bundled with the intraoperative neuromonitoring of electromyography (EMG) or motor evoked potentials(MEP) and, therefore, is not separately reportable.We looked at this coder'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 fortrain of four testing (CPT 95999) provided to the enrollee on March 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on August 5, 2020.
You asked the Plan to pay for the dental service. You say that you were not informed that there was a first time examination fee. You say that you cannot afford to pay this bill. You say that you need procedures done to your tooth right away. You also say that you would like this payment to be overridden. The Plan denied your request. The Plan says 1 comprehensive oral evaluation every 3 plan years. The Plan 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, the frequency limit of 1 comprehensive oral evaluation every 3 plan years has been exceeded. The record shows that the Plan paid for this service that you received on October 14, 2019, less than 3 years prior. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on August 5, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Positive Emission Tomography (PET) with Computed Tomography (CT) scan.

You asked the Plan to pre-approve a PET with CT scan. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary. 

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 a PET with CT scan. Our reviewer says that the documentation does not support that the requested PET with CT scan is medically reasonable or necessary. Our physician reviewer found the enrollee has stage IIIB melanoma. The documentation supports that the enrollee has had more than 3 PET with CT. Therefore, the enrollee does not meet criteria for the requested PET with CT.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a PET with CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a Positive Emission Tomography (PET) with Computed Tomography (CT) scan.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic nuclear medicine provided on August 24, 2020.
You asked the Plan to pay for the diagnostic nuclear medicine. The Plan denied your request. The Plan says the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they 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 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 diagnostic nuclear medicine provided on August 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodic oral evaluation, bitewings, and prophylaxis provided on August 4, 2020 by an OON provider.You asked the Plan to pay forthe periodic oral evaluation, bitewings, and prophylaxis. You say that you were informed that this treating provider was no longer a participating provider, but you would be reimbursed by the Plan for OON coverage.The Plan denied your request. The Plan says these services were rendered by an OON provider, and you do not have OON benefits under your preventive dental 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 covered when they are received OON.Therefore, we decided that the Plan does not have to pay forthe periodic oral evaluation, bitewings, and prophylaxis provided on August 4, 2020 by an OON provider.Your complaint about possibly being misled by the provider's office about coverageis 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forneuromonitoringservices (95861, 95868, 95927, 95938) provided on April 28, 2020.You asked the Plan to pay forneuromonitoring services. You say that this was billed correctly.The Plan denied your request. The Plan says this was not billed with the correct place of service.The Plan must follow Medicare rules. Medicare rules say that when services are furnished in a mobile unit, they are often provided to serve an entity for which another POS code exists. When a service is rendered to a patient who is a registered inpatient or an outpatient of a hospital the correct POS code is that of the appropriate inpatient POS code (at a minimum POS code 21) or that of the appropriate outpatient hospital POS code (at a minimum POS code 19 or 22, for outpatientservices performed off campus or on campus) We looked at the file and Medicare rules. The record shows that the services at issue were billed with POS 15 for a mobile unit, but the enrollee was a registered inpatient or an outpatient of a hospital. Based on this information, we decided that Medicare rules for coverage of neuromonitoring services have not been met.Therefore, we decided that the Plan does not have to pay forneuromonitoring services (95861, 95868, 95927, 95938) provided on April 28, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay fora dental filling (D2391) provided August 20, 2020.You asked the Plan to pay forthe filling. You say that the service should be covered.The Plan denied your request. The Plan says the benefit for fillings was exhausted at the time the service was provided.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 record shows you already had two fillings on February 27, 2020. The benefit for fillings was exhausted when the services at issue were received.Therefore, we decided that the Plan does not have to pay fora dental filling (D2391) provided August 20, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services you received on August 7,
2020.
You asked the Plan to waive the copayment for the lab services. You say that you received notification in the
mail that your plan is waiving copayments during the pandemic. The Plan denied your request. The Plan says
their copayment waiver program only applies to the following services: primary care office visits, specialist
office visits, physicians assistant or nurse practitioner visits, chiropractic and acupuncture services, podiatry
services, eye care, hearing exams, physical, occupational, and speech therapy, cardiac and pulmonary
rehabilitation, outpatient health and substance abuse visits, and opioid treatment services. The Plan says that
copayments for lab services are not being waived unless related to COVID-19 testing or treatment.
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 $10
copayment for lab services.
You have been asked to pay a $10 copayment for the lab services. Lab services are not part of this Plan's
copayment waiver program. 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 lab services you received
on August 7, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foracolonoscopy with biopsy provided on December 12, 2019.You asked the Plan to waive the copayment forcolonoscopy. You say that this should have been billed as a routine screening and not a diagnostic service.The Plandenied your request. The Plan says the copayment amount 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 $275 copayment for in-network colonoscopy with biopsy at an ambulatory surgical center. The record shows that a polyp was found and biopsy performed during this colonoscopy; therefore, this is considered to be a surgical service and not a screening service.You have been asked to pay $275 copayment for colonoscopy. Colonoscopy falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 fora colonoscopy with biopsy provided on December 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a presbyopia correction feature of an intraocular lens (IOL) provided on July 27, 2020.
You asked the Plan to pay for IOL feature. You say that you were told that your insurance was accepted, so you should only be billed for a $300 copayment. The Plan denied your request. The Plan says the denial of payment for this IOL feature is correct, because this is not covered by Medicare or the Plan. The Plan also says that they have approved coverage at the in-network benefit level for the remainder of this claim, per your request.
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 does not cover a presbyopia correcting feature for an intraocular lens (V2788).
We looked at the file and the Plan's rules. The Plan does not cover this presbyopia correcting function for an intraocular lens. Based on this information, we decided that the Plan's rules for coverage of IOL feature have not been met. Therefore, we decided that the Plan does not have to pay for a presbyopia correction feature of an intraocular lens (IOL) provided on July 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on January 9, 2020, by an OON provider.You asked the Plan to pay fora uterine ultrasound. You say that the enrollee stated that no other doctor would accept her.The Plan denied your request. The Plan says rules for payment have not been met.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 andpre-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 forthe medical services provided on January 9, 2020, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

e decided that the Plan does not have to pay forthe surgical services rendered on May 8, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 37222 is not supported.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 37222 is revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral iliac vessel; with transluminal angioplasty (List separately in addition to code for primary procedure).We find that CPT code 37222 is not supported in the medical record. Specifically, there is no documentation of an open or percutaneous endovascular revascularization of the iliac artery. 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 surgical services rendered on May 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe infectious detection assays using DNA/RNA provided on July 15, 2020.You asked the Plan to pay forthe infectious detection assays using DNA/RNA. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services provided werenot medically necessary.The Plan follows Medicare rules. Medicare rules say that infectious agent detection by nucleic acid (DNA or RNA) coded 87631 is only covered for certain indications.We asked our physician reviewer to carefully review the casefile and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the infectious detection assays using DNA/RNA. Our reviewer says that the documentation does not support that the services rendered were medically reasonable or necessary. Our physician reviewer found the documentation does not support the need for the study provided. There are no records to support the tests submitted. Therefore, the enrollee did not meet criteria for the services rendered. 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 infectious detection assays using DNA/RNA have not been met.Therefore, we decided that the Plan does not have to pay forthe infectious detection assays using DNA/RNA provided on July 15, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe frames (V2020) and lens tint (V2744) provided on May 18, 2020, by an out-of-network (OON) provider.You asked the Plan to pay forthe frames and lens tint. You say that your glasses were broken, and you were unable to find a network provider.The Plan denied your request. The Plan says there is no benefit for routine vision care services obtained from OON providers.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 when they are obtained from network providers.We looked at the file and the Plan's rules. The file indicates that you did not receiveprior authorization for services received OON and the Plan had network providers available to perform these services. Based on this 
information, we decided that the Plan's rules for coverage of the frames and lens tint have not been met.Therefore, we decided that the Plan does not have to pay forthe frames (V2020) and lens tint (V2744) provided on May 18, 2020, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve L4-L5, L5-S1 lumbar fusion.
You asked the Plan to pre-approve the surgery. You say that to deny these procedures due to tobacco/cigarette use is an infringement of your rights. The Plan denied your request. The Plan says this is not medically necessary.
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 the surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found smoking is a contraindication to spinal fusion. You are a current smoker. There is no documentation of smoking cessation. 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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve L4-L5, L5-S1 lumbar fusion.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for injections (64483, 64484) provided June 19, 2020.
You asked the Plan to pay for the injections. You say that these services were medically necessary. The Plan denied your request. The Plan says the billed units exceed the allowed amount.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. In this case, the MUE for CPT code 64483 is 1. You billed 2 units of this code, exceeding the MUE. Additionally, CPT code 64484 is an add-on code. The primary procedure was not approved, therefore, the add-on code cannot be covered. Based on this information, we decided that Medicare rules for coverage of the injections have not been met. Therefore, we decided that the Plan does not have to pay for injections (64483, 64484) provided June 19, 2020.