Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby), per patient, (attention directed exclusively to one patient) each 15 minutes (CPT Code G0453) and continuous intraoperative neurophysiology monitoring in the operating room, one on one monitoring requiring personal attendance, each 15 minutes (CPT Code 95940) provided to the enrollee on June 10, 2019.You asked the Plan to pay for the services. You say that the claim should be paid.The Plan denied your request. The Plan says the services are not supported by the records.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.Current Procedural Terminology (CPT) code G0453 59 (8 units) remains not supported. The submitted code requires a preceding procedure code and cannot be reimbursed separately. In addition, this code is included in Current Procedural Terminology (CPT) code 95940 and 95955. Therefore, the billed Healthcare Common Procedure Coding System (HCPCS) code, modifier and units cannot be verified.Current Procedural Terminology (CPT) code 95940 XP (8 units) remains not supported. The submitted code requires a preceding procedure code and cannot be reimbursed separately. In addition, this code is included in Current Procedural Terminology (CPT) code 95955. Therefore, the billed Healthcare Common Procedure Coding System (HCPCS) code, modifier and units cannot be verified. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay for continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby), per patient, (attention directed exclusively to one patient) each 15 minutes (CPT Code G0453) and continuous intraoperative neurophysiology monitoring in the operating room, one on one monitoring requiring personal attendance, each 15 minutes (CPT Code 95940) provided to the enrollee on June 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.You asked the Plan to pre-approve outpatient treatment. You say that despite continued treatment within the Plan network you are not recovering from your condition, so you would like to be treated by this provider.The Plan denied your request. The Plan says the denial of authorization for these services is correct, because this provider is out-of-network with the Plan and you can be treated within the Plan network.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 medical services to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on October 23, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were available in-network.
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 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 medical services provided to the enrollee by an out-of-network provider on October 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for electrical stimulation (97014) and mechanical traction therapy (97012) provided on January 2, 2020 through January 13, 2020.You asked the Plan to pay for the electrical stimulation and mechanical traction therapy. You say that you would like reconsideration because you believed these services would be covered.The Plan denied your request. The Plan says these services are non-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 mechanical traction therapy (97012) provided on January 2, 2020 through January 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested physician's services.
You asked the Plan to pre-approve the physician's services. You say that you have two personal references to see this orthopedic physician and that this physician has better reviews than the Plan's in-network physician. The Plan denied your request. The Plan says the Plan requires you to receive care from providers who are part of your primary care physician's (PCP) medical group.
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 contract with the Plan also says that the Plan requires the enrollee to receive care from providers who are part of the enrollee's primary care physician's (PCP) medical group. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the requested physician's services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy provided on January 8, 2020.You asked the Plan to waive the copayment for the colonoscopy. You say that you had a colonoscopy after the positive Cologuard test. You say this procedure was always covered in the past.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). Your contract with the Plan clearly says that you must pay a $250 copayment for each Medicare-covered in-network outpatient hospital facility visit. You have been asked to pay a $250 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient surgery, including services provide at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows the colonoscopy was performed due to a positive Cologuard test which makes the colonoscopy diagnostic in nature. 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 colonoscopy provided on January 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forarthroscopy (29876) provided on November 4, 2019.You asked the Plan to pay forthe arthroscopy. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the documentation submitted does not support the billed service.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 29876 is arthroscopy, knee, surgical; synovectomy, major, 2 or more compartments (eg, medial or lateral).We asked our coder 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 arthroscopy. Our reviewer says that CPT code 29876 does not meet criteria for billing or reimbursement consideration. Our reviewer found the documentation does not indicate that a synovectomy, major, 2 or more compartment procedure was performed.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 arthroscopy have not been met.Therefore, we decided that the Plan does not have to pay forarthroscopy (29876) provided on November 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for bone replacement graft for ridge preservation (D7953) provided August 28, 2019.
You asked the Plan to pay for the dental services. You say that you are requesting reconsideration for payment for a bone graft done during a dental procedure. The Plan denied your request. The Plan says this services 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. The health plan contract specifically lists bone replacement grafts and specialized implant surgical techniques, including radiographic/surgical implant index as excluded. This is on page 5 of the Dental PPO Certificate of Coverage under Exclusions and Limitations. 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 bone replacement graft for ridge preservation (D7953) provided August 28, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 28, 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 is not covered.
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 testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on September 28, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the adjunctive pre-diagnostic test (D0431) provided on February 10, 2020.
You asked the Plan to pay for the dental service. You say that this service should have been covered under your annual visit. The Plan denied your request. The Plan says the adjunctive pre-diagnostic test is not listed as 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 adjunctive pre-diagnostic test is not among those covered under this benefit. The Evidence of Coverage clearly states that any services not listed are not covered. Therefore, we decided that the Plan does not have to pay for the adjunctive pre-diagnostic test (D0431) provided on February 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an initial 15 minutes of general anesthesia (D9222) and 5 additional 15 minutes of general anesthesia (D9223).
You asked the Plan to pre-approve the dental services. You say that all of your teeth are falling out. You say that you have a chronic infection in your mouth. You say that you are losing weight and are not able to eat which leads to stress and headaches. The Plan denied your request. The Plan says general anesthesia is only covered when you receive certain services. The Plan also says that general anesthesia is not covered in conjunction with surgical extractions.
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 services are not covered in conjunction with the surgical extractions. Therefore, we decided that the Plan does not have to pre-approve an initial 15 minutes of general anesthesia (D9222) and 5 additional 15 minutes of general anesthesia (D9223).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on June 3, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the billed code 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 G0481 is "Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 8-14 drug class(es), including metabolite(s) if performed." We find that CPT code G0481 is not supported in the medical record. Specifically, the records provided do not support the 8-14 drug classes were tested on the date of service in question. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on June 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider on November 6, 2019.You asked the Plan to pay for the services. You say that the provider told you that they accepted your plan.The Plan denied your request. The Plan says the services were available in-network.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 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 medical services provided to you by an out-of-network provider on November 6, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve 3 additional acupuncture visits.
You asked the Plan to pre-approve acupuncture. You say that you are appealing. The Plan denied your request. The Plan says that the denial of authorization for these services is correct, because the Plan approved 5 visits and the 3 additional requested are not medically necessary. If your acupuncturist feels that more visits are needed, another request may be submitted.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90 period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. 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 acupuncture. Our reviewer says that you meet the criteria for the requested acupuncture visits. Our physician reviewer found you have chronic knee pain. The Plan denied your request because you had prior acupuncture, however the prior therapy was for your elbow. This request is within your covered benefits. Therefore, the requested acupuncture is medically reasonable and 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 acupuncture have been met. Therefore, we decided that the Plan has to pre-approve 3 additional acupuncture visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray and each additional intraoral periapical x-ray provided on February 12, 2020.
You asked the Plan to pay for the intraoral periapical x-rays. The Plan denied your request. The Plan says these services are not covered by your benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 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. The only x-rays that your plan covers once a year are bitewing x-rays. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray and each additional intraoral periapical x-ray provided on February 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the outpatient medical services provided from January 18, 2020, to January 19, 2020.
You asked the Plan to waive the cost share for the services provided. You say that you informed the nurse you do not take insulin. The Plan denied your request. The Plan says the claim was processed according to your contract.
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 file shows that you received blood glucose testing. Your plan says that you pay a $12 copay for lab tests. However, you were only charged a 20% coinsurance, which is less than the $12 copay. The testing service falls within the outpatient hospital services benefit category.
You received a Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) vaccine. The records do not show that you were injured or directly exposed to any illness related to the Tdap vaccine. Benefits for the vaccine may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
You received outpatient observation care. You have been asked to pay a 20% coinsurance for the services provided. The services fall within the outpatient hospital observation benefit category. 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 share for the outpatient medical services provided from January 18, 2020, to January 19, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copays for the computed tomography (CT) scans provided on January 22, 2020, and February 7, 2020.
You asked the Plan to waive the copays for the CT scans. You say that the tests should have been done on the same day. The Plan denied your request. The Plan says the copays were applied in accordance with your EOC and Medicare rules.
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 $175 copay for each Medicare-covered advanced radiology service.
The documentation shows that you received a CT scan of the chest on January 22, 2020. You received a CT scan of the abdomen and pelvis on February 7, 2020. A $175 copay was applied to each date of service. Your Plan contract says that you pay a copay for each advanced radiology service. The CT scans falls 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 copays for the computed tomography (CT) scans provided on January 22, 2020, and February 7, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for Computed Tomography (CT) of the heart (75571) provided August 15, 2019.
You asked the Plan to pay for the CT scan. You say that the services were medically necessary and properly billed. The Plan denied your request. The Plan says the claim was submitted with an incorrect diagnosis code.
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 75571 is not supported in the medical record. Specifically, a secondary only diagnosis code was billed as the primary diagnosis. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not have to pay for Computed Tomography (CT) of the heart (75571) provided August 15, 2019.