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

We decided that the Plan does not have to pay for the 6 extractions (D7140 x6) and two alveoloplasties in conjunction with extractions (D7310 x2) provided on November 17, 2020.

You asked the Plan to pay for the extractions and alveoloplasties. You say that you believe these services should be covered. The Plan denied your request. The Plan says annual maximum benefit for the 2020 plan year has been exceeded. The Plan also says that the extractions do not meet the medical requirements for coverage.

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 Plan offers a $2,000 annual dental benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are responsible for the full charges of any additional dental services. The record shows that you met the annual maximum benefit while processing this claim for the November 17, 2020 date of service and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the 6 extractions (D7140 x6) and two alveoloplasties in conjunction with extractions (D7310 x2) provided on November 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for infusion therapy services and an ultrasound extremity artery test provided from October 19, 2020, to October 31, 2020.

You asked the Plan to waive the copayments for infusion services and ultrasound. You say that you are requesting that the Plan pay more for these charges. The Plan denied your request. The Plan says the cost-sharing amounts you are being charged are 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 $255 copayment for each infusion visit and $110 copayment for ultrasound. For each infusion visit you have been asked to pay the allowed amount of $188.55, because this amount is less than the $255 copayment for services at an outpatient hospital. There were 13 visits, resulting in a total copayment of $2,451.15. With the $110 ultrasound copayment, your total copayment obligation is therefore $2,561.15.

You have been asked to pay less than $255 copayment for each infusion visit and $110 copayment for ultrasound. Infusion services and ultrasound fall within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" and "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" 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 copayments for infusion therapy services and an ultrasound extremity artery test provided from October 19, 2020, to October 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for observation care services (CPT 99218) provided to the enrollee on October 15, 2020 and October 16, 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 this was not reported properly.

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 99218 is "Initial observation care, per day, for the evaluation and management of a patient which requires these 3 key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission to outpatient hospital "observation status" are of low severity. Typically, 30 minutes are spent at the bedside and on the patient's hospital floor or unit."

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 allowable for CPT 99218 is one unit per day. The documentation submitted included CPT 99218 that was billed by a different provider for the same date of service. A more appropriate code should be used, for a consultation, or additional evaluation and management services.

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 observation care services (CPT 99218) provided to the enrollee on October 15, 2020 and October 16, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for psychotherapy provided on October 7, 2020.
You asked the Plan to waive the copayment for psychotherapy. You say that it was not communicated to you when the copayment waiver would end and now you are financially burdened. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
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 $40 copayment for each individual therapy visit for outpatient mental health care. You have been asked to pay a $40 copayment for psychotherapy. Psychotherapy falls within the outpatient mental health care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for psychotherapy provided on October 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two periodic oral evaluations, first intraoral periapical x-ray, three additional intraoral periapical x-rays, prophylaxis, and resin-based composite provided on December 1, 2020, and December 21, 2020 by an OON provider.
You asked the Plan to pay for the periodic oral evaluations, intraoral periapical x-rays, prophylaxis, and resin-based composite. You say that you were told by the facility that this treating provider was in-network. The Plan denied your request. The Plan says these services were rendered by a non-participating provider. The Plan also says that you were advised prior to the services being rendered that this provider does not participate in Medicare.
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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the two periodic oral evaluations, first intraoral periapical x-ray, three additional intraoral periapical x-rays, prophylaxis, and resin-based composite provided on December 1, 2020, and December 21, 2020 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the application of short leg cast (29405) and walking boot (L4361) provided December 2, 2020, to December 10, 2020.
You asked the Plan to waive the cost share for the application of short leg cast and walking boot. You say that you would like these cost shares waived. The Plan denied your request. The Plan says these cost shares processed correctly and no reimbursement is due.
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% coinsurance for durable medical equipment and $45 copayment for physician specialist services. You have been asked to pay a total cost share of $45 for the application of the short leg cast and a coinsurance of $54.02 ($270.09 Medicare allowed amount x 20% coinsurance) for the walking boot. These services fall within the physician specialist services and durable medical 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 share for the application of short leg cast (29405) and walking boot (L4361) provided December 2, 2020, to December 10, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the positron emission tomography (PET) scan coded 78815 provided on November 23, 2020.

You asked the Plan to pay for the positron emission tomography (PET) scan. 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.

In this case, the CPT Code Manual definition of code 78815 is positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid-thigh.

We find that CPT code 78815 is not supported in the medical record. Specifically, this code was billed reported with an appropriate diagnosis. PET procedures performed to inform the initial treatment strategy of tumors
(modifier PI) must be reported with an appropriate diagnosis. C53.9 (Malignant neoplasm of cervix uteri, unspecified)" is not listed as an appropriate diagnosis. Based on this information, we decided that Medicare rules for coverage of the positron emission tomography (PET) scan have not been met. Therefore, we decided that the Plan does not have to pay for the positron emission tomography (PET) scan coded 78815 provided on November 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided on January 7, 2021.

You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.

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 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 nurse practitioner services provided on January 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the podiatry services rendered on May 5, 2020 and May 19, 2020.

You asked the Plan to waive the copayments for these services. You say that it is your understanding that you will be reimbursed for the services. 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 $35 copayment for each in-network Medicare-covered podiatry visit. 

Review of the file shows that you received podiatry services on May 5, 2020 and May 19, 2020. You have been asked to pay a $35 copayment per visit for these services, for a total of $70. These services fall within the in-network Medicare-covered podiatry visit 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 podiatry services rendered on May 5, 2020 and May 19, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on October 23, 2020.
You asked the Plan to waive the copayment for the laboratory services. You say that you have a $0 copayment for labs. 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 a $10 copayment for laboratory tests. You have been asked to pay $7, which is less than the standard $10 copayment for the laboratory services. The laboratory 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 copayment for laboratory services provided on October 23, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied
your request. The Plan says rules for SNF care have not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is 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 pre-approve SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found that the beneficiary is an 82-year-old female
with acute kidney injury and complete heart block. While there are identifiable skilled therapy service needs,
there are no identifiable skilled nursing service needs. In addition, the beneficiary does not require skilled
nursing or therapy services on a daily basis and does not meet severity of illness or intensity of service criteria
for an inpatient basis in a skilled nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the sales tax used in other medical items or services (S9999)
provided May 28, 2020.
You asked the Plan to pay for the sales sax. You say that the medical records provided will show proof of
medical necessity. The Plan denied your request. The Plan says this code is not a valid code for Medicare
purposes.
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, HCPCS code S9999 is assigned a status code I = not valid for Medicare purposes. Medicare does
not reimburse separately for sales tax. Based on this information, we decided that Medicare rules for coverage
of the sales sax have not been met. Therefore, we decided that the Plan does not have to pay for the sales tax
used in other medical items or services (S9999) provided May 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wrist hand orthosis (L3905) provided October 2, 2020, from a non-certified Medicare provider.

You asked the Plan to pay for the wrist hand orthosis. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says payment cannot be made to a provider who is not eligible to participate in Medicare.

The Plan must follow Medicare rules. Medicare rules say that a provider or supplier must be enrolled in the Medicare program to receive payment. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the wrist hand orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the wrist hand orthosis (L3905) provided October 2, 2020, from a non-certified Medicare provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on June 1, 2020 to September 21, 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 procedure code G0482 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 G0482 is definitive drug testing, 15-21 drug classes. 

We find that CPT code G0482 is not supported in the medical record. Specifically, there is no documentation of testing of 15-21 drug classes. 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 drug testing rendered on June 1, 2020 to September 21, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency department visit (99283) provided November 19, 2020.

You asked the Plan to waive the copayment for the emergency visit. You say that you were told by your primary care provider to go this facility to get antibiotics. When you arrived they did not treat you or give you antibiotics and just sent you home The Plan denied your request. The Plan says the claim was processed and the correct copayment 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 copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $90 copayment for each Medicare covered emergency room visit.

You have been asked to pay $90 copayment for the emergency visit. The emergency visit falls within the Emergency care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency department visit (99283) provided November 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a second pair of glasses (V2020, V2101), two eyewear protection plans (V2799) and the sales tax (S9999) for these items.
You asked the Plan to pay for the second pair of glasses, protection plans and sales tax. You say that the total amount you spent on these items and service was less than the Plan's allowed $200, and you expect full reimbursement up to the maximum allowance. You feel the Plan has not paid their portion as agreed in the contract. The Plan denied your request. The Plan says that the $200 allowance can only be applied to the retail value of one pair of eyewear, which for glasses includes frames, two lenses, and upgrades. The Plan has paid for one pair of glasses, but the benefit as outlined in the contract does not apply to a second pair of eyewear, sales tax or protection plans.
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. The Plan covers the retail value of one pair of eyewear for up to $200 per year. We looked at the file and the Plan's rules. The Plan provided documentation that they paid for the first pair of glasses you purchased on the date in question. The contract clearly states that the $200 maximum allowance may only be applied to the retail value of one pair of glasses. This means that even though you still have money left in the allowance, a second pair of glasses and costs outside the retail value (such as sales tax and additional protection plans) will not be covered.
Based on this information, we decided that the Plan's rules for coverage of the second pair of glasses, protection plans, and sales tax have not been met. Therefore, we decided that the Plan does not have to pay for a second pair of glasses (V2020, V2101), two eyewear protection plans (V2799) and the sales tax (S9999) for these items.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist services on December 2, 2020.

You asked the Plan to waive the copayment for these services. You say that this is the first time the Plan hasn't covered the services. 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 $30 copayment per visit for specialist services. 

Review of the file shows that you received specialist services on December 2, 2020. Per the contract with the Plan, there is a $30 copayment per visit for specialist services. 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 is $20.51. Given that the allowed amount was less than the $30 copayment, you have been asked to pay $20.51 for these services.

The Plan has not denied coverage of these services. The amount you are being asked to pay is your contractual copayment. Therefore, we decided that the Plan does not have to waive the copayment for the specialist services on December 2, 2020.