Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye surgery procedure coded as 67299 provided January 12, 2021.

You asked the Plan to pay for the eye surgery procedure. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the billed code is not supported by the Medicare 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. 

In this case, the CPT Code Manual definition of code 67299 is unlisted procedure, posterior segment.

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 unlisted procedure, posterior segment. Our reviewer says that the criteria for coverage of the service as billed have not been met. Our reviewer found in this case, the operative report documents scleral application of tantalum rings and would be reported with S8030 instead of an unlisted procedure code. Medicare does not reimburse for services under S codes.0099 = "S" codes are unique temporary codes for private payor use. They are not valid nor payable by Medicare. 

We looked at this coder's reviewer, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the unlisted procedure, posterior segment have not been met. Therefore, we decided that the Plan does not have to pay for the eye surgery procedure coded as 67299 provided January 12, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation mileage.
You asked the Plan to pre-approve routine transportation. You say that the complexity of the enrollee's condition requires him to be seen at this facility. The Plan denied your request. The Plan says the denial of authorization for additional routine transportation mileage is correct, because routine transportation beyond 50 miles per one-way trips is not covered by the Plan.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine transportation up to 50 miles of driving distance per one-way trip.
We looked at your request, the records in the case file, and the rules. Transportation to the requested destination is more than 50 miles per one-way trip. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation mileage.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a core buildup (D2950), an intraoral periapical radiographic image (D0220), and an unspecified preventive procedure (D1999) provided from September 16, 2020, through October 15, 2020.
You asked the Plan to pay for a core buildup, an intraoral periapical radiographic image, and an unspecified preventive procedure. You say that the Plan referred you to this provider. The Plan denied your request. The Plan says the intraoral periapical radiographic image is a covered benefit, but you have exceeded the frequency limit of one every calendar year. The core buildup and unspecified preventive procedure are not covered benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a core buildup, an intraoral periapical radiographic image, and an unspecified preventive procedure have not been met. Specifically, the record shows that you had exceeded the frequency limit for the intraoral periapical radiographic image. Additionally, the core buildup and unspecified preventive procedure are not covered benefits. Therefore, we decided that the Plan does not have to pay for a core buildup (D2950), an intraoral periapical radiographic image (D0220), and an unspecified preventive procedure (D1999) provided from September 16, 2020, through October 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81479) provided January 6, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services billed is not covered under Medicare.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular risk assessment panels. We looked at the file and Medicare rules. The testing performed is non-covered. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81479) provided January 6, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81321, 81318, 81301, 81201) provided January 26, 2021.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim cannot be paid as billed.

The Plan must follow Medicare rules. Medicare rules say that if a laboratory assays two or more genes in a patient in parallel, then those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one HCPCS code must be submitted for the panel.

We looked at the file and Medicare rules. Multiple codes were billed for a single panel. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81321, 81318, 81301, 81201) provided January 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an oxygen concentrator (E1390) provided January 15, 2021, to April 15, 2021.
You asked the Plan to waive the coinsurance for an oxygen concentrator. You say that you have never had to pay a coinsurance in the past. The Plan denied your request. The Plan says the cost share has processed correctly in this case.
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 20% coinsurance for durable medical equipment. You have been asked to pay a 20% coinsurance for an oxygen concentrator. This item falls within the durable medical equipment benefit category. This means that you have been asked to pay the correct amount based on
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for an oxygen concentrator (E1390) provided January 15, 2021, to April 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (26440) provided November 16, 2020.
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services 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. We find that CPT code 26440 is not supported in the medical record. Specifically, the operative report provided does not support the service billed. Based on this information, we decided that Medicare rules for coverage of the surgical services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (26440) provided November 16, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided by a
participating provider on October 14, 2020.
You asked the Plan to waive the copayment for an emergency room visit. You say that you were only there for
5 minutes. You say that you were told you had to go to a different place to be treated. The Plan denied your
request. The Plan says the correct copayment has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50
copayment for emergency care.
You have been asked to pay a $50 copayment for an emergency room visit. Since an emergency room visit was
provided, the correct copayment has been applied. An emergency room visit falls within the emergency 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 waive the copayment for an emergency room visit provided by a participating provider on October 14, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the artery puncture collection of blood sample (36600) provided February 5, 2021.
You asked the Plan to waive the cost share for the artery puncture collection of blood sample. You say that you disagree with the classification of the procedure. The Plan denied your request. The Plan says the copayment processed correctly in this case.
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 $260 copayment for Medicare-covered surgery. You have been asked to pay a total cost share of $110.69 for the artery puncture collection of blood sample which is less than the required $260 copayment. This service falls within the Medicare-covered surgery benefit
category. We verified that this service is classified as a surgical procedure on arteries and veins. 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 share for the artery puncture collection of blood sample (36600) provided
February 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (00811) provided January 6, 2020.
You asked the Plan to pay for the anesthesia services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim was not filed timely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the anesthesia services was not filed until March 8, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for anesthesia services (00811) provided January 6, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided on March 20, 2021.
You asked the Plan to pay for the self-administered drugs. You say that you were admitted to the hospital and
do not know what was done as far as medication. The Plan denied your request. The Plan says selfadministered
drugs are not covered under Part B of Original Medicare.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs
provided on March 20, 2021.
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2740) on tooth #19 provided on March 10, 2021.

You asked the Plan to pay for the crown. You say that you needed a root canal even though you already had a crown on tooth #19. You also say that the crown needed to be replaced after the root canal. The Plan denied your request. The Plan says this service exceeds the frequency limitation in your benefit 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, if a porcelain, porcelain fused to metal (PFM) or cast metal crown is less than five years old, even if unserviceable, its replacement is not a covered dental service. The record shows that you received a crown on tooth #19 on September 13, 2017 and your crowns benefit for tooth #19 has been exhausted. Therefore, we decided that the Plan does not have to pay for the crown (D2740) on tooth #19 provided on March 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on January 27, 2021 by an OON provider.
You asked the Plan to pay for the periodontal maintenance. You say that you were told that this provider was participating with your plan. The Plan denied your request. The Plan says the allowed amount of $96.43 was applied to your annual deductible. The Plan also says that the OON provider is allowed to bill the difference between the billed amount and allowed amount.
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, you are responsible for a 50% coinsurance of the covered plan allowance after the $100 annual deductible is met. You are also responsible for the difference between the billed amount and allowed amount for covered dental services received OON. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on January 27, 2021 by an OON provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve digital hearing aids from an out-of-network (OON) provider.
You asked the Plan to pre-approve OON hearing aids. You say that the hearing aids offered by the Plan's providers are very expensive. Hearing aids from this out-of-network provider are much less expensive and the services offered are excellent. The Plan denied your request. The Plan says hearing aids will only be covered when they are purchased from a provider within the Plan's specified hearing provider network. There are in-network providers who are able to give you the necessary items and services, and there is no reason for an exception to be made.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays $700 per hearing aid device every three years when these devices are purchased from the Plan's specified hearing vendor network. We looked at the file and the Plan's rules. The requested provider in this case is not part of the Plan's specified routine hearing network. The Plan has network providers who can provide hearing aids. We found no exceptions that would require the Plan to pre-approve these items/services. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to pre-approve digital hearing aids from an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Life Alert device.
You asked the Plan to pre-approve the Life Alert device. You say that you would like reconsideration because you live alone and are diabetic and there are times when your sugar is very low and you do not have the energy to pick up the phone to dial 911. The Plan denied your request. The Plan says medical alert systems are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that Telephone Alert Systems are denied because they are emergency communication systems that do not serve a diagnostic or therapeutic purpose. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Life Alert device have not been met. Specifically, per Medicare, the requested Life Alert device is not a covered benefit. Therefore, we decided that the Plan does not have to pre-approve the Life Alert device
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a comprehensive oral evaluation - new or established patient (D0150) and extractions, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) performed by an oral surgeon.
You asked the Plan to pre-approve a comprehensive oral exam and tooth extractions performed by an oral surgeon. You say that the tooth extractions are medically necessary. The Plan denied your request. The Plan says services performed by an oral surgeon are not covered.
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. We looked at the file and Medicare rules. In this case you are requesting dental services to be performed by an oral surgeon. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are only covered when provided by a participating general dentist. Therefore, we decided that the Plan does not have to pre-approve a comprehensive oral evaluation - new or established patient (D0150) and extractions, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) performed by an oral surgeon.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve physician services. You say that you would like approval for these services to be provided out-of-network. The Plan denied your request. The Plan says these services can be provided 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 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 physician services to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a gingivectomy or gingivoplasty (D4212), a partial upper denture with flexible base (D5225), a partial lower denture with flexible base (D5226), and a bone replacement graft for ridge preservation (D7953 x 8).
You asked the Plan to pre-approve the dental services. You say that you do not want to have to pay $1,000 for dentures. You also say that you would like these services to be covered. The Plan denied your request. The Plan says the gingivectomy or gingivoplasty, partial dentures with flexible bases, and bone replacement grafts are not listed as covered services. The Plan also says that any services not listed are not covered.
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 gingivectomy or gingivoplasty, partial dentures with flexible bases, and bone replacement grafts are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a gingivectomy or gingivoplasty (D4212), a partial upper denture with flexible base (D5225), a partial lower denture with flexible base (D5226), and a bone replacement graft for ridge preservation (D7953 x 8).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services provided by a participating provider on February 17, 2021.
You asked the Plan to waive the copayment for specialist services. You say that this should be covered 100%. The Plan denied your request. The Plan says the correct copayment has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for physician/practitioner services/specialist. You have been asked to pay a $35 copayment for specialist services. The correct copayment has been applied to the services that were provided. Specialist services fall within the physician/practitioner services/specialist benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for specialist services provided by a participating provider on February 17, 2021.