Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for pulmonary function testing provided on
March 3, 2020.
You asked the Plan to waive the deductible for pulmonary function testing. You say that you disagree with the
out-of-network charges. 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. Your
contract with the Plan says that there is a $750 deductible for out-of-network outpatient diagnostic tests and
therapeutic services and supplies.
You received pulmonary function testing on March 3, 2020 with an out-of-network provider. The record shows
that you had only paid $203.38 toward the $750 deductible prior to receiving the services. Therefore, you are
responsible to pay the allowed amount of $100.68.
The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient
diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly
disclosing in the contract that there is a $750 deductible for out-of-network outpatient diagnostic tests and
therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time
pulmonary function testing was received on March 3, 2020. Therefore, we decided that the Plan does not have
to waive the deductible for pulmonary function testing provided on March 3, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Computed Tomography (CT) scan of the neck (76376,
70492, 70490, 70491)
You asked the Plan to pre-approve the CT scan. You say that the CT scan is medically necessary. The Plan
denied your request. The Plan says coverage criteria has not been met.
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 the CT scan. Our reviewer says that the
CT of the neck is not medically necessary. Our physician reviewer found notes indicate concern the ear
symptoms may be related to a condition in the neck so advanced imaging was ordered. The records do not
show the physician completed a thorough neurologic physical examination, plain film imaging, or differential
diagnosis.
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 CT scan have not been met. Therefore, we decided that the Plan does not
have to pre-approve a Computed Tomography (CT) scan of the neck (76376, 70492, 70490, 70491)
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for radiation therapy (G6002, 77336, 77525) provided from
December 12, 2019 to January 15, 2020.
You asked the Plan to pay for radiation therapy. You say that the Plan should cover this service. The Plan
denied your request. The Plan says this is experimental.
The Plan must follow Medicare rules. Medicare rules say that MAOs pay the enrollee the difference between
original Medicare cost-sharing incurred for qualified clinical trial items and services and the MA plan's innetwork
cost-sharing for the same category of items and services.
We looked at the file and Medicare rules. The record shows that original Medicare paid for the services at issue
with a 20% enrollee coinsurance. The Plan's cost sharing for these services is also a 20% coinsurance. The
Plan therefore has no responsibility on these services. Therefore, we decided that the Plan does not have to pay
for radiation therapy (G6002, 77336, 77525) provided from December 12, 2019 to January 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe breast biopsy provided on January 30, 2020.You asked the Plan to waive the copayment forthe breast biopsy. You say that you would like to appeal this claim. 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 inclear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 copayment for surgery services at an in-network outpatient hospital. You have been asked to pay a $200 copayment for the breast biopsy. The breast biopsy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 forthe breast biopsy provided on January 30, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided by a
participating provider on February 10, 2020 to March 9, 2020.
You asked the Plan to waive the copayment for physical therapy. You say that you were told that you would
have a $5 copayment. The Plan denied your request. The Plan says the correct copayment has been applied.
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 for outpatient rehabilitation services/physical therapy.
You have been asked to pay a $30 copayment for physical therapy. The total amount you are being asked to
pay is $360 ($30 x 12 visits = $360). Physical therapy falls within the outpatient rehabilitation services/physical
therapy 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 physical therapy provided
by a participating provider on February 10, 2020 to March 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for anesthesia provided on February 6, 2020.You asked the Plan to waive the coinsurance for anesthesia. You say that you disagree with the charges because the anesthesia should be included in the procedure.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 20% coinsurance for outpatient surgery, including services provided at hospital outpatient facilities.You received anesthesia on February 6, 2020. The allowed amount is $418 and 20% of that is $83.60.  You have been asked to pay the total coinsurance amount of $83.60 for anesthesia. Anesthesia falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 coinsurance for anesthesia provided on February 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital care provided January 11, 2020 to January 13, 2020.You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says the enrollee had other primary insurance on this date of service.The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible for this service until the primary insurer has denied the claim for these services.Therefore, we decided that the Plan does not have to pay for the inpatient hospital care provided January 11, 2020 to January 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the physician services rendered on March 30, 2020.You asked the Plan to waive the copayment for these services. You say that you disagree with the charges.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 $35 copayment for in-network specialist's office services. Review of the file shows that you received specialist services on March 30, 2020. You have been asked to pay a $35 copayment for these services. These services fall within the in-network specialist's office services 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 physician services rendered on March 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for biopsies of vaginal mucosa provided on February 26, 2020 and March 5, 2020.You asked the Plan to waive the copayments for biopsies of vaginal mucosa. You say that you feel that the charges are too high and that the procedure should have been done correctly the first time.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 $0 copayment for any surgical procedures provided during a colorectal screening and a $300 copayment for all other outpatient services not provided in an ambulatory surgical center.You received a biopsy of vaginal mucosa on February 26, 2020. A biopsy of vaginal mucosa is considered an outpatient surgical procedure. Therefore, you are responsible to pay the allowed amount of $296, which is less than the $300 copayment. You received a biopsy of vaginal mucosa on March 5, 2020. A biopsy of vaginal mucosa is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $300 copayment. The total amount you owe is: $596. You have been asked to pay the total copayment amount of $596for biopsies of vaginal mucosa. Biopsies of vaginal mucosa fall within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 biopsies of vaginal mucosa provided on February 26, 2020 and March 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6545.
You asked the Plan to pre-approve the compression stockings. You say that the enrollee needs the compression wraps to reduce swelling. The Plan denied your request. The Plan says are only used to cover a wound, and the enrollee did not have wounds on their legs.
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6545 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound. The record does not show that the enrollee has open venous stasis ulcers or a qualifying wound. This means that the enrollee does not have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6545.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on February 24, 2020.
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
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 psychotherapy services provided on February 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to
the enrollee on February 14, 2020.
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request.
The Plan says Comprehensive Genomic Profile (CGP) testing (Guardant-360? and NEXT-Generation?)
requires use of CPT81479, and the appropriate DEX Z identifier entered adjacent in the comment narrative
field.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare
rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay
for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on February 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve complete upper dentures.You asked the Plan to pre-approve the requested dentures. You say that the dentures you received were only temporary.The Plan denied your request. The Plan says this service exceeds the benefit allowance.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file, and Medicare rules. The documentation shows that you received immediate dentures on December 2, 2019. Your plan only covers dentures once per 60 months. Based on this information, we decided that the Plan's rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve complete upper dentures.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora pneumatic compression device.You asked the Plan to pay fora pneumatic compression device. You say that the device is necessary to prevent deep vein thrombosis.The Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism is a preventive service. Claims for E0675will be denied as not reasonable and necessary.  We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage.Therefore, we decided that the Plan does not have to pay fora pneumatic compression device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for radiation therapy (G6002, 77336, 77525) provided from January 2, 2020 to January 7, 2020.You asked the Plan to pay for radiation therapy. You say that the Plan should cover this service.The Plan denied your request. The Plan says this is experimental.The Plan must follow Medicare rules. Medicare rules say that MAOs pay the enrollee the difference between original Medicare cost-sharing incurred for qualified clinical trial items and services and the MA plan's in-network cost-sharing for the same category of items and services.We looked at the file and Medicare rules. The record shows that original Medicare paid for the services at issue with a 20% enrollee coinsurance. The Plan's cost sharing for these services is also a 20% coinsurance. The Plan therefore has no responsibility on these services.Therefore, we decided that the Plan does not have to pay for radiation therapy (G6002, 77336, 77525) provided from January 2, 2020 to January 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2740) on tooth #30.
You asked the Plan to pre-approve the crown. You say that you would like a crown approved for tooth #30 for the longevity of the tooth. The Plan denied your request. The Plan says the enrollee has had a root canal done on tooth #30, but the filling does not go completely to the tip of the root, and is therefore an inadequate fill. The Plan also says that a cap cannot be approved for a tooth that has an inadequate fill from a root canal treatment.
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 crown when the services are medically necessary and reasonable. 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 crown. Our reviewer says that the service is not medically necessary. Our physician reviewer found the provided x-rays show a fill on the distal root short of the apex by several millimeters, though there is clearly root canal sealer extruding from an accessory canal near the termination of the gutta percha point. Our reviewer found that although the accessory canal has been sealed, the amount that the main sealer point is short of the radiographic apex appears to indicate that the true apex is closer to radiographic apex than was instrumented. The risk of reinfection of the distal root is therefore increased, and a crown would not be indicated until the distal canal is instrumented closer to the radiographic apex, due to a compromised long term prognosis.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crown have not been met. Therefore, we decided that the Plan does not have to pre-approve a crown (D2740) on tooth #30.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean addition, endoskeletal system, below knee, flexible protective outer surface covering system (L5962) for the enrollee.You asked the Plan to pre-approvethese services. You say that this is a medical necessity.The Plan denied your request. The Plan says that there is no type of extraordinary activities that would justify the need for extra protection.The Plan must follow Medicare rules. Medicare rules say that the protective outer surface covering system is used by a beneficiary who has special needs for protection against unusually harsh environmental situations. We looked at the file and Medicare rules. The record does not show the enrollee is subject to a harsh environmental situation. 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 pre-approve an addition, endoskeletal system, below knee, flexible protective outer surface covering system (L5962) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for wound debridement and a duplex scan
provided on March 11, 2020.
You asked the Plan to waive the copayments for wound debridement and a duplex scan. You say that you
disagree with the charges because the wound was due to an accident due to the providers negligence. 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 $45
copayment for wound care provided in an outpatient hospital facility and a $180 copayment for advanced
imaging services.
You received wound debridement on March 11, 2020. Therefore, you are responsible to pay the $45
copayment.
You received a duplex scan on March 11, 2020. Therefore, you are responsible to pay the allowed amount of
$107.12, which is less than the $180 copayment.
The total amount you owe is: $152.12.
You have been asked to pay the total copayment amount of $152.12 for wound debridement and a duplex scan.
Wound debridement and a duplex scan 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 copayments for wound debridement and a
duplex scan provided on March 11, 2020.