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

We decided that the Plan does not have to waive the coinsurance for the outpatient clinic visit.

You asked the Plan to waive the coinsurance for the outpatient clinic visit. You say that you had a claims adjustment earlier in the year which resulted in meeting your out-of-pocket maximum for the year. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 in-network Medicare-covered surgery or other services at an outpatient hospital or ambulatory surgical center, including but not limited to hospital or other facility charges and physician or surgical charges.

You have been asked to pay $23.74 which is 20% of the allowed amount for the outpatient clinic visit. The allowed amount is $118.68. ($118.68 x 20% = $23.74). The outpatient clinic visit falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The record shows at the time this claim was processed, $1,065.28 had been applied towards your $1,100 out-of-pocket maximum amount.

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 the outpatient clinic visit.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for continuous intraoperative neurophysiology monitoring (G0453).

You asked the Plan to pay for the continuous intraoperative neurophysiology monitoring. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code G0453 was not reported with a valid parent code.

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, we have confirmed that code the continuous intraoperative neurophysiology monitoring is a Type 1 add-on code. This means that there are specific primary procedures that this code can be billed with. CPT code G0453 has not been billed with an appropriate primary code. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for continuous intraoperative neurophysiology monitoring (G0453).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit.

You asked the Plan to waive the copayment for the emergency room visit. You say that you should not have been discharged so soon and should not have to pay the copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $100 copayment for Medicare-covered emergency room visit.

You have been asked to pay a $100 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. The record shows you were treated in the emergency room. 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 emergency room visit.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a drug test.

You asked the Plan to pay for the drug test. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.

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 drug test. 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 a drug test.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services provided by an out of network (OON) provider.

You asked the Plan to pay for outpatient hospital services. You say that you were trying to protect yourself. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that these services could have been provided in-network.

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 outpatient hospital services provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share amount for the bitewing x-rays, 4 radiographic images, (D0274).

You asked the Plan to waive the cost share amount for the dental service. You say that you went to the dentist for a routine exam. You say that you were left with a balance of $19 instead of the $10 that you were expecting. The Plan denied your request. The Plan says 2 bitewing x-rays (D0272) are covered per calendar year. The Plan says that 4 bitewing x-rays (D0274) is not covered. The Plan says that the alternate benefit of 2 bitewing x-rays was applied. The Plan also says that if the alternate benefit was not applied, you would be responsible for the full cost.

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 set of 4 bitewing x-rays is not among those covered under this benefit. The record shows that the Plan applied the alternative benefit of 2 bitewing x-rays, which is a covered service. You are responsible for the difference between the 2 services. If an alternate benefit was not applied, the 4 bitewing x-rays would have been denied, and you would have been responsible for the full amount, since the plan only covers 2 bitewing x-rays per calendar year. Therefore, we decided that the Plan does not have to waive the cost share amount for the bitewing x-rays, 4 radiographic images, (D0274).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you additionally for dental services.

You asked the Plan to reimburse you additionally for the dental services. You say that prophylaxis is covered twice a year. The Plan denied your request. The Plan says you have received the maximum dental allowance.

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 reimbursement exceeds your allowance for the year. Therefore, we decided that the Plan does not have to reimburse you additionally for dental services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for parenteral nutrition solution (B4185).

You asked the Plan to pay for parenteral nutrition solution. You say that this item is compounded with other items. The Plan denied your request. The Plan says there is not a delivery ticket for this item.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.

The record does not contain a valid proof of delivery for the supplies provided in this case. The item at issue is not listed on the submitted delivery invoice. 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 pay for parenteral nutrition solution (B4185).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services.

You asked the Plan to pay for the psychotherapy services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.

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 psychotherapy 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 psychotherapy services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the intravenous (IV) tubing and infection control supplies.

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 procedure codes S1015 and S8301 are not separately payable.

The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes.

We looked at the file and Medicare rules. Billed procedure codes S1015 and S8301 have a status indicator of I and are not valid for Medicare purposes. Therefore, we decided that the Plan does not have to pay for the intravenous (IV) tubing and infection control supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (PCD) and the segmental gradient pressure pneumatic appliance used with the PCD.

You asked the Plan to pay for the PCD and segmental gradient pressure pneumatic appliance. You say that the items in dispute were ordered by a physician and were medically necessary. You say that the items in dispute were decided to be used by the physician at the time of surgery, which made requesting an authorization prior to the service impossible. The Plan denied your request. The Plan says the pneumatic compression device and supplies are not covered by Medicare to prevent deep vein thrombosis during and/or following surgery, at home, or in any setting.

The Plan must follow Medicare rules. Medicare rules say that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. Items that are used for a preventative service or function are excluded from coverage under the Medicare DME benefit. 

We looked at the file and Medicare rules. The records show that the PCD and the segmental gradient pressure pneumatic appliance used with the PCD were used to prevent the enrollee from developing deep vein thrombosis or blood clots, as well as pulmonary embolisms. This means that the items in dispute were used for a preventative service or function. Based on this information, we decided that Medicare rules for coverage of the PCD and segmental gradient pressure pneumatic appliance have not been met. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (PCD) and the segmental gradient pressure pneumatic appliance used with the PCD.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services.

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 procedure code 10061 is not supported.

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 10061 is incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or multiple.

We find that CPT code 10061 is not supported in the medical record. Specifically, the operative report does not contain documentation of a complicated or multiple incision and drainage of an abscess. 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 surgical services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services.

You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says this provider has opted out of Medicare.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. 

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the dental services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services provided by an out of network (OON) provider.

You asked the Plan to pay for radiology services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that these services could have been provided in-network.

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 radiology services provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the implants (D6010) for teeth # 22 and 27, the abutment supported removable denture for edentulous arch (D6111), and the cone beam CT image capture with field of view of both jaws (D0383).

You asked the Plan to pay for the implants, the lower denture, and the cone beam CT. You say that the services should be covered. The Plan denied your request. The Plan says implants are not listed and therefore are not a covered service. The Plan says that abutment supported removable denture for edentulous arch is not listed as a covered service. The Plan says that cone beam CT image capture with field of view of both jaws is not listed as a covered service either.

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 implants (D6010) for teeth # 22 and 27, the abutment supported removable denture for edentulous arch (D6111), and the cone beam CT image capture with field of view of both jaws (D0383).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the specialist office visits or the EEG.

You asked the Plan to waive the copayments for the specialist office visits and the EEG. You say that you only pay copayments for out-of-network providers. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $50 copayment for in-network physician specialist services and 20% coinsurance up to a copayment maximum of $250 for in-network diagnostic procedures and tests.

You have been asked to pay a $50 copayment for each of the specialist office visits. ($50 x 8 visits = $400). You have been asked to pay $64.77 which is 20% of the allowed amount for the EEG. The allowed amount is $323.83. ($323.83 x 20% = $64.77). The specialist office visits fall within the "Physician/Practitioner services, including doctor's office visits" benefit category. The EEG 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 copayments for the specialist office visits and the EEG.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the surgical removal of residual tooth roots (D7250) for
tooth #31.

You asked the Plan to pre-approve the dental service. You say that the enrollee has severe periodontal disease.
You say that the enrollee has excessive decay and loss of tooth structure where the teeth are no longer
restorable. You say that the teeth need to be extracted in order to treat and prevent further infection. The Plan
denied your request. The Plan says the provided documentation does not support the request for the surgical
removal of residual tooth roots for tooth #31.

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 covers the dental
service when the services are medically necessary and reasonable.

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 dental service. Our reviewer says
that the surgical removal of residual tooth roots for tooth #31 is not medically necessary. Our physician
reviewer found the crown of the tooth is intact. The reviewer found that in this instance, due to the tipping of
the tooth, the extraction may be more difficult however it would not be properly coded as removal of residual
roots as the tooth is essentially intact at the outset. Therefore, the reviewer found there is no necessity for the
requested code.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of the dental service have not been met. Therefore, we decided that the Plan does
not have to pre-approve the surgical removal of residual tooth roots (D7250) for tooth #31.
Appeal type: Imaging
Decision: Partially Favorable

We decided that the Plan has to reduce the cost share for the CT scan. We decided that the Plan does not have to waive the cost share for the CT scan and the lumbar injection.

You asked the Plan to waive the cost share for the CT scan. You say that you do not feel that you have to pay a $315 copayment. The Plan says that the claim was reprocessed and you have been charged the correct cost sharing amount.

We decided that the Plan has to reduce the cost share for the CT scan.

The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles, and coinsurance). The records show that the allowed amount for the CT scan is $231.32. ($231.32 x 20% = $46.26).

The Plan says that you must pay $231.32 for the CT scan. Based on the plan contract, however, you cannot be asked to pay more than $46.26 for the CT scan. Therefore, we decided that the Plan has to reduce the coinsurance for the CT scan from $231.32 to $46.26.

We also decided that the Plan does not have to waive the cost share for the CT scan and the lumbar injection.

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 the CT scan and an $18.68 copayment for the lumbar injection, which is less than the standard copayment amount. Therefore, we decided that the Plan does not have to waive the cost share for the CT scan and the lumbar injection.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the durable medical equipment (A4556, A4456, A4630, A4557).

You asked the Plan to pay an additional amount for the durable medical equipment. You say that you would like these claims reprocessed. The Plan denied your request. The Plan says the claim has processed correctly.

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 $750 deductible for durable medical equipment.

The item or service you asked the Plan to pay an additional amount for falls within the benefit category durable medical equipment. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible for durable medical equipment. The allowed amount applied to the enrollee's deductible and therefore, additional payment is not due from the Plan. This cost sharing is a contractual obligation that had not been met at the time the durable medical equipment was received.
Therefore, we decided that the Plan does not have to pay an additional amount for the durable medical equipment (A4556, A4456, A4630, A4557).