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

We decided that the Plan does not have to waive the copayment for the laboratory services rendered on February 23, 2021.

You asked the Plan to waive the copayment for these services. You say that the doctor did labs when there was no need for them to be done. The Plan denied your request. The Plan says the copayment was 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 $10 copayment for x-rays, laboratory, and other diagnostic tests.

Review of the file shows that you received laboratory services on February 23, 2021. You have been asked to pay a $10 copayment for these services. These services fall within the x-rays, laboratory, and other diagnostic tests benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the laboratory services rendered on February 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the porcelain/ceramic crown (D2740) received December 21, 2020.

You asked the Plan to pay for the porcelain/ceramic crown. You say that you were told by your provider that the service would be covered with 50% coinsurance. The Plan denied your request. The Plan says the requested service is not covered under your 2020 supplemental benefit.

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 porcelain/ceramic crown (D2740) received December 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection of collagenase provided on November 30, 2020.
You asked the Plan to waive the coinsurance for injection. You say that this charge is extremely high for this drug, and your doctor does not think it should be that much. The Plan denied your request. The Plan says the coinsurance amount you are being charged is correct. The Plan also says that they have waived the specialist visit copayment, so you are only being charged for the Medicare Part B prescription drug coinsurance.
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 an injection of Medicare Part B prescription drugs. The allowed amount of the claim is $4,715.10, resulting in a coinsurance obligation of $943.02. You have been asked to pay 20% coinsurance for injection. Injection falls within the Medicare Part B Prescription Drugs 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 coinsurance for an injection of collagenase provided on November 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and electrocardiogram provided on February 2, 2021 by an out of network provider.

You asked the Plan to pay for the office visit and electrocardiogram. You say that the facility and physician are contracted providers. The Plan denied your request. The Plan says you did not request prior authorization for the non-urgent 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 services at issue in this appeal. The Plan did not pre-approve the service at 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 the office visit and electrocardiogram provided on February 2, 2021 by an out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for the pontic. We decided that the Plan does not have to pay for the
implant retainer crowns.

You asked the Plan to pay for the dental services. You say that you were given a code the dentist was going to
bill. You say that you were advised it would be covered at 50% in or out of network. You say that you were
never told that the dentist had to be participating with Medicare. You also say that your booklet does not say
that the dentist has to be participating with Medicare either. The Plan denied your request. The Plan says the
provider in this case has opted out of Medicare. The Plan also says that payment cannot be made to a provider
who has opted out of Medicare.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

We decided that the Plan has to pay for the pontic.

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of the pontic has been met. The record does not show that you signed a contract with the provider to
acknowledge they were fee for service. Additionally, the Evidence of Coverage clearly states that bridges are a
covered service. Therefore, we decided that the Plan has to pay for the pontic.

We also decided that the Plan does not have to pay for the implant retainer crowns.

Though the Plan offers a dental benefit in excess of Medicare coverage, implant retainer crowns are not among
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the implant
retainer crowns.

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular genetic screening testing provided to the enrollee
on December 16, 2020.

You asked the Plan to pay for the services. You say that this test should be added to payer policies as soon as
possible. The Plan denied your request. The Plan says Medicare says screening services with no relation to a
medical diagnosis of disease for the health of the patient are not a benefit.

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 the services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the enrollee was evaluated in the emergency department for 2-3 days of weakness. The enrollee reported
no respiratory symptoms. The physical examination noted no respiratory abnormalities. While screening for
CoViD-19 during the pandemic may have been reasonable, the deployment of an entire respiratory screening
panel was not medically necessary or reasonable.

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 molecular genetic screening testing provided to the enrollee on December 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ostomy belt provided on November 3, 2020.
You asked the Plan to pay for the services provided. You say that the item is covered by Medicare. The Plan denied your request. The Plan says the item was purchased from a provider who is not certified with Medicare.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that you receive your care from a provider who is eligible to provider services under Original Medicare. The provider in this case is not a provider with the Plan or Medicare. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at 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 the ostomy belt provided on November 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on November 3, 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 billed are not 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. 

We find that the laboratory services are not supported in the medical record. Specifically, laboratory asssays of two or more genes in an enrollee in parallel are non-covered. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on November 3, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit provided on November 16, 2020 by an OON provider.
You asked the Plan to pay for the domiciliary or rest home visit. You say that the rendering physician provider depends upon the hospital staff to verify eligibility and to obtain the proper authorization from the enrollee's insurance company. The Plan denied your request. The Plan says this service was rendered by a non-participating provider. The Plan also says that prior authorization was not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 domiciliary or rest home visit provided on November 16, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services coded 99152 provided on June 4, 2020.

You asked the Plan to pay for the moderate sedation 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. 

In this case, the CPT Code Manual definition of code 99152 is moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older. 

We find that CPT code 99152 is not supported in the medical record. Specifically, the documentation submitted did not indicate the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; therefore, the billed service cannot be verified. Based on this information, we decided that Medicare rules for coverage of the moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services coded 99152 provided on June 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the compression stockings identified with code A6530 that were issued on December 4, 2020.

You asked the Plan to pay for the compression stockings. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the items received are not a covered benefit.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are noncovered because they do not meet the statutory definition of a surgical dressing. 

Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. While the Plan does have a benefit in which these items are covered, they are only covered once every six months. The documentation shows that the enrollee previously received compression stockings on August 19, 2020. Six months had not passed since the enrollee previously received compression stockings. Therefore, we decided that the Plan does not have to pay for the compression stockings identified with code A6530 that were issued on December 4, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services provided from
November 10, 2020, through November 11, 2020.
You asked the Plan to pay for the outpatient hospital services. The Plan denied your request. The Plan says no authorization has been 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 services at 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 outpatient hospital services provided from November 10, 2020, through November 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for dermatology services provided on November 16, 2020, by an
OON provider.
You asked the Plan to pay for dermatology 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 by the member's
primary care physician. 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 dermatology services provided on November 16,
2020, by an OON provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient consultation for a new or established patient services coded 99254 provided on November 1, 2020.
You asked the Plan to pay for the inpatient consultation for a new or established patient 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 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 99254 is inpatient consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 80 minutes are spent at the bedside and on the patient's hospital floor or unit. We find that CPT code 99254 is not supported in the medical record. Specifically, this code has a status code of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the inpatient consultation for a new or established patient services have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient consultation for a new or established patient services coded 99254 provided on November 1, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the debridement services (11042) provided
from August 31, 2020, through October 26, 2020.
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to
the services provided.
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 $325
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including
but not limited to hospital or other facility charges and physician or surgical charges.
You have been asked to pay $975 ($325 copayment x 3 procedures) for the outpatient surgery services
provided. 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 debridement services (11042) provided
from August 31, 2020, through October 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on November 4, 2020.
You asked the Plan to pay for the comprehensive evaluation. You say that you were dissatisfied with the care provided at your previous dentist and went to see a new one. You feel this new dental provider is much better and the Plan should cover the evaluation with the new dentist. The Plan denied your request. The Plan says you previously had a comprehensive oral evaluation that was covered by the Plan in April of 2019. Comprehensive oral evaluations can only be covered once every three years. You were not eligible for another comprehensive exam on the date of service, and therefore payment cannot be made. The Plan also states that your other concerns are being addressed separately.
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 evaluation is in a frequency that is greater than what is covered under this benefit. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on November 4, 2020.
You may wish to contact the Plan for the status of your other concerns.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound (76642), diagnostic mammography (77066) and diagnostic digital breast tomosynthesis (G0279) provided on August 20, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the ultrasound, diagnostic mammography and diagnostic digital breast tomosynthesis. You say that you would like reconsideration because this service was medically necessary and appropriate. The Plan denied your request. The Plan says the provider should have verified the member's eligibility, health benefits and obtained authorization prior to the member s visit before providing services to the member as outlined on the member's ID card.
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 ultrasound (76642), diagnostic mammography (77066) and diagnostic digital breast tomosynthesis (G0279) provided on August 20, 2020 by an out of network (OON) provider.