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

We decided that the Plan does not have to pay for the bilateral face joint injections provided on December 15, 2020.

You asked the Plan to pay for the bilateral face joint injections. You say that the Plan should pay this claim. The Plan denied your request. The Plan says this code was not billed correctly per the bilateral surgery indicator of 1 guidance.

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 64494 is 1. You billed 2 units of this code, exceeding the MUE. The claim should have been submitted with 1 unit and modifier 50. Based on this information, we decided that Medicare rules for coverage of the bilateral face joint injections have not been met. Therefore, we decided that the Plan does not have to pay for the bilateral face joint injections provided on December 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for chiropractic services provided by a participating provider on January 16, 2021, to February 6, 2021.
You asked the Plan to waive the deductible for chiropractic services. You say that you should only owe $4. The Plan denied your request. The Plan says the correct deductible amount has been applied.
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 $500 deductible. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible for certain services. Chiropractic services apply for a deductible. This cost sharing is a contractual obligation that had not been met at the time chiropractic services was received on January 16, 2021 to February 6, 2021. Therefore, we decided that the Plan does not have to waive the deductible for chiropractic services provided by a participating provider on January 16, 2021, to February 6, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on January 15, 2021 by an out of network (OON) provider.
You asked the Plan to pay for lab test. You say that you did not think your doctor would do a biopsy without knowing whether your insurance would cover it. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and the ordering physician is also out-of-network with the Plan.
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 laboratory testing provided on January 15, 2021 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for an office visit and surgical removal of impacted cerumen (ear wax) provided on January 12, 2021.
You asked the Plan to pay for specialist services. You say that you were out of town and lost hearing in your ear, so needed this treatment prior to returning home so you would be able to drive. The Plan denied your request. The Plan says that the denial of payment for these services is correct, because this provider is out-of-network with the Plan and you were not referred by a participating provider.
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. Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not submit medical records for these services, nor did the Plan submit any documented attempts to obtain medical records. You say that you were outside of the Plan's service area and needed these services before you could safely return to the Plan service area. Without medical records, we cannot determine whether the services you received constituted urgently needed services. Therefore, the Plan has not shown that its decision to deny payment is correct or justified according to Medicare rules or your contract with the Plan. Therefore, we decided that the Plan has to pay for an office visit and surgical removal of impacted cerumen (ear wax) provided on January 12, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the laboratory services described by current procedural terminology (CPT) code 0037U provided on August 24, 2020.
You asked the Plan to pay for CPT code 0037U. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed.
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. The Plan denied payment for the laboratory service as the Plan says, per Medicare guidelines, if a laboratory procedure produces multiple reportable test results, only a single CPT code shall be reported for the procedure. The Plan says the denial remains upheld as non-covered as Medicare denies coverage when a laboratory assays two or more genes in a patient in parallel. The Plan says one CPT code must be submitted for the panel. In this case, the file shows that the provider only billed CPT code 0037U. Therefore, we find that the Plan's denial rationale is not clear. Therefore, we decided that the Plan has to pay for the laboratory services described by current procedural terminology (CPT) code 0037U provided on August 24, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for dual-energy X-ray absorptiometry (DXA), bone density scan (77080) screening digital tomosynthesis (77063) screening mammography (77067) provided November 24, 2020.
You asked the Plan to waive the copayment for the diagnostic service. You say that nowhere on the EOC does it say you have a cost share. Per the EOC it says covered every 24 months and $0 copay. The Plan denied your request. The Plan says the claim was processed with the correct copayment applied per the Evidence of Coverage.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $45 copayment for each covered x-ray after you meet your $250 deductible.
You have been asked to pay $43.97 for the diagnostic service. Since this amount is less than the copay amount, you are responsible for the lesser amount. The diagnostic service falls within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for dual-energy X-ray absorptiometry (DXA), bone density scan (77080) screening digital tomosynthesis (77063) screening mammography (77067) provided November 24, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transurethral waterjet ablation of the prostate (0421T).
You asked the Plan to pre-approve a transurethral waterjet ablation of the prostate. You say that the requested service is a medical necessity for the enrollee. The Plan denied your request. The Plan says the medical necessity of the requested service has not been documented.
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 a transurethral waterjet ablation of the prostate. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is noted to have benign prostatic hypertrophy. The medical records submitted do not sufficiently address the elements of the coverage rule to allow a determination of whether the elements are satisfied. Therefore, the elements of the coverage rule are not satisfied. 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 transurethral waterjet ablation of the prostate have not been met. Therefore, we decided that the Plan does not have to pre-approve a transurethral waterjet ablation of the prostate (0421T).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on February 5, 2021 by an out of
network (OON) provider.
You asked the Plan to pay for office visit. You say that this service was medically necessary. The Plan denied
your request. The Plan says the denial of payment for this service is correct, because this provider is out-ofnetwork
with the Plan and authorization was not 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 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 an office visit provided on February 5, 2021 by an
out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the MRI provided on November 13, 2020.
You asked the Plan to waive the copayment for the MRI. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received an MRI on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.
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 $155 copayment for Outpatient diagnostic tests. We looked at the file, the Plans contract and Medicare rules. The file shows that you received an MRI on November 13, 2020. You have been asked to pay a $155 copayment for the MRI. The MRI falls within the Outpatient diagnostic tests 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 MRI provided on November 13, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for genetic testing provided on November 23, 2020.
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because Medicare denies coverage for all cardiovascular risk assessment panels - except the basic lipid panel - for symptomatic patients with suspected or documented cardiovascular disease.
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. This testing was ordered by an in-network provider. The file does not show that the plan provided notice that genetic testing would not be covered. Under Medicare rules, this means genetic testing is considered approved by the plan. Therefore, we decided that the Plan has to pay for genetic testing provided on November 23, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for a custom fabricated abutment (D6057).
You asked the Plan to pay for the custom fabricated abutment. You say that the enrollee needs this service to be approved for coverage. The Plan denied your request. The Plan says that this service is not covered under the enrollee's 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. We looked at the file and Medicare rules. The EOC says that the enrollee has a maximum allowance of $3,500 per year for comprehensive dental services. The contract also says that implant services are a covered benefit. The record shows that the enrollee has a balance of $1,189 remaining in their comprehensive dental allowance. Based on this information, we decided that the Plan's rules for coverage of the custom fabricated abutment have been met. Therefore, we decided that the Plan has to pay for a custom fabricated abutment (D6057).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on November 18, 2020.

You asked the Plan to pay for the dental service. You say that it was your understanding that you were covered for 1 cleaning per year. You also say that you feel this service should be covered. The Plan denied your request. The Plan says periodontal maintenance is not listed as a covered service.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on November 18, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation received January 30 and February 4, 2021.

You asked the Plan to waive the copayment for the ambulance transportation. You say that your card says you pay $90 for emergencies. The Plan denied your request. The Plan says the correct cost share applied to the claim.

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 $200 copayment for each one-way ambulance trip. 

You have been asked to pay $400 in copayments for the ambulance transportation. The ambulance transportation falls within the Ambulance 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 ambulance transportation received January 30 and February 4, 2021.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay up to $1,500 for the problem focused limited oral evaluation, first intraoral
periapical x-ray, crown repair, and endodontic therapy. We decided that the Plan does not have to pay more
than $1,500 for the problem focused limited oral evaluation, first intraoral periapical x-ray, crown repair, and
endodontic therapy.
You asked the Plan to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray,
crown repair, and endodontic therapy. You say that you were not aware that this provider had opted out of
Medicare. The Plan says that these services were rendered by a Medicare opt out provider.
We decided that the Plan has to pay up to $1,500 for the problem focused limited oral evaluation, first
intraoral periapical x-ray, crown repair, and endodontic therapy.
The Plan follows Medicare rules. Medicare rules say that the health plan must provide you with a clear and
accurate description of the Original Medicare and/or mandatory/optional supplemental benefits offered under
your plan contract including applicable conditions and limitations and any other conditions associated with the
use or receipt of the benefits. The rules also say that Medicare plans must make reasonable and diligent efforts
to gather and forward information to the IRE.
The record shows that you received care from a Medicare opt out provider. The contract does not clearly state
that services rendered by a Medicare opt out provider would not be covered. You also have an annual
maximum benefit of $1,500 for dental services. You reasonably believed that these services would be covered
up to the $1,500 maximum benefit. Therefore, we decided that the Plan has to pay up to $1,500 for the problem
focused limited oral evaluation, first intraoral periapical x-ray, crown repair, and endodontic therapy.
We also decided that the Plan does not have to pay more than $1,500 for the problem focused limited
oral evaluation, first intraoral periapical x-ray, crown repair, and endodontic therapy.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan does not need to pay more
than $1,500 for dental services. Therefore, we decided that the Plan does not have to pay more than $1,500 for
the problem focused limited oral evaluation, first intraoral periapical x-ray, crown repair, and endodontic
therapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cleanings (D1110), fluoride (D1206), limited evaluation (D0140), bitewing x-rays (D0270, D0274), periapical x-ray (D0220), core buildup (D2950) and periodic oral evaluation (D0120) provided from February 26, 2020, to November 13, 2020.
You asked the Plan to pay for the dental services. You say that you chose this provider because you felt they provided the best possible dental care with reasonably priced services. The Plan denied your request. The Plan says out-of-network dental care is 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. The Plan only covers certain supplemental dental services when they are provided in-network.
Though the Plan offers a dental benefit in excess of Medicare coverage, items or services received from out-of-network providers are not covered under this benefit. In addition, some of the requested services are not among those covered under the benefit and are not eligible for coverage regardless of the network status of the provider. Therefore, we decided that the Plan does not have to pay for the cleanings (D1110), fluoride (D1206), limited evaluation (D0140), bitewing x-rays (D0270, D0274), periapical x-ray (D0220), core buildup (D2950) and periodic oral evaluation (D0120) provided from February 26, 2020, to November 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on August 21, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the physician services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.
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 the physician services provided on August 21, 2020 by an out of network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance transport provided to the enrollee.
You asked the Plan to pay for this claim. You say that this transport should be covered by the Plan. The Plan denied your request. The Plan says due to the enrollee's hospice status on the date of service, this claim must be submitted to Original Medicare first for review.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for ambulance transport provided to the enrollee.