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

We decided that the Plan does not have to pay more for the two periodontal scalings and root planings (D4342 x2) provided on October 14, 2020 by an OON provider.

You asked the Plan to pay more for the scalings and planings. You say that you believe these services should be covered up to your $1,500 annual dental allowance. The Plan denied your request. The Plan says the total cost share of $364.00 applied correctly as your liability. The Plan also says that cost sharing is a contractual obligation under the Plan and cannot be waived.

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, you are responsible for a 50% coinsurance for each periodontal scaling and root planing (D4342) plus the difference between the billed and allowed amounts for services received OON. Therefore, we decided that the Plan does not have to pay more for the two periodontal scalings and root planings (D4342 x2) provided on October 14, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a neurostimulator for the enrollee.
You asked the Plan to pre-approve the stimulator. You say that this is medically necessary. The Plan denied
your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the stimulator. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found this is not being requested as a last resort. All options have not been exhausted. There has been
no indication of a surgical consult to rule in/out the possibility of a surgery for the low back problems.
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 stimulator have not been met. Therefore, we decided that the Plan does not
have to pre-approve a neurostimulator for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injections provided on November 6, 2019.
You asked the Plan to pay for Injection(s), anesthetic agent and/or steroid, plantar common digital nerve(s) (64455RT, 64455RTXS). You say that the Plan should pay this claim. The Plan denied your request. The Plan says you did not bill as required by Medicare coding regulations.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. In this case, the MUE for CPT code 64455 is 1. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of Injection(s), anesthetic agent and/or steroid, plantar common digital nerve(s) (64455RT, 64455RTXS) have not been met. Therefore, we decided that the Plan does not have to pay for the injections provided on November 6, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (80307, G0483) provided on August 5, 2020.
You asked the Plan to pay for drug testing. You say that this is supported in the records. The Plan denied your request. The Plan says this was billed with an incorrect POS.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The services at issue were billed with POS 81 for an independent laboratory, but the records show that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (80307, G0483) provided on August 5, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for MammaPrint testing (81479, 81521) provided on November 16, 2020 by an out of network (OON) provider.
You asked the Plan to pay for MammaPrint testing. You say that this is a covered service. The Plan denied your request. The Plan says this was 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 services 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 MammaPrint testing (81479, 81521) provided on November 16, 2020 by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient rehabilitation services, physical therapy provided from June 22, 2020, through June 29, 2020.
You asked the Plan to pay for the outpatient rehabilitation services, physical therapy. You say that prior authorization was not obtained due to some COB issues with the patient and the insurance information provided to our office at the time of service. The Plan denied your request. The Plan says 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 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 outpatient rehabilitation services, physical therapy provided from June 22, 2020, through June 29, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided on January 8, 2021, and January 22, 2021.
You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you disagree with the increase in charges. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay 20% coinsurance for Medicare Part B prescription drugs. The enrollee received a Medicare Part B drug on January 8, 2021. The allowed amount is $2,089.80 and 20% of that is $417.96. The enrollee received a Medicare Part B drug on January 22, 2021. The allowed amount is $2,089.80 and 20% of that is $417.96. The total amount you owe is: $835.92. The enrollee has been asked to pay the total coinsurance amount of $835.92 for Medicare Part B drugs.
Medicare Part B drugs fall within the Medicare Part B prescription drugs benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided on January 8, 2021, and January 22, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the services you received on December 9, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the services were not authorized.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. You were provided for the services by a contract provider. The file does not show that the Plan provided notice that the services would not be covered. Under Medicare rules, this means the services is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the services you received on December 9, 2020.
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 for the fillings (D2331 x 3) provided on September 15, 2020.
You asked the Plan to pay for the dental service. You say that you got hit in the mouth with a baseball when you were younger. You say that some of the resin has worn off and you needed it to be replaced. You say that because it was the result of an accident, this should be a medical claim and not a dental claim. The Plan denied your request. The Plan says the fillings you received are dental in nature. The Plan also says that routine dental services are not covered by Medicare.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the fillings (D2331 x 3) provided on September 15, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on September 22, 2020.
You asked the Plan to pay for the ambulance services. You say that you were following the Covid executive order for treatment in place. 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 does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on September 22, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on September 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing charges for an office visit, an echocardiograph, a Medicare Part B drug and nuclear medicine provided from December 7, 2020, to December 21, 2020.
You asked the Plan to waive the cost-sharing charges for an office visit, an echocardiograph, a Medicare Part B drug and nuclear medicine. You say that you should not be responsible for the 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for provider and professional services provided by a specialist, 20% coinsurance for diagnostic procedures and tests provided at an outpatient hospital facility and a $250 copayment for advanced imaging services provided at an outpatient hospital facility. Your contract with the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs You had a specialist visit on December 7, 2020. Therefore, you are responsible to pay the $35 copayment. You received an echocardiograph at an outpatient hospital facility on December 15, 2020. The total allowed amount is $471.30 and 20% of that is $94.26. You received a Medicare Part B drug on December 21, 2020. The total allowed amount is $20.28 and 20% of that is $4.06. You received nuclear medicine at an outpatient hospital facility on December 21, 2020. Therefore, you are responsible to pay the $250 copayment. The total amount you owe is: $383.32. You have been asked to pay the total amount of $383.32 for an office visit, an echocardiograph, a Medicare Part B drug and nuclear medicine. An office visit, an echocardiograph and nuclear medicine fall within the outpatient diagnostic tests and therapeutic services and supplies benefit category. A Medicare Part B drug falls within the Medicare Part B prescription drugs 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 cost-sharing charges for an office visit, an echocardiograph, a Medicare Part B drug and nuclear medicine provided from December 7, 2020, to December 21, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a participating provider on November 18, 2020.
You asked the Plan to waive the copayment for an injection. You say that you do not agree with this 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 $280 copayment for outpatient surgery/outpatient hospital. You have been asked to pay a $280 copayment for an injection. The injection that was provided is considered an outpatient surgery; therefore, the correct copayment has been applied. An injection falls within the outpatient surgery/outpatient hospital 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 outpatient surgery provided by a participating provider on November 18, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer placement (22869).
You asked the Plan to pre-approve the interspinous spacer. You say that the requested procedure is medically
necessary. The Plan denied your request. The Plan says this procedure is investigational and is not covered.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the interspinous spacer. Our reviewer
says that the requested services are not considered medically reasonable and necessary in this case. Our
physician reviewer found Interspinous spacers remain experimental. More research is needed to show safety
and efficacy of the devices.
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 interspinous spacer have not been met. Therefore, we decided that the Plan
does not have to pre-approve an interspinous spacer placement (22869).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic ultrasound provided by a participating provider on November 17, 2020.
You asked the Plan to waive the copayment for a diagnostic ultrasound. You say that you had this sonogram based on the results of a mammogram. You say that you do not feel like you should have to pay for this. 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 $110 copayment for outpatient diagnostic tests/radiological diagnostic services. You have been asked to pay a $110 copayment for each diagnostic ultrasound. The total amount you are being asked to pay for two diagnostic ultrasounds is $110.68 ($55.34 + $55.34 = $110.68). The correct copayment has been applied to the services provided. A diagnostic ultrasound falls within the outpatient diagnostic tests/radiological diagnostic 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 a diagnostic ultrasound provided by a participating provider on November 17, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for vertebral corpectomy (CPT 63081) provided to the enrollee on October 27, 2020.
You asked the Plan to pay for the surgery. You say that this should be paid for. The Plan denied your request. The Plan says CPT 63081 is not supported by the medical records submitted.
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 63081 is "Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s)." 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 surgery. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found CPT code 63081 is not appropriate. The operative report does not describe the performance of a partial of complete vertebral corpectomy. 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 surgery have not been met. Therefore, we decided that the Plan does not have to pay for vertebral corpectomy (CPT 63081) provided to the enrollee on October 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on December 10, 2020.
You asked the Plan to waive the copayment for the office visit. You say that you should not be charged a second copayment as it was a requested follow up by the doctor. 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 $35 copayment for each specialist visit. You have been asked to pay a $35 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. There is no provision in the contract which indicates a copayment would be waived for a service performed as a follow-up. 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 office visit provided on December 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on June 26, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on June 26, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for a stroke. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.