Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the needle electromyography; 2 extremities with or without related paraspinal areas represented by code 95861 provided on February 11, 2021.

You asked the Plan to pay for code 95861. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the medical records do not support the billing of code 95861.

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 95861 is Needle electromyography; 2 extremities with or without related paraspinal areas.

We find that CPT code 95861 is not supported in the medical record. Specifically, the submitted documentation
indicates a needle electromyography; 1 extremity with or without related paraspinal areas was performed and
code 95861 cannot be verified. Based on this information, we decided that Medicare rules for coverage of code
95861 have not been met. Therefore, we decided that the Plan does not have to pay for the needle
electromyography; 2 extremities with or without related paraspinal areas represented by code 95861 provided
on February 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories for the
enrollee.

You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied
your request. The Plan says this is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.

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 wheelchair. Our reviewer says that
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found there is no
documentation of a personal mobility deficit that impairs participation in mobility related activities of daily
living such as toileting, feeding, grooming and bathing in customary locations within the home. The medical
records noted above document that the enrollee is walking with stand by assistance with a walker unlimited
distances. There is no evidence that the mobility deficit cannot be helped by a walker, cane, or manual
wheelchair. It is not clear if the enrollee could operate the power wheelchair. The provided medical records do
not document the presence of qualifying diagnosis for a group 3 power wheelchair. As the records do not
document that criteria for the requested power wheelchair are met, there is no documentation that the requested
accessories are eligible for coverage as defined by Medicare criteria.

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 wheelchair have not been met. Therefore, we decided that the Plan does not
have to pre-approve a group 3 power wheelchair and accessories for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a medical eye exam (92004) provided on January 28, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for a medical eye exam. You say that you were not advised or informed that the provider was not part of the Plan's network. You also say it is not your fault and you should not be liable for this bill. The Plan denied your request. The Plan says services were provided by an out-of-network provider without prior authorization. The Plan also says that there are in-network providers available for these services. 

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. The records provided for review do not show that the services at issue were urgent or emergent. 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 a medical eye exam (92004) provided on January 28, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an insertion of a tube into your gallbladder with imaging and catheter placement (47490) provided on March 18, 2021.
You asked the Plan to waive the copayment for an outpatient procedure. You say that you were discharged from the hospital and told to return in two weeks to remove a pump. The Plan denied your request. The Plan says the copayment 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 a $350 copayment for same-day outpatient surgery in an outpatient hospital facility.
You have been asked to pay a $350 copayment for an outpatient procedure. The records show you received an outpatient surgical procedure at an outpatient hospital facility. The EOC confirms $350 is the required copayment for this service. An outpatient procedure falls within the outpatient hospital 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 an insertion of a tube into your gallbladder with imaging and catheter placement (47490) provided on March 18, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on August 8, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service 
(POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on August 8, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on October 2, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. You say that this was just a flu shot. The Plan denied your request. The Plan says prior authorization was not obtained for these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for physician services provided on October 2, 2020 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that RFA 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 pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show that you had prior medial branch block (MBB) injections that provided greater than 80 percent pain relief for a temporary period of time. The criteria for coverage of RFA are not met, as the MBBs provided only temporary relief. The RFA is therefore not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve extractions (D7210 x19), implant removal (D6100 x3), and alveoloplasty (D7310 x4).
You asked the Plan to pre-approve extractions, implant removal, and alveoloplasty. You say that the services are medically necessary. The Plan denied your request. The Plan says extractions are a covered benefit, but you have exceeded the frequency limitation of 2 extraction per calendar year. Implant removal, and alveoloplasty are not 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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of extractions, implant removal, and alveoloplasty have not been met. Specifically, the frequency
limit for extractions has been met. Additionally, implant removal, and alveoloplasty are not covered benefits. Therefore, we decided that the Plan does not have to pre-approve extractions (D7210 x19), implant removal (D6100 x3), and alveoloplasty (D7310 x4).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a virtual visit provided by a participating provider on March 23, 2021.

You asked the Plan to waive the coinsurance for a virtual visit. You say that you do not agree with this coinsurance. You say that you should not have any charges for these services. The Plan denied your request. The Plan says that the correct coinsurance 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 20% coinsurance for virtual care/in-network. 

You have been asked to pay a 20% coinsurance of the allowed amount for a virtual visit. The total allowed amount is $57.21. The total amount you are being asked to pay is $11.44 ($57.21 x 20% = $11.44). A virtual visit falls within the virtual care/in-network 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 a virtual visit provided by a participating provider on March 23, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a sensor supply for a CGM.
You asked the Plan to pre-approve a sensor supply for a CGM. You say that the requested item is a medical necessity for you. The Plan denied your request. The Plan says that rules for coverage for continuous glucose monitor supplies have not been met.
The Plan must follow Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 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 sensor supply for a CGM. Our reviewer says that the requested item is a medical necessity in this case. Our physician reviewer found that you have been instructed to not administer Novolog at a meal if your blood glucose is below 120; therefore, there is adjusting of the dose of insulin based on the blood glucose level. You have been treated with 3-4 daily shots of insulin. 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 sensor supply for a CGM have been met. Therefore, we decided that the Plan has to pre-approve a sensor supply for a CGM.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the resin-based composite (D2393) and crown re-cement (D2920) provided on February 15, 2021.
You asked the Plan to pay more for the resin-based composite (D2393) and crown re-cement (D2920). You say that you figured the Plan would cover 50% of the bill but only 20% of the bill was covered. You say that the claim should be reviewed and more of the bill should be covered. The Plan denied your request. The Plan says the claim processed correctly per your out-of-network benefits.
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 claim processed correctly per your out-of-network benefits.
The Plan paid 100% of the allowed amount for the resin-based composite and 50% of the allowed amount for the crown re-cement. You are responsible for any amount greater than what the Plan pays. Therefore, we decided that the Plan does not have to pay more for the resin-based composite (D2393) and crown re-cement (D2920) provided on February 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing represented by code 81455 provided on February 3, 2021.

You asked the Plan to pay for code 81455. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

We looked at the file and Medicare rules. Medicare says that genetic testing submitted under code 81455 will be denied as not medically necessary as it is unlikely to impact therapeutic decision-making in the clinical management of the enrollee. Therefore, we decided that the Plan does not have to pay for the genetic testing represented by code 81455 provided on February 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory work provided on December 1, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the laboratory work. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim originally denied for not meeting Medicare NCD/LCD criteria, but the services are not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The record shows the enrollee was referred by an out-of-network provider. Therefore, we decided that the Plan does not have to pay for the laboratory work provided on December 1, 2020 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for ophthalmology services you received from an out-of-network doctor on May 20, 2021.

You asked the Plan to waive the deductible for the out-of-network ophthalmology services. You say that all previous visits with this provider were paid as in-network. The Plan denied your request. The Plan says your previous claims with this provider were from dates of service in 2020. In 2021, this provider now bills under an out-of-network provider number, which is why these claims processed as out-of-network. The Plan says that you were charged this cost sharing correctly because you had not yet met your annual deductible for out-of-network services.

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 $500 deductible for out-of-network services.

You have been asked to pay the full allowed amount for the out-of-network ophthalmology services because you had not yet met your out-of-network deductible. 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 deductible for ophthalmology services you received from an out-of-network doctor on May 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the filling (D2330) for tooth # 17 provided on May 17, 2021.
You asked the Plan to pay for the dental service. You say that you gave the office your card when you arrived for your appointment. You say that you were never told that they were not in network. You also say that you would not have had the work done had you known. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also says that dental services performed out of network are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage and fillings are listed as covered, dental services performed out of network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the filling (D2330) for tooth # 17 provided on May 17, 2021.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pre-approve the crowns (D2750). We decided that the Plan does not have to
pre-approve the prefabricated abutments (D6056).
You asked the Plan to pre-approve the crowns (D2750). You say that you would like the crowns to be covered
for the enrollee. The Plan says that these services are not covered under the enrollee's benefit plan.
We decided that the Plan has to pre-approve the crowns (D2750).
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. This request is for a crown (D2750) which the Plan denied saying this service is
not covered. The EOC clearly states that crowns are a covered benefit. The 2021 EOC does not clearly state
which types of crowns or crown codes are covered. We made a request to the Plan for a list of covered dental
codes, but this information was not returned to us. Therefore, we decided that the Plan has to pre-approve the
crowns (D2750).
We also decided that the Plan does not have to pre-approve the prefabricated abutments (D6056).
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, implant services are not among those
covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the prefabricated
abutments (D6056).
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.