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

We decided that the Plan does not have to pay for the outpatient hospital services provided from January 29,
2020 to January 30, 2020.

You asked the Plan to pay for the outpatient hospital services. 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.

We looked at the file and Medicare rules. Medicare says that all therapy services with HCPCS/CPT code(s) in the 97000-97799 series must include the corresponding therapy modifier, GP or GO. In this case, the provider billed codes 97110, 97116, and 97530 without the GP modifier. Therefore, we decided that the Plan does not have to pay for the outpatient hospital services provided from January 29, 2020 to January 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the incisional biopsy of oral tissue (D7286) received
December 14, 2020, from the dental provider.
You asked the Plan to pay for the incisional biopsy of oral tissue-soft. You say that this was a biopsy, not an
extraction and should be covered. The Plan denied your request. The Plan says the requested service is not
covered under your supplemental 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 the
incisional biopsy of oral tissue (D7286) received December 14, 2020, from the dental provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic eye exam you had on October 21, 2020.
You asked the Plan to waive the copayment for the diagnostic eye exam. You say that you feel this was a routine exam and it should not have a copayment. The Plan denied your request. The Plan says you were charged this copayment correctly because you did not have a routine eye exam. You we evaluated for puckering of the macula and secondary cataract, so this was not a routine eye exam.
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 $30 copayment for exams to diagnose and treat diseases and conditions of the eye. You have been asked to pay a $30 copayment for the diagnostic eye exam. The diagnostic eye exam falls within the 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. Therefore, we decided that the Plan does not have to waive the copayment for the diagnostic eye exam you had on October 21, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation (A0120).
You asked the Plan to pre-approve the additional routine transportation. You say that you need more rides to
continue your treatment at the wound facility. The Plan denied your request. The Plan says this service is
covered under your benefit package, but exceeds the maximum count allowed per period.
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 a maximum of 60 one-way trips per year.
We looked at your request, the records in the case file, and the rules. You are requesting 65 additional trips for
routine transportation. Your benefit only allows sixty (60) trips for this service. You have used 59 one-way
trips allowed by the Plan; an additional (65) trips would exceed your benefit limit. Based on this information,
we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation.
Therefore, we decided that the Plan does not have to pre-approve additional routine transportation (A0120)
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee is left hand dominant, which is the side the stroke affected. You also say that you are requesting continued consideration for inpatient rehabilitation in order for the enrollee to return to her prior level of function. The Plan denied your request. The Plan says the enrollee does not require an intensive rehabilitation therapy program, or physician supervision by a rehabilitation physician. The Plan also says that the enrollee's needs can be addressed at a lower level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that the enrollee does not require treatment by multiple therapies, including either physical therapy or
occupational therapy, and an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. Our physician reviewer also found that there is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the Positron emission tomography (PET) with concurrently
acquired computed tomography (CT) scan and additional supplies represented by codes 78815 and 99072
provided on December 18, 2020.

You asked the Plan to pay for codes 78815 and 99072. 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. 

We looked at the file, the Plan's contract and Medicare rules. We find that the PET/CT scan is not supported as billed. Specifically, this PET/CT scan was not billed with an appropriate diagnosis code per Medicare guidelines. Furthermore, code 99072 has a status code of "B" under the Medicare Physicians Fee Schedule Database (MPFSDB) and no separate payment is made for this code under the fee schedule as payment is bundled into the payment for the services to which this code is incident to. Therefore, we decided that the Plan does not have to pay for the Positron emission tomography (PET) with concurrently acquired computed tomography (CT) scan and additional supplies represented by codes 78815 and 99072 provided on December 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown - porcelain/ceramic (D2740) received March 8, 2021 from the out-of-network provider.
You asked the Plan to pay for the crown. You say that you should be reimbursed for the crown. The Plan denied your request. The Plan says the requested service is subject to a frequency limitation.
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 only covered under this benefit for one procedure per calendar year. The Plan has submitted evidence that a claim was paid for a crown on February 3, 2021. When you received the crown on March 8, 2021 your benefit was exhausted. Therefore, we decided that the Plan does not have to pay for the crown - porcelain/ceramic (D2740) received March 8, 2021 from the out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and cleaning (D1110)
provided on January 14, 2021, by an out-of-network provider.

You asked the Plan to pay for the evaluation and cleaning. You say that you expected to have a $0 copayment
for the dental services. The Plan denied your request. The Plan says the enrollee chose to see an out-of-network
dentist for the requested services. The Plan has paid the full allowed amount for these services; however, outof-
network providers are allowed to bill enrollee's the remaining cost up to the total charges.

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 will cover out-of network
dental care, however the Plan only pays up to a certain amount for services.

If you choose to see an out-of-network provider, you might be billed for charges above what the Plan pays,
even for services listed as a $0 copayment.

The out-of-network provider billed the Plan a total of $186 for the evaluation and cleaning provided on January
14, 2021. The Plan's maximum allowed fee for both of these services totals $67. The Plan paid the full $67
allowed amount. In-network providers have agreed to not bill enrollees for the remaining charges and accept
the Plan's maximum fee as full payment. However, out-of-network providers do not have this agreement and
are allowed to bill an enrollee for the charges above what the Plan pays, up to the full billed amount. You have
been asked to pay $119 for the evaluation and cleaning. ($186 total bill - $67 Plan payment = $119 remaining
charges.) This means you have been asked to pay the correct amount based on your contract with the Plan.
Therefore, we decided that the Plan does not have to pay any additional amount for the periodic oral evaluation
(D0120) and cleaning (D1110) provided on January 14, 2021, by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics provided on February 25, 2021.

You asked the Plan to pay for foot orthotics. You say that you have back, foot and knee pain. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on February 25, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory service (88112) rendered by the out of
network (OON) provider on March 24, 2021.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal.

The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the laboratory service (88112) rendered by the out of network (OON) provider on March 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services represented by code 99153 provided on February 16, 2021.

You asked the Plan to pay for code 99153. 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.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

We looked at the file and Medicare rules. In this case, the review shows that the medical records provided represent professional charges; however, procedure code 99153 was provided in a facility with a place of service code of 22. Procedure code 99153 has a PC/TC Modifier Status of 3, which specifies a Technical Component only code. Therefore, we decided that the Plan does not have to pay for the moderate sedation services represented by code 99153 provided on February 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on December 8, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 for the office visit provided on December 8, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the thoracentesis provided on February 18, 2021.
You asked the Plan to waive the copayment for the thoracentesis. You say that you did not get the results from the thoracentesis. The Plan denied your request. The Plan says you were charged the 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 $325 copayment for Outpatient Surgery at an outpatient hospital facility. You have been asked to pay a $325 copayment for the thoracentesis. The thoracentesis falls within the Outpatient Surgery at an outpatient hospital facility 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 thoracentesis provided on February 18, 2021.
Please note, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two guided tissue regenerations (D3432 x2), two surgical extractions (D7210 x2), osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla (D7950), and two bone replacement grafts for ridge preservation (D7953 x2) provided on September 2, 2020.

You asked the Plan to pay for the guided tissue regenerations, surgical extractions, osseous, osteoperiosteal, or cartilage graft, and bone replacement grafts. You say that you would like this claim to be processed under your medical insurance. The Plan denied your request. The Plan says Medicare does not cover routine dental services and your plan does not cover dental implants or any dental services that are not required to treat a broken jaw or a medical disease. The Plan also says that dental computed tomography scans and oral surgical procedures such as extractions, bone grafting, and tissue regeneration are not procedures that treat a medical disease, and have been provided in this case to prepare the jaw for dental implants.

Medicare generally does not cover dental services. The Plan follows the same rule. 

The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare.

Therefore, we decided that the Plan does not have to pay for the two guided tissue regenerations (D3432 x2), two surgical extractions (D7210 x2), osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla (D7950), and two bone replacement grafts for ridge preservation (D7953 x2) provided on September 2, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory test provided on October 7, 2020.

You asked the Plan to pay for infectious disease (bacterial or viral respiratory tract infection), pathogenspecific
nucleic acid (DNA or RNA), 22 targets including severe acute respiratory syndrome coronavirus 2
(SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as detected or not detected
(0202U). You say that the Plan should pay the claim. The Plan denied your request. The Plan says there is no
available APC fee schedule rate.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.

We looked at the file and Medicare rules. The test exceeds the number of pathogens covered. Based on this
information, we decided that Medicare rules for coverage of infectious disease (bacterial or viral respiratory
tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets including severe acute respiratory
syndrome coronavirus 2 (SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as
detected or not detected (0202U) have not been met. Therefore, we decided that the Plan does not have to pay
for the laboratory test provided on October 7, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for radiologic examination, shoulder (73030) provided March 24, 2021.
You asked the Plan to waive the copayment for the diagnostic service. You say that you were having issues lifting and reaching with your arm after receiving the COVID-19 vaccine. You have a sports/exercise business and it affected that and you want the Plan to cover your copayment. The Plan denied your request. The Plan says the claim was processed with the correct copayment applied per the Evidence of Coverage.
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 $60 copayment for Medicare covered x-rays and ultrasounds. You have been asked to pay $42.55 for the diagnostic service. Since the allowed amount of $42.55 was less than the $60 copayment, you are responsible for the lesser amount. The diagnostic service falls within the Outpatient diagnostic tests and therapeutic services and supplies 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 radiologic examination, shoulder (73030) provided March 24, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the IV (intravenous) tubing extension set (S1015), and the infection control supplies, not otherwise specified, (S8301) provided on December 5, 2020.
You asked the Plan to pay for the supplies. You say that the services were medically necessary. The Plan denied your request. The Plan says as the claim was billed with a CPT code which is invalid for usage with Medicare; we find that Medicare rule for payment of this claim has not been met. The Plan says that if you determine that a billing error occurred during the initial submission of the denied claim, submission of a corrected claim would be accepted.
The Plan must follow Medicare rules. Medicare rules say that procedure codes with a Status Code of "I", indicate that these codes are not valid for Medicare purposes and are not payable.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the supplies have not been met. Therefore, we decided that the Plan does not have to pay for the IV (intravenous) tubing extension set (S1015), and the infection control supplies, not otherwise specified, (S8301) provided on December 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit received by a chiropractor on January 29, 2021.

You asked the Plan to pay for the office visit. You say that you would like this service to be paid. The Plan denied your request. The Plan says the services received are not a covered benefit.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the office visit received by a chiropractor on January 29, 2021.