Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided from January 30, 2019, to
October 14, 2019, by an OON provider.
You asked the Plan to pay for the dental services. You say that you were told that this provider was in-network.
The Plan denied your request. The Plan says these services were rendered by a non-participating provider. The
Plan also says that these services are only covered when they are rendered by a participating provider.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
covered when they are received OON. The record shows that you did not contact the Plan until August 6, 2019,
after services had been rendered. Therefore, we decided that the Plan does not have to pay for the dental
services provided from January 30, 2019, to October 14, 2019, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation, panoramic x-ray, and
extraction of coronal remnants provided on August 12, 2020.
You asked the Plan to pay for the comprehensive oral evaluation, panoramic x-ray, and extraction. You say that
you have seen this provider for many years, and were not made aware of any changes to your plan. The Plan
denied your request. The Plan says this provider opted out of Medicare effective September 9, 2015, to
September 9, 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
comprehensive oral evaluation, panoramic x-ray, and extraction of coronal remnants provided on August 12,
2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services.

You asked the Plan to pay for anesthesia for diagnostic or therapeutic nerve blocks and injections (when block
or injection is performed by a different physician or other qualified health care professional); prone position
(01992). You say that the anesthesia services were medically necessary. The Plan denied your request. The
Plan says anesthesia for the enrollee's diagnosis is not considered medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.

We looked at the file and Medicare rules. Use of moderate sedation and Monitored Anesthesia Care (MAC) is
usually unnecessary. Documentation must clearly establish the need for such sedation in the specific patient.
There is no documentation of a qualifying indication for general anesthesia in the records. Based on this
information, we decided that Medicare rules for coverage of anesthesia for diagnostic or therapeutic nerve
blocks and injections (when block or injection is performed by a different physician or other qualified health
care professional); prone position have not been met. Therefore, we decided that the Plan does not have to pay
for the anesthesia services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system (E2300).
You asked the Plan to pre-approve a power seat elevation system. You say that the item which remains in
dispute is medically necessary. The Plan denied your request. The Plan says a power seat elevation is noncovered
because it is not primarily medical in nature.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose. Medicare rules say that a power seat elevation feature (E2300) is non-covered because it is
not primarily medical in nature.
Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system (E2300).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency room services (99285) provided July 15, 2020.
You asked the Plan to pay for the emergency room services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim was not filed correctly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 99285 is not supported in the medical record. Specifically, the diagnosis code listed was not a valid primary diagnosis code. Based on this information, we decided that Medicare rules for coverage of the emergency room services have not been met. Therefore, we decided that the Plan does not have to pay for emergency room services (99285) provided July 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (88104, 88305, 88312, 88361) provided on August 6, 2020.
You asked the Plan to pay for laboratory services. You say that these tests were ordered by the physician and should be covered. The Plan denied your request. The Plan says these tests were not billed with the required modifier.
The Plan must follow Medicare rules. Medicare rules say that only the hospital may bill for the TC of a physician pathology service provided to an inpatient or outpatient. We looked at the file and Medicare rules. The record shows that the services at issue were provided to a hospital outpatient. Only the hospital can bill for the technical component of these services; therefore, these services must be billed with a modifier to indicate the professional component. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (88104, 88305, 88312, 88361) provided on August 6, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy and lab work (88305, 45380).

You asked the Plan to waive the copayment for the diagnostic colonoscopy and lab work. You say that you were not charged for these services by your previous insurance carrier. The Plan denied your request. The Plan says the copayments were applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $270 copayment for Medicare covered outpatient surgery in an ambulatory surgical center or hospital outpatient facility. Additionally, the Plan contract says that enrollees will be expected to pay a $20 copayment per visit for laboratory tests, non-radiological diagnostic tests, flat film X-rays, and ultrasounds.

You have been asked to pay a $270 copayment for the colonoscopy. In this case, the colonoscopy was performed due to a medical history of colonic polyps and is therefore considered diagnostic. The Plan contract states that the outpatient surgery copayment applies to a diagnostic colonoscopy. Additionally, you were asked to pay a $20 copayment for lab work. This 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 the diagnostic colonoscopy and lab work (88305, 45380).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the anoscopy.

You asked the Plan to waive the coinsurance for the anoscopy. You say that this procedure was not surgical so you should not have a copayment. The Plan denied your request. The Plan says you were charged the 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 $250 copayment for Outpatient Surgery.

You have been asked to pay a $114.96 copayment for the anoscopy. This copayment is less because the allowed amount for the procedure is less than your copayment. The anoscopy falls within the Outpatient Surgery benefit category. Medicare considers Anoscopy; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) 46600 to be a surgical procedure. 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 anoscopy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient office visits (99203, 99214).

You asked the Plan to waive the copayment for the office visits. You say that there was no copay. You do not agree with the decision for your share of the cost. The Plan denied your request. The Plan says the claims were processed and the correct copayment was 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 $30 copayment for each visit in a contracted urgent care center or walk-in clinic for Urgently needed service.

You have been asked to pay $60 ($30 + $30) for the office visits. The office visits fall within the Urgently needed service 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 outpatient office visits (99203, 99214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2750) for tooth #29.
You asked the Plan to pre-approve the crown. You say that the enrollee has an abscess under a crown that they need taken care of. The Plan denied your request. The Plan says there is no evidence of decay or missing crown to support the need for replacement.
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 crown 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 crown. Our reviewer says that the crown for tooth #29 is not medically necessary to replace. Our physician reviewer found the documents show the presence of a periapical radiolucency associated with tooth #29. A root canal and post have been approved to treat this. Our reviewer found that in most cases, a root canal can be performed by access through a crown. At this time it appears that the crown is adequate. Our physician reviewer also found that if the crown becomes non-serviceable after the root canal, a replacement crown can be considered for coverage. 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 crown have not been met. Therefore, we decided that the Plan does not have to pre-approve a crown (D2750) for tooth #29.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the ophthalmological services(92002) services provided on September 16, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the ophthalmological services. You say that a provider performing services in a nursing home facility is not responsible to obtain authorization. Their visit should fall under the authorization that the nursing home has for the stay. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 ophthalmological services(92002) services provided on September 16, 2020 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 services provided on August 13, 2018.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was not submitted timely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the services was not filed until September 25, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the services provided on August 13, 2018.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services rendered from April 21, 2020 to April 30, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the physical therapy codes were not billed correctly.

The Plan must follow Medicare rules. Medicare rules say that therapy codes must be billed with a GO, GN, or GP modifier. 

We looked at the file and Medicare rules. The file shows that some of the therapy claims were not billed with one of the required therapy modifiers. 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 skilled nursing facility (SNF) services rendered from April 21, 2020 to April 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe knee orthosis single upright, prefabricated, off-the-shelf (L1851)  suspension sleeve (L2397) provided August 24, 2020.You asked the Plan to pay forthe orthosis. You say that medical necessity has been met and telehealth is CMS approved.The Plandenied your request. The Plan says the services are not necessary for treatment of the patient's condition.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked ourphysician 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 orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case.
Our physician reviewer found the documentation in the case file does not support that the requested knee orthoses and sleeves were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is insufficient documentation of an examination of the enrollee, and there is insufficient credible objective documentation of joint laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered.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 orthosis have not been met.Therefore, we decided that the Plan does not have to payforthe knee orthosis single upright, prefabricated, off-the-shelf (L1851)  suspension sleeve (L2397) provided August 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient services provided from September 26, 2020, to September 29, 2020.

You asked the Plan to waive the copayment for the inpatient services. You say that you cannot afford the copayments. The Plan denied your request. The Plan says you were charged the copayments 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 $393 copayment each day for days 1-5 for Inpatient Hospital Care. 

You have been asked to pay a $393 copayment each day for 3 days of inpatient services. The inpatient services fall within the Inpatient Hospital Care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient services provided from September 26, 2020, to September 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extraction.

You asked the Plan to pay for the dental service. You say that you were advised by a plan representative that the provider was in network and that simple extractions would be covered as long as they did not have to cut to make a surgical cut to remove the tooth. You say that your tooth was removed without having a surgical cut. You also say that you believe that this service would have been covered if it had been done by your general dentist. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that dental services that you receive out of network are not covered. The Plan also says that surgical extraction 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, dental services performed out of network are not covered. Additionally, the surgical extraction is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the surgical extraction.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a neuromuscular stimulator (E0745) provided on May 15, 2020.

You asked the Plan to pay for a neuromuscular stimulator. You say that the requested item was medically necessary. The Plan denied your request. The Plan says rules for payment have not been met.

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 pay for a neuromuscular stimulator. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the documentation in the case file does not support that the requested neuromuscular stimulator was medically reasonable and necessary for the enrollee in this case. A physical examination of the ankles and feet would reasonably be required to adequately assess whether the coverage criteria were met. The documentation does not support that the neuromuscular stimulator was medically reasonable and necessary in this case, as there is insufficient documentation of a credible evaluation and physical examination of the ankles and feet. 

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 neuromuscular stimulator have not been met. Therefore, we decided that the Plan does not have to pay for a neuromuscular stimulator (E0745) provided on May 15, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the duplex scan (93880).

You asked the Plan to pay for the duplex scan. The Plan denied your request. The Plan says only one unit is
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.

We find that an additional unit of CPT code 93880 is not supported in the medical record. Specifically, the
records show that only one unit of code 93880 was provided on the date of service in question. The Plan has
processed and paid for one unit of code 93880. Based on this information, we decided that Medicare rules for
coverage of the duplex scan have not been met. Therefore, we decided that the Plan does not have to pay for
the duplex scan (93880).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for lab services provided by a participating provider on May 18, 2020.You asked the Plan to waive the deductible for lab services. You say that you do not believe that you should owe anything. 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 $400 deductible for outpatient diagnostic tests/laboratory. The item or service you asked the Planto waive the deductible for falls within the benefit category outpatient diagnostic tests/laboratory. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $400 deductible for outpatient diagnostic tests/laboratory. This cost sharing is a contractual obligation that had not been met at the time lab services was received on May 18, 2020. The total amount you are being asked to pay is $198.74. Therefore, we decided that the Plan does not have to waive the deductible for lab services provided by a participating provider on May 18, 2020.