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

We decided that the Plan does not have to waive the out of network member liability for the filling (D2391) and the cleaning (D1110) provided from December 8, 2020, to December 28, 2020.
You asked the Plan to waive the out of network member liability for the dental services. You say that when you signed up for dental you were advised you could continue seeing your dentist and the services would be covered at 100%. You also say that you would like all of the services, except the Covid protection, to be covered in full. The Plan denied your request.
The Plan says dental services performed out of network are paid based on the maximum allowable fee schedule. The Plan also says that out of network providers may bill you for any amount above what the plan pays 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, dental services performed out of network may have a higher cost share. Member liability is a contractual obligation you agreed to when you enrolled in the Plan's dental coverage.
CPT Code
Billed Amount
Allowed Amount
Plan Paid
Your Responsibility
D2391
$239
$75
$75
$164
D1999
$15
$0
$0
$15
D1110
$129
$68
$68
$61
D1999
$15
$0
$0
$15
TOTAL:
$255
Therefore, we decided that the Plan does not have to waive the out of network member liability for the filling (D2391) and the cleaning (D1110) provided from December 8, 2020, to December 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (code D0150) and intraoral imaging (code D0210) provided on October 20, 2020.

You asked the Plan to pay for dental services. You say that you were not told you could only have these services once every 3 years. The Plan denied your request. The Plan says the denial of payment for these services is correct, because you previously had these services covered on November 26, 2019.

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.

These services are covered once every 3 plan years. You previously received both a comprehensive oral evaluation (D0150) and intraoral imaging (D0210) on November 26, 2019; therefore, the benefit for these services was exhausted. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (code D0150) and intraoral imaging (code D0210) provided on October 20, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the debridement of subcutaneous tissue (11042) provided on December 7, 2020 and December 14, 2020.
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to the services provided.
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 $350 copayment for in-network Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges. You have been asked to pay $589.30 ($294.65 copayment x 2) for the outpatient surgeries provided. This is the Plan allowed amount which is less than the applicable copayments for these services. 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 copayments for the debridement of subcutaneous tissue (11042) provided on December 7, 2020 and December 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for neuromuscular diagnostic procedure (95999) provided on November 9, 2020.

You asked the Plan to pay for Unlisted neurological or neuromuscular diagnostic procedure (95999). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the Train of Four is considered a bundled procedure and payment is included in payment for the already approved neuromonitoring.

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, we have confirmed that code Unlisted neurological or neuromuscular diagnostic procedure (95999) has a bundled relationship with the paid neuromonitoring codes and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for neuromuscular diagnostic procedure (95999) provided on November 9, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on December 1, 2020 by an out of network (OON) provider.
You asked the Plan to pay for psychotherapy 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 psychotherapy services provided on December 1, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic mammogram rendered on January 12, 2021.

You asked the Plan to waive the copayment for these services. You say that the services should be covered at 100 percent. The Plan denied your request. The Plan says the copayment was applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for each in-network x-ray service, including diagnostic mammogram.

Review of the file shows that you received a diagnostic mammogram on January 12, 2021. The mammogram was not screening in nature. Per the contract with the Plan, there is a $50 copayment for each in-network x-ray service, including diagnostic mammogram. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. However, the Medicare allowed amount for these services was $48.27. Given that the allowed amount was less than the $50 copayment, you have been asked to pay $48.27 for these services.

The Plan is not denying payment for these services for an out-of-network provider. The amount you are being asked to pay is your contractual cost share. Therefore, we decided that the Plan does not have to waive the copayment for the diagnostic mammogram rendered on January 12, 2021.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for emergency ambulance transportation (A0425, A0429) received on
January 29, 2021.
You asked the Plan to pay for emergency ambulance transportation. You say that the fire rescue team and
animal control recommended that you go to the hospital. The Plan denied your request. The Plan says that
based on Medicare policy, you do not meet criteria for an ambulance transport in this occurrence.
Medicare pays for ambulance services only when an emergency exists or when other means of transport would
endanger the patient's health. The Plan follows the same rules.
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of emergency ambulance transportation have been met. The record shows that you suffered bite
wounds from a dog that you are not familiar with. While you received treatment for your wounds prior to the
ambulance transport, you did not know if the dog was immunized for rabies or if the bite could lead to other
harmful conditions (e.g., wound infection, tetanus). A prudent layperson would have believed that without
immediate medical attention there would be serious jeopardy to your health in this case. Therefore, we decided
that the Plan has to pay for emergency ambulance transportation (A0425, A0429) received on
January 29, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on February 1, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that the for conditions that have both an underlying etiology and multiple body system manifestations due to the underlying etiology ICD10-CM has a coding convention that requires the underlying condition be sequenced first, if applicable, followed by the manifestation. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Specifically, the record shows that the claim was billed with primary diagnosis code, F06.4. This code has a code first note, which means it is a manifestation code and must be sequenced after an etiology code. 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 the services provided on February 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiomyopathy testing provided on October 7, 2020.
You asked the Plan to pay for the services provided. 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. The records provided do not show that the results of the test would be used in the management of a specific medical problem. The test at issue in this appeal was requested for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for the cardiomyopathy testing provided on October 7, 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 July 13, 2020.

You asked the Plan to pay for the dental service. You say that this service should be covered. The Plan denied your request. The Plan says 1 limited oral evaluation is covered per plan year. The Plan also says that the frequency limit has been exceeded.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage the service is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a limited oral evaluation that you received on April 27, 2020. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on July 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on December 1, 2020.
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says the service was not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 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 by an out-of-network provider on December 1, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee x-ray (73560) provided on January 16, 2021.

You asked the Plan to pay for the knee x-ray. You say that you would like reconsideration because these were separate services. The Plan denied your request. The Plan says this service is bundled to another service billed on the same day by the same physician, or a physician of the same specialty in the same billing group, which is considered the same provider.

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, we have confirmed that code 73560 has a bundled relationship with code 73564 and cannot be paid as billed. This code cannot be paid as a separate line item. Please note, this code has been billed with modifier 77 which cannot be used to bypass the NCCI PTP edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the knee x-ray (73560) provided on January 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180), three preventive procedures (D1999 x3), and four periodontal scalings and root planings (D4341 x4) provided from August 25, 2020, to November 5, 2020 by an OON provider.
You asked the Plan to pay for the comprehensive periodontal evaluation, preventive procedures, and scalings and planings. You say that you believe these services should be covered. The Plan denied your request. The Plan says the comprehensive periodontal evaluation and preventive procedures are not covered benefits. The Plan also says that the scalings and planings were paid correctly up to the annual maximum allowable for an OON 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, the comprehensive periodontal evaluation (D0180) and preventive procedure (D1999) are not among those covered under this benefit. The contract also clearly states that providers are paid based on contracted rates for each covered service. The contract also says that services rendered OON are not covered. Therefore, we decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180), three preventive procedures (D1999 x3), and four periodontal scalings and root planings (D4341 x4) provided from August 25, 2020, to November 5, 2020 by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pharmacogenomics (PGx) testing provided on August 25, 2020.

You asked the Plan to pay for the PGx testing. You say that this testing was medically necessary to guide therapeutic decision-making. The Plan denied your request. The Plan says the rules say that this is a panel and must always be billed with a single code.

The Plan must follow Medicare rules. Medicare rules say that to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.

In this case, no progress note from the treating physician was submitted for review. There is no documentation that this testing is being requested to decide if a certain medication is contraindicated or that it will impact treatment in any way. It appears this was ordered for screening purposes, which does not meet Medicare coverage criteria. Therefore, we decided that the Plan does not have to pay for the pharmacogenomics (PGx) testing provided on August 25, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the physical therapy (PT) services rendered from August 20, 2020 to September 18, 2020.
You asked the Plan to waive the copayments for these services. You say that the copayments should be waived due to COVID. The Plan denied your request. The Plan says the copayments were 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 a $20 copayment for Medicare-covered physical therapy visits.
Review of the file shows that you received PT services for six dates of service from August 20, 2020 to September 18, 2020. You have been asked to pay a $20 copayment per visit for these services, for a total of $120. These services fall within the Medicare-covered physical therapy visits 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 copayments for the physical therapy (PT) services rendered from August 20, 2020 to September 18, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health services (90837) provided on October 9, 2020.
You asked the Plan to pay for the outpatient mental health services. You say that the services were medically necessary. The Plan denied your request. The Plan says there were network providers available.
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 services 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 these services. Therefore, we decided that the Plan does not have to pay for outpatient mental health services (90837) provided on October 9, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the inpatient hospital services provided from January 21, 2021, to January 27, 2021
You asked the Plan to pay for the inpatient services. The Plan denied your request. The Plan says that the enrollee was in the same hospital within the last 30 days with the same problem.
The Plan follows Medicare rules. Medicare rules say that an inpatient readmission is only covered under certain medical indications. 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 inpatient services. Our physician reviewer found that in this case, the enrollee was previously admitted for ureteral stone management and scheduled ureteral stent exchange and was discharged January 6, 2021. The procedure was aborted due to concern of skin infection from larvae infestation. A repeat computed tomography (CT) scan demonstrated active infection in the kidney. The enrollee had not received pre-procedure antibiotics at the skilled nursing facility. The enrollee was started on antibiotic therapy. The enrollee was readmitted on January 21, 2021 for management of the stones. The readmission was medically necessary because the initial planned procedure was aborted due to intervening medical complications. The enrollee was not previously prematurely discharged as she required a course of intravenous antibiotics. The initial discharge was not circumvention of the prospective payment system. The elements of the coverage rule are satisfied. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the inpatient services have been met. Therefore, we decided that the Plan has to pay for the inpatient hospital services provided from January 21, 2021, to January 27, 2021
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.The rules say that plans may choose the networks of providers available to enrollees and may require enrollees to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Managed Care Manual, Chapter 1, Section 20.2.If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that, with limited exceptions, members of the Plan must use network providers to get medical care and services. The only exceptions are emergencies, urgently needed care when the network is not available (generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan authorizes the use of out-of-network providers. You can find this information on page 43 of the Plan's 2021 Evidence of Coverage.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 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 services provided by an out-of-network provider on February 19, 2021.