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

We decided that the Plan does not have to waive the copayment for telehealth services provided by a participating provider on January 4, 2021.
You asked the Plan to waive the copayment for telehealth services. You say that you don't think you should have to pay for this. You say that you did not want to go to the hospital because you were afraid of catching Covid-19. 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 $40 copayment for physician/practitioner services/specialist. You have been asked to pay a $40 copayment for telehealth services. The correct copayment has been applied to the services that were provided. Telehealth services fall within the physician/practitioner services/specialist 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 telehealth services provided by a participating provider on January 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for an emergency room visit (27266, 36415, 73501, 73502, 80048, 80053,85025, 85610, 85730, 90471, 90715, 96361, 96374, 96375, 99285, G0378, J1170, J1885, J2250, J2270, J2704, J7030) provided from October 9, 2020, to October 10, 2020.
You asked the Plan to pay for an emergency room visit. You say that this was medically necessary. The Plan denied your request. The Plan says this was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that when multiple medical visits on the same day in the same revenue center are submitted on separate claims, hospitals should report condition code G0 on the second claim. We looked at the file and Medicare rules. A claim for an emergency room visit with the same provider on the same date of service was previously submitted. The claim at issue is missing the required G0 condition code. Based on this information, we decided that Medicare rules for coverage of an emergency room visit have not been met. Therefore, we decided that the Plan does not have to pay for an emergency room visit (27266, 36415, 73501, 73502, 80048, 80053,85025, 85610, 85730, 90471, 90715, 96361, 96374, 96375, 99285, G0378, J1170, J1885, J2250, J2270, J2704, J7030) provided from October 9, 2020, to October 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the out of network cost share for the scaling and root planing (D4341) for the upper left and lower left quadrants, and the resin based composites (D2391) for teeth # 15 and # 18.

You asked the Plan to waive the out of network cost share for the dental services. You say that you, nor the plan, pre-approved the services that you received. You say that you were led to believe that the provider was in network. You say that after the services were provided, you were informed that "unnecessary/additional" work was performed. You say that you are being double billed for the services. You also say that The Plan denied your request. The Plan says scaling and root planing is covered once every 3 years per quadrant. The Plan says that the frequency limit has been exceeded. The Plan says that the provider in this case is out of network. The Plan also says that out of network providers may bill you for any amount greater than the payment made by the Plan to the provider.

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 scaling and root planing is listed as a covered service, the frequency limit for this service has been exceeded. The record shows that the Plan paid for the scaling and root planing for the lower left quadrant. Additionally, out of network providers may bill you for any amount greater than the payment made by the Plan to the provider. Therefore, we decided that the Plan does not have to waive the out of network cost share for the scaling and root planing (D4341) for the upper left and lower left quadrants, and the resin based composites (D2391) for teeth # 15 and # 18.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on October 13, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the testing is 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 test at issue in this appeal, molecular genetic screening, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on October 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an orthosis (L0650) provided September 16, 2020.
You asked the Plan to pay for the orthosis. You say that the orthosis was medically necessary. The Plan denied your request. The Plan says documentation does not support the billed service.
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 CPT code L0650 is not supported in the medical record. Specifically, the documentation shows no record of a claim for the referring physician. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met. Therefore, we decided that the Plan does not have to pay for an orthosis (L0650) provided September 16, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on July 23, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the claims were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that inpatient services must be billed with POS code
21.
We looked at the file and Medicare rules. The file shows that the enrollee was inpatient for the date of service
at issue and the services were not billed with POS code 21. 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 testing services rendered on July 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 panel rendered on September 30, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was billed incorrectly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the Guardant360 panel rendered on September 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for assisted living facility care (99336) provided on November
24, 2020.
You asked the Plan to pay for the assisted living facility care. You say that the services were medically
necessary. The Plan denied your request. The Plan says there were network providers available. No pre-authorization
was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service
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 assisted living facility care (99336) provided on November 24, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional transportation mileage (A0170).
You asked the Plan to pre-approve the additional transportation mileage. You say that the additional mileage is needed to see a provider for surgical follow-up. The Plan denied your request. The Plan says the requested mileage exceeds the allowable amount per trip under your transportation benefit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers up to 60 one-way transportation trips per year. Each trip cannot exceed 50 miles. We looked at your request, the records in the case file, and the rules. The mileage requested is 66 miles. The plan benefit is limited to 50 miles per trip. There is no exception provided in the plan contract for additional mileage. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve additional transportation mileage (A0170).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound provided on December 11, 2020.
You asked the Plan to waive the copayment for the ultrasound. You say that your mammogram is free, and you don't understand why you were charged a $15 copayment. 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 $15 copayment for Medicare-covered x-rays and ultrasounds from an in-network provider. You have been asked to pay a $15 copayment for the ultrasound. The ultrasound falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The ultrasound is considered a diagnostic imaging service. 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 ultrasound provided on December 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital care (99232) provided October 15, 2020.
You asked the Plan to pay for the hospital care. You say that the services were medically necessary. The Plan denied your request. The Plan says payment has already been issued for this service.
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 99232 is subsequent hospital care. We find that CPT code 99232 is not supported in the medical record. Specifically, the plan has already issued payment for this service on the date of service at issue. Records do not support payment for more than one unit. Based on this information, we decided that Medicare rules for coverage of the hospital care have not been met. Therefore, we decided that the Plan does not have to pay for hospital care (99232) provided October 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME.

You asked the Plan to waive the coinsurance for DME. You say that you disagree with the charges because the device was necessary. 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 DME and related supplies.

You received DME. The allowed amount is $3,164 and 20% of that is $632.80.

You have been asked to pay the total coinsurance amount of $632.80 for DME. DME falls within the DME and related 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 coinsurance for DME.
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 you need IRF care. The Plan denied your request.
The Plan says rules for IRF care have not been met.
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. Our
physician reviewer found you were admitted to an acute care hospital for altered mental status, slurred speech
and facial droop. 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. Finally, 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.
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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 power wheelchair (K0823).
You asked the Plan to pre-approve a Group 2 power wheelchair. You say that you cannot walk and have
neuropathy in your feet and legs. The Plan denied your request. The Plan says the requested item is not
medically necessary.
The Plan must follow Medicare rules. The rules state that the information submitted by the supplier or provider
must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare
coverage criteria have been met.
The record does not contain valid relevant medical records which support medical necessity for the supplies
requested in this case. The record shows that the Plan made several attempts to obtain the necessary
documentation without success. Therefore, we decided that the Plan does not have to pre-approve a Group 2
power wheelchair (K0823).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a prostate specific antigen test (G0103) provided on December 31, 2020.
You asked the Plan to pay for a prostate specific antigen test. You say that this should be covered because it is only a few days off from the frequency limitation. The Plan denied your request. The Plan says this was provided less than 12 months after your previous test.
The Plan must follow Medicare rules. Medicare rules say that Medicare Part B covers prostate cancer screening tests/procedures for the early detection of prostate cancer. Each test may be paid at a frequency of once every 12 months. We looked at the file and Medicare rules. The record shows that your previously received a prostate specific antigen test on January 2, 2020, less than 12 months prior to the prostate specific antigen test at issue. Based on this information, we decided that Medicare rules for coverage of a prostate specific antigen test have not been met. Therefore, we decided that the Plan does not have to pay for a prostate specific antigen test (G0103) provided on December 31, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray (71045) provided August 31, 2020.
You asked the Plan to pay for the x-ray. You say that the services were medically necessary. The Plan denied your request. The Plan says documentation does not support multiple units of CPT code 71045 being billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 71045 is not supported in the medical record. Specifically, only 1 radiology report was provided as documentation. Insufficient clinical documentation was provided to support more than 1 unit. Based on this information, we decided that Medicare rules for coverage of the x-ray have not been met. Therefore, we decided that the Plan does not have to pay for an x-ray (71045) provided August 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional intraoral periapical x-ray or pay more than a 50% coinsurance for the resin-based composite provided on December 3, 2020.
You asked the Plan to pay for the additional intraoral periapical x-ray and resin-based composite. You say that you were advised that this provider was in-network with your plan. You also say that you would like these services to be paid in full. The Plan denied your request. The Plan says your benefits for the additional intraoral periapical x-ray had been satisfied and the frequency limitation had been exceeded. The Plan also says that you are responsible for the difference between the billed amount and allowed amount for services received out-of-network.
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, intraoral x-rays are limited to one procedure per calendar year. The record shows that you received a first intraoral periapical x-ray on December 3, 2020 and your intraoral x-rays benefit had been exhausted. The Plan contract also says that you must pay a 50% coinsurance for restorations. The record shows that the Plan paid 50% coinsurance for the resin-based composite provided on December 3, 2020, and you are responsible for the remaining 50% coinsurance. Therefore, we decided that the Plan does not have to pay for the additional intraoral periapical x-ray or pay more than a 50% coinsurance for the resin-based composite provided on December 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an eye examination (92014) provided on June 9, 2020.
You asked the Plan to waive the copayment for an eye examination. You say that you would like the plan to pay for the service. 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 $45 copayment for an eye examination. You have been asked to pay a $45 copayment for an eye examination. An eye examination falls within the vision 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 an eye examination (92014) provided on June 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on November 25, 2020.
You asked the Plan to pay for the comprehensive oral evaluation. You say that you believe this service should be covered. The Plan denied your request. The Plan says this service exceeds the frequency limitation in your benefit plan.
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, comprehensive oral evaluation (D0150) is limited to one procedure every three plan years. The record shows that you received a comprehensive oral evaluation (D0150) on May 1, 2019 and your comprehensive oral evaluation (D0150) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on November 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the out of network cost share the extraction (D7140) provided
on October 6, 2020.
You asked the Plan to waive the out of network cost share the dental service. You say that you were advised by
the Plan and your provider that he is in network. The Plan denied your request. The Plan says the provider in
this case is out of network. The Plan says that out of network providers may bill you for any amount greater
than the MAC payment made by the plan to the provider. The Plan also says that the there is no record of a
phone call to the Plan.
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 extractions are a covered service,
out of network providers may still bill you for any amount greater than the MAC payment made by the plan to
the provider. Therefore, we decided that the Plan does not have to waive the out of network cost share the
extraction (D7140) provided on October 6, 2020.