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

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150).

You asked the Plan to pay for the comprehensive oral evaluation. You say that you were required to get a comprehensive oral evaluation because you were seen by a new dentist. 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, comprehensive oral evaluation (D0150) is limited to one procedure every three plan years. The record shows that you received a comprehensive oral evaluation (D0150) and your comprehensive oral evaluation (D0150) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of intraoral x-rays provided on 
November 2, 2020. 
 
You asked the Plan to pay for the complete series of intraoral x-rays. You say that you were advised that this 
service was covered. The Plan denied your request. The Plan says this service is not covered. The Plan also 
says that you did not contact the Plan prior to this date of service to verify benefits and provider eligibility. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. The record also shows that the provider contacted the Plan on 
November 11, 2020, and was advised then that the complete series of intraoral x-rays was not a covered benefit 
under your plan. Therefore, we decided that the Plan does not have to pay for the complete series of intraoral x-
rays provided on November 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 27269 is not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

In this case, the CPT Code Manual definition of code 27269 is open treatment of femoral fracture, proximal end, head, includes internal fixation, when performed.

We find that CPT code 27269 is not supported in the medical record. Specifically, there is no documentation of open treatment of a femoral fracture with internal fixation. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services rendered.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive cardiovascular panel (81286, 81407, 81408, 
81479) provided on August 20, 2020. 
 
You asked the Plan to pay for a comprehensive cardiovascular panel. You say that this was medically 
necessary. The Plan denied your request. The Plan says this is not a covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular 
(CV) risk assessment panels, except the basic lipid panel, for symptomatic (with signs and symptoms) patients 
with suspected or documented CV disease because panel testing is not specific to a given patient?s lipid 
abnormality or disease. 
 
We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not 
covered. Based on this information, we decided that Medicare rules for coverage of a comprehensive 
cardiovascular panel have not been met. Therefore, we decided that the Plan does not have to pay for a 
comprehensive cardiovascular panel (81286, 81407, 81408, 81479) provided on August 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiovascular risk assessment testing.

You asked the Plan to pay for the cardiovascular risk assessment testing. You say that you would like reconsideration because this testing is medically necessary. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular disease.

The Plan must follow Medicare rules. Medicare rules say that a claim that is submitted for Cardiovascular Disease Screening shall be submitted with specific CPT codes.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the cardiovascular risk assessment testing have not been met. Specifically, this testing is not a covered benefit. Therefore, we decided that the Plan does not have to pay for cardiovascular risk assessment testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on August 28, 2020. 
 
You asked the Plan to pay for the lumbar-sacral orthosis (L0650). You say that the orthosis was medically 
necessary. The Plan denied your request. The Plan says they were unable to discover any evidence of an 
established relationship between the enrollee and the ordering physician. 
 
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 lumbar-sacral orthosis (L0650). Our 
reviewer says that the orthosis was not medically necessary. Our physician reviewer found the provided records 
did not support this request. There were no objective image findings to support the diagnosis and there was no 
documented direct physical examination or report of prior conservative efforts to relieve the low back pain 
such as formal physical therapy. Therefore, this request for lumbar orthosis will be considered not medically 
necessary at this time. 
 
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 lumbar-sacral orthosis (L0650) have not been met. Therefore, we decided 
that the Plan does not have to pay for the lumbar-sacral orthosis provided on August 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-rays (D0274).

You asked the Plan to pay for the bitewing x-rays. You say that you believe this service should be covered. The Plan denied your request. The Plan says the frequency limit for this service had 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, bitewing x-rays (D0270, D0272, D0273, D0274, D0277) are limited to one procedure per plan year. The record shows that you received bitewing x-rays (D0272) and your bitewing x-rays benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the bitewing x-rays (D0274).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy (HIT) services provided on June 
24, 2020 billed with codes 99601 and 99602. 
 
You asked the Plan to pay for the HIT services. You say that this service is medically necessary and should be 
covered. The Plan denied your request. The Plan says the codes used for these services are not valid for 
Medicare billing. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The CPT codes 99601 and 99602 has status indicators of "I" in the Physician Fee Schedule, meaning they are 
invalid for Medicare billing purposes. Based on this information, we decided that Medicare rules for coverage 
of the HIT services have not been met. Therefore, we decided that the Plan does not have to pay for the home 
infusion therapy (HIT) services provided on June 24, 2020 billed with codes 99601 and 99602.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the walking boot (L4360).

You asked the Plan to waive the cost share for the walking boot. You say that you would like this cost share reprocessed as you do not believe you had a deductible. The Plan denied your request. The Plan says the claim has processed correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $185 deductible for durable medical equipment.

The item or service you asked the Plan to waive the cost share for falls within the benefit category durable medical equipment. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $185 deductible for durable medical equipment. This cost sharing is a contractual obligation that had not been met at the time the walking boot. Therefore, we decided that the Plan does not have to waive the cost share for the walking boot (L4360).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care.

You asked the Plan to pay for the acute inpatient hospital care. You say that inpatient admission for this patient was appropriate and should be paid. The Plan denied your request. The Plan says the services provided could have been rendered in the outpatient observation setting.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.

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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee presented to the emergency room with vaginal bleeding and concern for a mass. She underwent a dilation and curettage procedure with cystoscopy and Hysteroscopy with biopsies taken. She tolerated the procedure and was discharged home with scheduled follow-up on 10/30/2020. The review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights.

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 acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy provided by an out-of-network provider.

You asked the Plan to pay for psychotherapy. You say that you didn't realize you were no longer covered for psychotherapy services. You say that you want the services to be covered. The Plan denied your request. The Plan says this provider is not a network provider with the Plan.

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 psychotherapy provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses (L1833 and L2937) provided on October 3, 
2020. 
 
You asked the Plan to pay for the knee orthoses. You say that you would like reconsideration because these 
orthoses are medically necessary. The Plan denied your request. The Plan says it appears this member did not 
receive a video or telephonic visit by the ordering physician in order to warrant the codes billed. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 knee orthoses. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is insufficient documentation of an appropriate evaluation of the enrollee, and there is 
insufficient credible objective documentation of joint laxity. 
 
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 knee orthoses have not been met. Therefore, we decided that the Plan does 
not have to pay for the knee orthoses (L1833 and L2937) provided on October 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for immune globulin (flebogamma) and 
intravenous (IV) therapy administration services provided on October 7, 2020. 
 
You asked the Plan to waive the cost-sharing for Part B drug and IV administration services. You say that no 
one told you how much these services would cost, and this is too much money. The Plan denied your request. 
The Plan says the cost-sharing amounts you are being charged is correct. 
 
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 20% 
coinsurance for Part B drug and $150 copayment for IV administration service. The allowed amount of the Part 
B drug is $2,911.61, resulting in a coinsurance amount of $582.32. For the outpatient hospital IV 
administration services, you have been asked to pay $62.76 which is less than the $150 copayment for 
outpatient hospital non-surgical services. Your total cost-sharing obligation is therefore $645.08. 
 
You have been asked to pay 20% coinsurance for Part B drug and less than $150 copayment for IV 
administration service. Part B drug and IV administration services fall within the "Medicare Part B Prescription 
Drugs" and "Outpatient Hospital Services" benefit categories. 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-sharing 
for immune globulin (flebogamma) and intravenous (IV) therapy administration services provided on October 
7, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic radiology services provided on October 24, 2020. 
 
You asked the Plan to pay for the diagnostic radiology services. The Plan denied your request. The Plan says 
the Plan requires utilization of network providers when possible and available and requires authorization for 
certain services. No medical necessity for an out-of-network provider such as an urgent or an emergent 
situation that has been documented.   
 
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 
diagnostic radiology services. 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 diagnostic radiology services provided on  
October 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the suspension sleeves for use with knee braces provided on 
October 13, 2020. 
 
You asked the Plan to pay for the suspension sleeves. You say that the enrollee requires these braces to treat 
their medical conditions as documented by the physician. The Plan denied your request. The Plan says the 
documentation does not support that payment should be made in this case. This supplier is not Medicare-
certified. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 suspension sleeves. Our reviewer says 
that the requested items are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation does not support that there is an established relationship between the 
enrollee and ordering physician. The documentation does not support that a physical exam was done. The 
review has determined that the items at issue in this case are not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the suspension sleeves have not been met. Therefore, we decided that the Plan 
does not have to pay for the suspension sleeves for use with knee braces provided on October 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for blood bank physician services (CPT 86077) provided to the 
enrollee on October 5, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says CPT 86077 has an MUE value of 1, but billed 2 units. 
 
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 86077 is "Blood bank physician services." 
 
We asked our coding 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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our coding reviewer found the 
provider billed a total of 2 units of 86077 on a single date of service.  Medicare National Correct Coding 
Initiative Policy - Medically Unlikely Edits  (MUE) states 86077 has a MUE indicator of "2" which only allows 
for the billing of 1 unit of this service per date of service, therefore 86077 is not eligible for payment due to 
inappropriate billing. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for blood bank physician services (CPT 86077) provided to the enrollee on October 5, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on August 21, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says that you 
must receive your care from a network provider. In most cases, care you receive from an out-of-network 
provider (a provider who is not part of our Plan?s network) will not be covered. If you need medical care that 
Medicare requires our Plan to cover and the providers in our network cannot provide this care, you can get this 
care from an out-of-network provider. You, or your PCP, must obtain authorization from the Plan prior to 
seeking care. 
 
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 
laboratory services. 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 laboratory services provided on August 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the myocardial perfusion imaging (SPECT scan).

You asked the Plan to waive the copayment for the SPECT scan. You say that this test is part of a stress test and you were not capable of doing a treadmill stress test. You said that all prior stress tests had zero copayments. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that it has waived the cost sharing that was assessed for the other services you had on the same date, so you are only responsible for the copayment for the SPECT scan.

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 $225 copayment for diagnostic radiology services.

You have been asked to pay a $225 copayment for the SPECT scan. The SPECT scan falls within the diagnostic radiology services benefit category. This copayment applies regardless of the reason for this 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 myocardial perfusion imaging (SPECT scan).