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

We decided that the Plan does not have to pay for the endodontic therapy (D3330) provided on November 4, 2020.

You asked the Plan to pay for the endodontic therapy. You say that you would like this claim to be reconsidered for coverage. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan. The Plan also says that no calls were made to the Plan prior to this date of service requesting benefits or cost share assessment.

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 endodontic therapy (D3330) provided on November 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for routine electroencephalography (EEG) procedures (95822) provided July 8, 2020.

You asked the Plan to pay for the EEG procedure. You say that you billed this ancillary electroneurodiagnostic service from POS-15, mobile unit, which was correct and reimbursable. The Plan denied your request. The Plan says this service is not reimbursable for this provider in this place of 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 95822 is Electroencephalography (EEG).

We find that CPT code 95822 is not supported in the medical record. Specifically, the billed place of service (POS) 15 is not supported. The documentation submitted and/or claims data indicate that the enrollee was an inpatient at the time services were provided. Payment for this service is included in the payment to the facility and not separately reimbursable. Based on this information, we decided that Medicare rules for coverage of the EEG procedure have not been met. Therefore, we decided that the Plan does not have to pay for routine electroencephalography (EEG) procedures (95822) provided July 8, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit coded 99285 and the service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility coded 99053 provided on November 10, 2020.

You asked the Plan to pay for the emergency department visit and the service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

We find that CPT codes 99285 and 99053 are not supported in the medical record. Specifically, the emergency department visit billed is a duplicate service to another claim billed by another provider on the same date of service. Therefore, code 99285 is not payable. Code 99053 has a status code of "B". A status code of B means that this code is always bundled. This means this code is not separately payable. Based on this information, we decided that Medicare rules for coverage of the emergency department visit and the service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility have not been met. Therefore, we decided that the Plan does not have to pay for the emergency department visit coded 99285 and the service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility coded 99053 provided on November 10, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for a diagnostic colonoscopy provided by a participating provider on September 25, 2020.

You asked the Plan to waive the co-payment for a diagnostic colonoscopy. You say that you had a positive Cologuard. You say that the doctor said you were due for a colonoscopy. The Plan denied your request. The Plan says the correct co-payment has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 co-payment for outpatient surgery/ambulatory surgery center.

You have been asked to pay a $200 co-payment for a diagnostic colonoscopy. The colonoscopy that was provided was diagnostic in nature; therefore, the correct co-payment has been applied. A diagnostic colonoscopy falls within the outpatient surgery/ambulatory surgery center benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the co-payment for a diagnostic colonoscopy provided by a participating provider on September 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on January 11, 2019.

You asked the Plan to pay for the dental service. You say that you received a bill on January 15, 2021 for $84. You say that you thought that your insurance covered preventive services. You also say that you thought that this has been paid long ago. The Plan denied your request. The Plan says this service is dental in nature. The Plan says that dental services are not included in your coverage. The Plan also says that dental services are only covered under the extra optional supplemental benefits which you disenrolled from on December 31, 2017.

Medicare generally does not cover dental services. The Plan follows the same rule.

The service 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 limited oral evaluation (D0140) provided on January 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on February 2, 2021, to February 3, 2021 by an out of network (OON) provider.

You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.

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 physician services provided on February 2, 2021, to February 3, 2021 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an extraction (D7210), deep sedation/general anesthesia (D9222, D9223), and therapeutic parenteral drugs (D9612) provided on October 21, 2020.

You asked the Plan to pay for an extraction, deep sedation/general anesthesia, and therapeutic parenteral drugs. You say that the services at issue were medically necessary. The Plan denied your request. The Plan says the extraction and the deep sedation/general anesthesia are covered benefits; however, the benefit maximum had already been met before this date. The therapeutic parenteral drugs are 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.

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of an extraction, deep sedation/general anesthesia, and therapeutic parenteral drugs have not been met. Specifically, the record shows that you had exhausted your dental benefit maximum prior to this date of service on May 18, 2020. Additionally, therapeutic parenteral drugs are not a covered benefit. Therefore, we decided that the Plan does not have to pay for an extraction (D7210), deep sedation/general anesthesia (D9222, D9223), and therapeutic parenteral drugs (D9612) provided on October 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the intraoral
- complete series of radiographic images (D0210). received January 11, 2021.

You asked the Plan to pay for the comprehensive oral evaluation and the complete series of radiographic images. You say that the new dental provider did not have access to previous x-rays and needed to perform a complete oral evaluation. The Plan denied your request. The Plan says the requested services exceed the frequency limitation set in the Plan's 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 exceed those covered under this benefit. The Plan has submitted evidence that you received the requested services within the last three years. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the intraoral - complete series of radiographic images (D0210). received January 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the member liability for the periodic oral evaluation (D0120), the prophylaxis (D1110), and the bitewing x-rays (D0274) provided on January 14, 2021.

You asked the Plan to waive the member liability for the dental services. You say that the claim amount was not paid in full. You say that preventive dental services are to be covered for both in and out of network providers per your plan documents and Medicare.gov documents. You also say that the claim should be paid in full. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also says that out of network providers may bill you for any amount greater than the payment made by the plan to the provider.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage and the services are listed as covered, if you choose to see an out of network dentist, you might be billed for charges above what the plan pays, even for services listed as $0 co-payment.

TOTAL:
$176

This is a contractual obligation you agreed to when you enrolled in the Plan's dental coverage. Therefore, we decided that the Plan does not have to waive the member liability for the periodic oral evaluation (D0120), the prophylaxis (D1110), and the bitewing x-rays (D0274) provided on January 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee walker provided on October 30, 2020.

You asked the Plan to pay for the knee walker. You say that you were told you could make the purchase. The Plan denied your request. The Plan says the service was not covered by Medicare or the plan.

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. Lower leg platform, with or without wheels are not medically necessary. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the knee walker provided on October 30, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for ultrasound, breast, unilateral, real time with image documentation, including axilla when performed, complete (76641) provided September 29, 2020.

You asked the Plan to waive the co-payment for the diagnostic services. You say that you never expected that you had to pay $130.37 for an ULT screening until you received a bill statement. Please evaluate the case thoroughly and notify you why you were charged a copay. The Plan denied your request. The Plan says the claim was processed and the correct co-payment was 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 co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $130.37 $155 co-payment for each Medicare covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a free-standing facility.

You have been asked to pay $130.37 for the diagnostic services. Since the Medicare allowable was less than the co-payment amount you are responsible for the lesser amount. the diagnostic services fall 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 co-payment for ultrasound, breast, unilateral, real time with image documentation, including axilla when performed, complete (76641) provided September 29, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy provided on November 10, 2020.

You asked the Plan to waive the copayment for the colonoscopy. You say that you should not have to pay the copayment.The Plan denied your request. The Plan says the copayment applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $225 for each in-network, Medicare-covered outpatient hospital facility visit.

You have been asked to pay a $225 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient surgery including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The colonoscopy is considered a surgical service. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment for the colonoscopy provided on November 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for lab work provided by a participating provider on January 7, 2021.

You asked the Plan to waive the co-payment for lab work. You say that you had to get the lab work done the next day because your doctor's office cannot do the lab work. The Plan denied your request. The Plan says the correct co-payment has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 co-payment for outpatient diagnostic tests/lab work.

You have been asked to pay a $10 co-payment for lab work. When additional services, like lab work, is provided during an annual wellness exam, additional co-payments are applied; therefore, the correct co-payment has been applied. Lab work falls within the outpatient diagnostic tests/lab work benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the co-payment for lab work provided by a participating provider on January 7, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardio genomic testing services provided on September 21, 2020.

You asked the Plan to pay for the services provided. You say that the tests determine whether cardiac conditions are the result of a hereditary gene mutation. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment testing, except the basic lipid panel.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.

We looked at the file and the rules. There are insufficient records to show that the ordered testing was diagnostic, prognostic, or clearly correlated to any test result with given interventions. The testing was requested for screening purposes. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the cardio genomic testing services provided on September 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for the wrist hand finger orthosis (L3808) provided December 8, 2020.

You asked the Plan to waive the co-payment for the orthosis. You say that you were surprised at the $52.05 copay bill from team post-op, obviously a big mark-up. This is the first time you've had to cover a copay. The Plan denied your request. The Plan says the claim was processed and the correct cost share was 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 co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for all other Medicare covered prosthetic or orthotic devices, including replacement or repairs of such devices and related supplies.

You have been asked to pay $52.05 ($260.25 x 20%) for the orthosis. The orthosis falls within the Prosthetic devices and related 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 co-payment for the wrist hand finger orthosis (L3808) provided December 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on December 9, 2020.

You asked the Plan to pay for the problem focused limited oral evaluation. You say that you needed this service in order to receive a 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, problem focused limited oral evaluation (D0140) and is limited to one procedure per plan year. The record shows that you received a problem focused limited oral evaluation (D0140) on April 30, 2020 and your problem focused limited oral evaluation (D0140) benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on December 9, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for outpatient hospital services and coinsurance for an injection provided by a participating provider on January 5, 2021, to January 12, 2021.

You asked the Plan to waive the co-payment for outpatient hospital services and coinsurance for an injection. You say that you think that it is unfair to charge a co-payment and a coinsurance. The Plan denied your request. The Plan says the correct charges have been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 co-payment for outpatient hospital services/Part B drugs and a 20% coinsurance for outpatient hospital services/Part B drugs.

You have been asked to pay a $250 co-payment for outpatient hospital services and a 20% coinsurance of the allowed amount for an injection. The total allowed amount is $1,488.56. The amount you are being asked to pay for an injection is $297.71 ($1,488.56 x 20% = $297.71). The total amount you are being asked to pay is $797.71 ($250 + $250 + $297.71 = $797.71). Outpatient hospital services and an injection falls within the outpatient hospital services/IV therapy and outpatient hospital services/Part B drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the co-payment for outpatient hospital services and coinsurance for an injection provided by a participating provider on January 5, 2021, to January 12, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home personal care services (T1019).

You asked the Plan to pre-approve the home personal care services. You say that the personal care aide services are necessary. The Plan denied your request. The Plan says this service is custodial in nature and is not covered. You are not currently receiving any skilled home services.

The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy.

We looked at the file and Medicare rules. The services requested are personal care services and are not skilled nursing or therapy services. The aide services are custodial in nature. Based on this information, we decided that Medicare rules for coverage of the home personal care services have not been met. Therefore, we decided that the Plan does not have to pre-approve home personal care services (T1019).