Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the knee replacement and PT evaluation provided from November 12, 2019 through November 13, 2019.
You asked the Plan to waive the cost share for the knee replacement and PT evaluation. You say that you were in the hospital overnight. You say that this should be an inpatient copayment. The Plan denied your request. The Plan says the cost share 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 20% coinsurance for each covered surgery or observation room service in an in-network outpatient hospital and a $30 copayment for each in-network covered physical, occupational and speech therapy visit. You have been asked to pay a total of $2,070.31 for the knee replacement and PT evaluation.
Service
Allowed Amount
Standard Cost
Member Liability
Knee Replacement
$10,201.54
20%
$2,040.31
PT Evaluation
$8306
$30
$30
TOTAL:
$2,070.31
The knee replacement falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The PT evaluation falls within the "Outpatient rehabilitation services" benefit category. The records show that the knee replacement was an outpatient procedure. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost share for the knee replacement and PT evaluation provided from November 12, 2019 through November 13, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for excisions (11442x3) provided on November 14, 2019.
You asked the Plan to pay for the excisions. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation does not support the units 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 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 excisions. Our reviewer says that while seven cysts were removed, only five excisions were performed to do so. Of the five excisions performed, three meet the size requirements (1.1 x 2cm diameter) for the billed code. Therefore, the billing of three units of excision (11442, 11442.51 x 2) is supported. Our physician reviewer found the health plan has agreed to pay for four units of excision (11442, 11442.51 x 3). The additional three units are not supported. 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 excisions have not been met. Therefore, we decided that the Plan does not have to pay for excisions (11442x3) provided on November 14, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CT scan of the head (70470).
You asked the Plan to pre-approve a CT scan of the head (70470). You say that the requested CT scan of the head is medically necessary. The Plan denied your request. The Plan says the requested CT scan of the head is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. 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 a CT scan of the head (70470). Our reviewer says that the requested CT scan of the head is not medically necessary. Our physician reviewer found based on the documentation provided, the enrollee was evaluated by a physician on 2/18/2020 for feeling "different." A physical examination noted no objective findings. A urine dip detected leukocyte esterase. The enrollee was assessed to likely have a urinary tract infection and was started on antibiotics. There is no further documentation to explain why a CT of the head was ordered two days later. The documentation does not support that a CT scan of the head is medically necessary or reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CT scan of the head (70470) have not been met. Therefore, we decided that the Plan does not have to pre-approve a CT scan of the head (70470).
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
You asked the Plan to pre-approve the continuous glucose monitor. You say that you need to be able to monitor your blood sugar in order to avoid sudden hyper and hypoglycemia, which could lead to your sudden death. You say that the recent blood results submitted support the need for the requested CGM. The Plan denied your request. The Plan says the medical records provided do not show that the enrollee meets the coverage criteria.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor. 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 the continuous glucose monitor. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the records do not show that the enrollee takes insulin or checks blood glucose 4 times per day. There is no reason given as to why the enrollee, who is not on a medication that causes low blood glucose levels, would need a CGM. 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 continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral exam (D0150), prophylaxis (D1110), bitewing x-rays (D0274), and the panoramic x-ray (D0330) provided on November 5, 2019.
You asked the Plan to pay for the dental services. You say that you were under the impression that your dental coverage was part of your Medicaid coverage. The Plan denied your request. The Plan says the oral exam, prophylaxis, bitewing x-rays, and panoramic x-ray are not listed as covered services.
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 dental services you received are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive oral exam (D0150), prophylaxis (D1110), bitewing x-rays (D0274), and the panoramic x-ray (D0330) provided on November 5, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray provided on January 1, 2020.
You asked the Plan to pay for the x-ray. The Plan denied your request. The Plan says during the enrollee's hospice election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the chest x-ray provided on January 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ankle-foot orthosis (AFO) rendered on January 14, 2020. 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 the services were not medically necessary. The Plan must follow Medicare rules. Medicare rules say that an AFO is covered when specific criteria are met. 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 these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the submitted documentation does not support that the AFO was medically necessary for the enrollee. There is no documentation of weakness or deformity of the feet and ankles which requires stabilization for medical reasons. We looked at this physician's review, the file, and Medicare rules. 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 ankle-foot orthosis (AFO) rendered on January 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses purchased on January 8, 2020.
You asked the Plan to pay for the eyeglasses. You say that you want the Plan to pay $300. The Plan denied your request. The Plan says you exhausted your benefit allowance.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. You exhausted your benefit allowance, because the Plan paid the $300 for your eyeglasses. Your EOC states, the Plan pays up to a total of $300 every 12 months for eyeglasses, frames, lenses or contact lenses from participating network providers. Therefore, you are responsible for the remainder of the costs. Therefore, we decided that the Plan does not have to pay for the eyeglasses purchased on January 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical preparation by excision (15004, 15005, 15002 and 15003) provided on October 14, 2019. You asked the Plan to pay for the surgical preparation. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the services billed. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We asked our coder 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 surgical preparation. Our reviewer says that CPT codes 15004, 15005, 15002 and 15003 do not meet criteria for billing or reimbursement consideration. Our reviewer found there is no evidence that the enrollee underwent surgical excision of any area in preparation for receipt of a skin graft or wound vac. 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 surgical preparation have not been met. Therefore, we decided that the Plan does not have to pay for surgical preparation by excision (15004, 15005, 15002 and 15003) provided on October 14, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoral complete series images (D0210) provided on December 27, 2019.
You asked the Plan to pay for the intraoral complete series. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this service can only be done once every 36 months and the service was already done on 08/14/2017.
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 covers the intraoral complete series once every 36 months. We looked at your request, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the intraoral complete series have not been met. Specifically, the record indicates that you received this service in August 2017. The Plan only covers this service once per 36 months. Therefore, we decided that the Plan does not have to pay for intraoral complete series images (D0210) provided on December 27, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for dermatology services (CPT 17004) provided to the enrollee on September 12, 2019.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 Current Procedural Terminology (CPT) code 17004 59 (1 unit) remains 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 17004 is "destruction, premalignant lesions (eg, actinic keratoses), 15 or more lesions." 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 services. Our reviewer says that the services at issue in this were not coded correctly. Our physician reviewer found according to the note of 2019-09-12, two actinic keratosis lesions were treated with liquid nitrogen. A review of the records show that only two lesions were treated, instead of the 15 or more that are required by the code billed.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 services have not been met.Therefore, we decided that the Plan does not have to pay for dermatology services (CPT 17004) provided to the enrollee on September 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, additional intraoral periapical x-ray provided on November 20, 2019.
You asked the Plan to pay for the problem focused limited oral evaluation and intraoral periapical x-rays. You say that this visit was necessary for the enrollee in order to determine the treatment that was necessary to fix the broken tooth. The Plan denied your request. The Plan says the benefits for these services had been satisfied and the frequency limitations 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, exams are limited to two procedures per calendar year. The record shows that the enrollee received a periodic oral evaluation on January 29, 2019 and August 22, 2019 and the enrollee's exams benefit was then exhausted. The contract also says that intraoral x-rays are limited to one procedure per calendar year. The record shows that the enrollee received a first intraoral periapical x-ray on August 22, 2019 and the enrollee's intraoral x-rays benefit was then exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, additional intraoral periapical x-ray provided on November 20, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that the enrollee has been having these services for years and until recently the Plan has paid for them. You say that the enrollee has to have the ambulance services to go to her appointments because she has multiple sclerosis. You stated that the enrollee deserves to have her claims paid. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when they meet certain origin and destination requirements. A doctor's office is not a covered destination. The services you have asked the Plan to pay for are ambulance transport services to a doctor's office. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a rubber mat.
You asked the Plan to pre-approve the rubber mat. You say that you are requesting a rubber mat for the shower. The Plan denied your request. The Plan says a rubber mat does not serve a purpose that is primarily medical in nature and is considered a convenience item because it is not used to treat a medical condition.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a rubber mat.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump with oxygenator or
heat exchanger (99190) provided on December 12, 2019.
You asked the Plan to pay for the assembly and operation of a pump with oxygenator or heat exchanger. You
say that this was a mandatory service. The Plan denied your request. The Plan says payment of this service is
included in the DRG.
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that
CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the
OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule.
The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of
"C" on Addendum B of the 2019 OPPS/ASC final rule. This means the service has been designated as
"inpatient only", and therefore must be billed as part of an inpatient admission. Therefore, we decided that the
Plan does not have to pay for the assembly and operation of a pump with oxygenator or heat exchanger (99190)
provided on December 12, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the x-ray provided on January 24, 2020.
You asked the Plan to waive the deductible for the x-ray. You say that you should not have to start over again with the deductible since the x-ray should be covered as a part of your surgery. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
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 $750 deductible that applies towards x-rays.
The x-ray you asked the Plan to waive the deductible for falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible that applies towards x-rays. Please note, there is no provision in the contract which indicates the deductible would be waived if performed as a follow-up to a surgical procedure.
This cost sharing is a contractual obligation that had not been met at the time the x-ray was received on January 24, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the x-ray provided on January 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an OB/GYN office visit provided on October 28, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an OB/GYN office visit. You say that these services were provided in good faith. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained.
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 has network providers available who can provide 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 an OB/GYN office visit provided on October 28, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from October 24, 2019 through October 28, 2019 provided by an in-network provider.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you have never paid over a $90 copayment for inpatient hospital care. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that you were admitted on October 24, 2019 and discharged on October 28, 2019. You were asked to pay a $360 copayment per day from October 24, 2019 through October 27, 2019, days 1-4 of your inpatient hospital care. You were discharged on October 28, 2019 and there was no copayment charge for the day of discharge. Per your contract there is a $360 copayment per day required for days 1-5. 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 inpatient hospital care from October 24, 2019 through October 28, 2019 provided by an in-network provider.