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

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on December 23, 2020.

You asked the Plan to pay for the office visit. You say that you attached medical records for review and the claim should be reprocessed. The Plan denied your request. The Plan says prior authorization was required but 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 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 office visit provided by an out-of-network provider on December 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit rendered on March 9, 2021.

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 services are not covered.

The Plan must follow Medicare rules. Medicare rules say that exams for a non-medical purpose are not covered. 

We looked at the file and Medicare rules. The file shows that the office visit at issue was not performed for the diagnosis or treatment of an illness or injury. 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 office visit rendered on March 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a cystourethroscopy provided on December 11, 2020.

You asked the Plan to waive the coinsurance for a cystourethroscopy. You say that the enrollee cannot afford the charges. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay 20% coinsurance for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. 

The enrollee received a cystourethroscopy on December 11, 2020. The total allowed amount is $1,534.64 and 20% of that is $306.93.

The enrollee has been asked to pay the total coinsurance amount of $306.93 for a cystourethroscopy. A cystourethroscopy falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for a cystourethroscopy provided on December 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray, each additional intraoral periapical x-ray, panoramic x-ray, and 2D oral/facial photographic image provided on January 13, 2021.

You asked the Plan to pay for the intraoral periapical x-rays, panoramic x-ray, and 2D oral/facial photographic image. You say that you would like these services to be covered. The Plan denied your request. The Plan says these services are not covered. The Plan also says that you did not contact the Plan prior to the date of service to verify benefits.

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 first intraoral periapical x-ray, each additional intraoral periapical x-ray, panoramic x-ray, and 2D oral/facial photographic image provided on January 13, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scans coded 72125, 74176, 71250 provided on August 26, 2020.

You asked the Plan to pay for the computed tomography (CT) scans. 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 72125, 74176, 71250 are not supported in the medical record. Specifically, the documentation provided to support the services rendered were for a different enrollee. This means documentation for the correct enrollee was not received by the provider. Based on this information, we decided that Medicare rules for coverage of the computed tomography (CT) scans have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scans coded 72125, 74176, 71250 provided on August 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, prophylaxis, and resin-based composite provided on February 3, 2021 by an OON provider.

You asked the Plan to pay for the periodic oral evaluation, prophylaxis, and resin-based composite. You say that you were advised by an independent agent and the Plan that this provider was in-network. You also say that you would like these services to be covered. The Plan denied your request. The Plan says these services were rendered by a dentist who does not participate with the Plan. The Plan also says that there was no record of you being told by the Plan that this provider was in-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, the requested items or services are not covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, prophylaxis, and resin-based composite provided on February 3, 2021 by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on December 14, 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 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 December 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the flu vaccine rendered on November 12, 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 procedure code 90688 is not covered.

The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are statutorily excluded. 

We looked at the file and Medicare rules. Billed procedure code 90688 (flu vaccine) has a status indicator of X and is excluded from Medicare payment. Therefore, we decided that the Plan does not have to pay for the flu vaccine rendered on November 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a core buildup (D2950) and a crown (D2740) on tooth #2, provided November 23, 2020.

You asked the Plan to pay for a core buildup and a crown on tooth #2. You say that the distal lingual cusp had completely fractured but there was enough tooth structure remaining to restore the tooth. The Plan denied your request. The Plan says the treatment may not last the time frame required before it can be replaced.

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 a core buildup and a crown on tooth #2 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 pay for a core buildup and a crown on tooth #2. Our reviewer says that criteria for a core buildup and crown are not met in this case. Our physician reviewer found although there were only four-millimeter pockets noted, the total amount of missing bone cannot be evaluated. Periodontal involvement can severely compromise the long-term stability of a tooth and impact upon the decision to place a crown. Given that the radiograph was not readable it is impossible to determine if the tooth and the finished crown would have a reasonable long term prognosis. 

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 a core buildup and a crown on tooth #2 have not been met. Therefore, we decided that the Plan does not have to pay for a core buildup (D2950) and a crown (D2740) on tooth #2, provided November 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular stimulator provided on September 30, 2020.

You asked the Plan to pay for the neuromuscular stimulator, electronic shock unit (E0745). You say that the neuromuscular stimulator is medically necessary. The Plan denied your request. The Plan says the documentation submitted did not include an itemized shipping/billing invoice to indicate the specific supplies or proof of delivery for the billed date of service.

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. There is no invoice or proof of delivery document in the file. 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 the neuromuscular stimulator provided on September 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for frames (V2020), and lenses (V2781, V2311, V2783) received on December 3, 2020.

You asked the Plan to pay an additional amount for frames, and lenses. You say that you want the Plan to pay an additional amount for the items. The Plan denied your request. The Plan says the benefits were applied correctly. The benefit allowance of $150 was applied to the purchase leaving a member responsibility of $629.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services up to a $150 allowance, then you are responsible for paying the difference.

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of frames, and lenses have not been met. Specifically, the record shows that you had exhausted your eyewear benefit maximum of $150 and are therefore, responsible for paying the remainder of $629. Therefore, we decided that the Plan does not have to pay an additional amount for frames (V2020), and lenses (V2781, V2311, V2783) received on December 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment testing provided on December 3, 2020.

You asked the Plan to pay for the cardiovascular risk assessment testing. 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 payable.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. Cardiovascular risk assessment panels are only covered for certain indications. 

Review of the file shows that the plan uses Local Coverage Determination (LCD) L36139, L36129, and L36523 to support their denial. However, LCD L36139, L36129, and L36523 are not valid for the provider's billing state of Texas. Therefore, we are unable to use LCD L36139, L36129, and L36523 to substantiate our decision. 

While cardiovascular risk assessment panels are covered for certain indications, the file does not support that the enrollee met criteria for these services. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment testing provided on December 3, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for revascularization (CPT 37233) services provided to the enrollee on November 5, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the records do not support the services 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. 

In this case, the CPT Code Manual definition of code 37233 is "Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral."

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found CPT code 37233 is an add on code - coding for atherectomy of an additional tibial artery. It is used with code 37229 (atherectomy of initial tibial artery). CPT code 37229 has been billed and apparently covered. The documentation demonstrates that a total of two tibial arteries underwent atherectomy. This would be coded as CPT 37229 (not at issue in this case) and CPT 37233 (one instance). The documentation supports only a single instance of CPT 37233 as only one additional tibial artery underwent atherectomy.

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 services have not been met. Therefore, we decided that the Plan does not have to pay for revascularization (CPT 37233) services provided to the enrollee on November 5, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic exercises (97110) provided on February 3, 2020.

You asked the Plan to pay for the therapeutic exercises. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says there is a more appropriate CPT code for the services 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. 

In this case, the CPT Code Manual definition of code 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. 

We find that CPT code 97110 is not supported in the record. Specifically, the record indicates that these services were provided in a home health setting. There is a more appropriate CPT code to bill for the rendered services. Based on this information, we decided that Medicare rules for coverage of the therapeutic exercises have not been met. Therefore, we decided that the Plan does not have to pay for therapeutic exercises (97110) provided on February 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the simple extraction (D7140), surgical extraction (D7210), and two removals of residual tooth roots (D7250 x2) provided on January 13, 2021.

You asked the Plan to pay for the extractions and removals of residual tooth roots. You say that you were not aware that the Dental Rider would not take effect until the following month when you called to activate it. The Plan denied your request. The Plan says these services are not covered benefits under your dental plan. The Plan also says that you were advised during your call to the Plan that the Dental Rider would not be effective until February 1, 2021.

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 simple extraction (D7140), surgical extraction (D7210), and two removals of residual tooth roots (D7250 x2) provided on January 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on February 10, 2021.

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 laboratory services rendered on February 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapy, radiology, dental, and physician services provided on October 29, 2020 to November 20, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the therapy, radiology, dental, and physician services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit when provided by an OON 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 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 therapy, radiology, dental, and physician services provided on October 29, 2020 to November 20, 2020 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 limited oral evaluation (D0140), the initial periapical x-ray (D0220), and the additional periapical x-ray (D0230) provided on January 12, 2021.

You asked the Plan to pay for the dental services. You say that you developed a painful abscess. You say that the services that were performed were necessary to diagnose your pain. You also say that you were prescribed a medication which gave you swift relief. The Plan denied your request. The Plan says limited oral evaluation is not listed as a covered service. The Plan says that periapical x-rays are not listed as covered services 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 limited oral evaluation (D0140), the initial periapical x-ray (D0220), and the additional periapical x-ray (D0230) provided on January 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for cataract surgery provided on May 28, 2020 by an out of network (OON) provider.

You asked the Plan to pay for cataract surgery. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by a participating provider. The Plan says that there are in-network providers available for these services.

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 cataract surgery provided on May 28, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on October 14, 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 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 14, 2020.