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

We decided that the Plan does not have to waive the copayment for the diagnostic mammogram you had on July 7, 2020.
You asked the Plan to waive the copayment for the diagnostic mammogram. You say that Medicare provides a free mammogram annually. You said that you had breast cancer surgery in 2019. The Plan denied your request. The Plan says you were charged this copayment 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 x-ray services. You have been asked to pay a $35 copayment for the diagnostic mammogram. Records show that this mammogram was ordered due to your history of breast cancer. Your contract explicitly states that diagnostic mammograms are for individuals with a history of breast cancer and that the outpatient diagnostic test copayment will apply for diagnostic mammograms. 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 diagnostic mammogram you had on July 7, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe magnetic resonance imaging (MRI) you had on July 16, 2020You asked the Plan to waive the copayment forthe MRI. You say that you had to get two MRIs, so you don't think you should pay this copayment.The Plan denied your request. The Plan says this copayment was charged correctly.  The Plan says that because the allowed amount for the MRI ($217.58) is less than your copayment responsibility, you areresponsible for the full 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 $300 copayment for outpatient diagnostic tests. You have been asked to pay a $300 copayment for the MRI. The MRI falls within the outpatient diagnostic tests benefit category. This copayment applies regardless of the reason for the test. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe magnetic resonance imaging (MRI) you had on July 16, 2020
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (43999) provided January 2, 2020.
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The Plan denied your request. The Plan says this CPT code is not separately payable.
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 43999 is Other Procedures on the Stomach. We find that CPT code 43999 is not supported in the medical record. Specifically, this procedure is included in billed CPT code 43239. CPT code 43999 is not separately payable. Based on this information, we decided that Medicare rules for coverage of the surgical services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (43999) provided January 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on March 11, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. There was no documentation in the case file to support that the laboratory testing at issue in this appeal was not 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 provided on March 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and panoramic x-ray (D0330) provided on June 30, 2020.
You asked the Plan to pay for the comprehensive oral evaluation and panoramic x-ray. You say that you needed the x-ray and exam to see what work was necessary to fix your mouth. You say that you want the charge forgiven. The Plan denied your request. The Plan says the maximum dental benefit has been met.
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 also have a maximum benefit of one comprehensive oral evaluation and panoramic x-ray every 3 years. The Plan paid for a comprehensive oral evaluation and panoramic x-ray provided on January 30, 2020, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and panoramic x-ray (D0330) provided on June 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to payforthe anesthesia services coded 00402 and the injection services coded 64450 provided on November 13, 2019.You asked the Plan to pay forthe anesthesia services and the injection services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not supported by the documentation.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 codes 00402 and 64450 are not supported in the medical record. Specifically, te documentation submitted does not include an anesthesia note to indicate anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; reconstructive procedures on breast was performed; therefore, code 00402 cannot be verified. The documentation submitted did not include a block note to indicate injection(s), anesthetic agent(s) and/or steroid; other peripheralnerve or branch was performed; therefore, code 64450 cannot be verified. Based on this information, we decided that Medicare rules for coverage of the anesthesia services and the injection services have not been met.Therefore, we decided that the Plan does not have to pay forthe anesthesia services coded 00402 and the injection services coded 64450 provided on November 13, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe self-administered drugs Temazepam and Magnesium Hydroxide provided from February 11, 2020, through February 14, 2020.You asked the Plan to pay forthe self-administered drugs Temazepam and Magnesium Hydroxide. You say that the hospital wouldn't allow you to bring your medications from home. You say that the bill should be reimbursed.The Plan denied your request. The Plan says self-administered drugs are not covered under Part B.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pay forthe self-administered drugs Temazepam and Magnesium Hydroxide provided from February 11, 2020, through February 14, 2020.Benefits for the self-administered drugs Temazepam and Magnesium Hydroxidemay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal scaling and root planing (D4341) for all 4 quadrants provided on June 23, 2020. You asked the Plan to pay for the dental service. The Plan denied your request. The Plan says periodontal scaling and root planing 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. The Evidence of Coverage clearly states that any services not listed are not covered. Therefore, we decided that the Plan does not have to pay for the periodontal scaling and root planing (D4341) for all 4 quadrants provided on June 23, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay forrespiratory virus testing provided on May 20, 2020.You asked the Plan to pay forlab test. You say that you are appealing based on medical necessity, and this code is approved for payment when billed to Medicare.The Plan denied your request. The Plan says that the denial of payment for this service is correct, because this test is not covered by Medicare.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 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 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 specify whether the ordering physician was in-network or out-of-network with the Plan. The record does not include prior notice from the Plan that this testing would not be covered. This testing was not explicitly excluded from Medicare coverage for this date of service in the geographic location ofthe servicing laboratory. Without this information, we cannot determine whether the lab order made constituted plan-directed care. Therefore, the Plan has not shown that its decision to deny payment is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay forrespiratory virus testing provided on May 20, 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 ifthere 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional eight (8) physical therapy visits.You asked the Plan to pre-approve an additional eight (8) physical therapy visits. You say that the service should be approved as yourphysical therapist saidthat he felt the continued physical therapy is medically necessary. Yousay that you areimproving because of the therapy sessions and you feel that further visits would help to improve your right arm as it has limited mobility, significant pain and is impacting the quality of your life negatively. The Plan denied your request. The Plan says eight (8) additional physical therapy visits have been denied as not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.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 additional eight (8) physical therapy visits. Our reviewer says that skilled services are not necessary torestore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the requested additional therapy is not generally accepted as specific and effective therapy for your condition. You have had priortherapy for this condition and itdoes not appear that your functional deficits requirethe unique skills of a professional therapist to safely and effectively provide treatment orthat the services can be safely and effectively performed only by a therapist,or under the supervision of a therapist. You have been authorized additional sessions to review an independent exercise program. Thespecialized skill, knowledge and judgment of a qualified therapist is notrequired to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration.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 additional eight (8) physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional eight (8) physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the ophthalmic biometry by partial coherence interferometry with intraocular lens power calculation (92136) provided on February 19, 2020 by an out of network (OON) provider.
You asked the Plan to pay for ophthalmic biometry by partial coherence interferometry with intraocular lens power calculation. You say that the services rendered were medically necessary. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services rendered by an out-of-network provider.
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 has network providers available who can provide 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 ophthalmic biometry by partial coherence interferometry with intraocular lens power calculation (92136) provided on February 19, 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 RFA. You say that the requested RFA is medically necessary. The Plan
denied your request. The Plan says the enrollee does not meet criteria for RFA.
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 RFA. Our reviewer says that the
enrollee does not meet criteria for RFA. Our physician reviewer found the enrollee has chronic low back pain
on the Right side without significant radiation. The enrollee has had only one set of diagnostic facet blocks.
The request is for RFA of the lumbar facets. The LCD requires 2 sets of diagnostic blocks, not just one.
Therefore, at this point, the request is deemed not medically reasonable or 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 RFA have not been met. Therefore, we decided that the Plan does not have to
pre-approve radiofrequency ablation (RFA)
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT scan chest and CT scan of abdomen and pelvis to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve these CT scans. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services can be provided by a network provider.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve CT scan chest and CT scan of abdomen and pelvis to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician's services provided on June 17, 2020.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says thePlan has to pay for care from out-of-network providers only incases involving emergencies, out of area urgent care and pre-approved 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 Plandid not pre-approve the physician's services.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 the physician's services provided on June 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora specialist visit provided on July 6, 2020.You asked the Plan to waive the copayment fora specialist visit. You say that the provider could not place the catheter properly and it caused you pain and an infection.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 $10 copayment for specialist services. You have been asked to pay a $10 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 fora specialist visit provided on July 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oximeter device (E0445).
You asked the Plan to pre-approve an oximeter device. You say that this is medically necessary. The Plan
denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that oximeters and replacement probes will be denied
as non-covered because they are monitoring devices that provide information to the treating practitioner to
assist in managing the beneficiary's treatment.
We looked at the file and Medicare rules. The requested item is not covered by Medicare or the Plan. Based on
this information, we decided that Medicare rules for coverage of an oximeter device have not been met.
Therefore, we decided that the Plan does not have to pre-approve an oximeter device (E0445).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forperiodontal scaling and root planing provided.

You asked the Plan to pay for the periodontal scaling and root planing. You say that having good dental health benefits your overall health. You say that the services should be approved and paid.The Plan denied your request. The Plan says the frequency limitation has been exceeded

.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 also have a maximum benefit of periodontal scaling and root planing once per quadrant every three years. The Plan paid for scaling and root planing in the right quadrants on and scaling and root planing in the left quadrants, which exhausted your benefit.Therefore, we decided that the Plan does not have to pay for periodontal scaling and root planing provided.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for CT scans provided on July 20, 2020.
You asked the Plan to waive the copayments for CT scans. You say that you disagree with the charges because you only received one CT scan. 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 $275 copayment for each CT scan. The medical records show that you received two CT scans on July 20, 2020. Therefore, you are responsible to pay a $275 copayment per each CT scan. The total amount you owe is: $275 (copayment) x 2 (CT scans) = $550. You have been asked to pay the total copayment amount of $550 for CT scans. CT scans fall within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for CT scans provided on July 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for observation care provided from January 24, 2020, through January 25, 2020.You asked the Plan to pay for the observation care.The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.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. ThePlan did not pre-approve the servicesat 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 observation care provided from January 24, 2020, through January 25, 2020.