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

We decided that the Plan does not have to pre-approve alveoloplasty and deep sedation for an approved extraction.
You asked the Plan to pre-approve the Alveoloplasty and deep sedation. You say that this dental work is necessary before the enrollee can take the medication she needs. The Plan denied your request. The Plan says while the extraction itself was approved, deep sedation and Alveoloplasty are not covered by the enrollee's dental 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 pre-approve alveoloplasty and deep sedation for an approved extraction.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ECG provided on August 13, 2019 by an OON provider.You asked the Plan to pay forthe ECG. You say that the documentation provided supports the need for service.The Plan denied your request. The Plan says the rendering provider is a non-network provider. The Plan also says that enrollee was referred by a non-network provider.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe ECG provided on August 13, 2019 by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Computed Tomography (CT) scan of the chest.You asked the Plan to pre-approveCT scan. You say that you are appealing with medical records.The Plan denied your request. The Plan says the denial of authorization for this test is correct, because the records submitted do not include results of prior chest imaging for comparison.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan wascorrect in denying the request to pre-approve CT scan. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested CT scan. Our physician reviewer found this CT scan was ordered for follow-up on a pulmonary nodule. Lungs wereclear on examination, no reported respiratory symptoms were noted, and no reports showing results of prior chest imaging including the size and location of this observed nodule were provided. Without this information, it is difficult to determine which surveillance pattern would be most appropriate. Therefore, without sufficient support made for this request, the chest CT scan will be considered not medically reasonable and necessary at this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CT scan have not been met.Therefore, we decided that the Plan does not have to pre-approvea Computed Tomography (CT) scan of the chest.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the endoscopy provided on May 31, 2018.
You asked the Plan to waive the copayment for the endoscopy. You say that you were informed this would be preventive. You say that you have a limited income and want help. The Plan denied your request. The Plan says the copayment 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 $295 copayment for Medicare-covered surgery. You have been asked to pay a $295 copayment for the endoscopy. The endoscopy falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The endoscopy is considered 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 copayment for the endoscopy provided on May 31, 2018.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on June 1, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records stating exactly what tests are to be performed.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order/lab requisition stating exactly what tests were to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on June 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments for the allergen immunotherapy services provided from September 6, 2019 to September 20, 2019.
You asked the Plan to reduce the copayments for the allergen immunotherapy services. You say that the amount you have been asked to pay is more than what you were told you would have to pay. 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 Medicare-covered physician specialist services. For each date of service, you have been asked to pay the allowed amount of the claim because these amounts are less than the $$50 copayment for the allergen immunotherapy services.
You have been asked to pay a $9.61 copayment for the allergen immunotherapy services on each date of service. The allergen immunotherapy services fall within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows you were billed for code 95115 which is considered a physician service.
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 reduce the copayments for the allergen immunotherapy services provided from September 6, 2019 to September 20, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approvesingle-photon emission computed tomography (SPECT) nuclear stress test.You asked the Plan to pre-approveSPECT test. You say that the enrollee cannot walk on a treadmill.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the documentation does not support the medical necessity for a nuclear stress test.The Plan follows Medicare rules. Medicare rules say that cardiovascular nuclear medicine testing is only covered for evaluation of certain conditions. 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 SPECT test. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested SPECT test. Our physician reviewer found if stress testing were thought to be medically necessary then treadmill electrocardiography would be sufficient, because the baseline electrocardiogram is interpretable and the records document that the enrollee is able to ambulate. Coverage criteria for nuclear stress testing is not met because there are no documented covered indications for the procedure such as uninterpretable electrocardiogram, left ventricular dysfunction, known coronarydisease, prior coronary intervention, or documented high risk non-cardiac procedure.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SPECT test have not been met. Therefore, we decided that the Plan does not have to pre-approvesingle-photon emission computed tomography (SPECT) nuclear stress test.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forlesion removal provided on September 16, 2019.You asked the Plan to waive the copayment forthe lesion removal. You say that this was not a hospital visit. You say that you paid a $25 copayment for the visit.The Plan denied your request. The Plan says the copayment 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 $275 copayment for Medicare-covered outpatient services at hospital facilities. You have been asked to pay $157.86, which is less than the standard $275 copayment for the lesion removal. The lesion removal falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The lesion removal is considered a surgical procedure that was billed by the hospital. This means that you have been asked to pay the correct amount based on your contract with the Plan. Thiscost 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 forlesion removal provided on September 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe office visit provided on October 3, 2019.You asked the Plan to waive the copayment forthe office visit. You say that you were seen for an annual exam and there should be no copayment due for that office visit. 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 $10 copayment for each covered visit or consultation in an outpatient location with your PCP or other primary care physician. You have been asked to pay a $10 copayment for the office visit. The office visit falls within the"Physician/Practitioner services, including doctor's office visits" benefit category. The medical records show that you were treated for hip bursitis in addition to the annual physical.This means that you have been asked to pay the correct amount basedon your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment forthe office visit provided on October 3, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe endoscopy provided on October 30, 2019.You asked the Plan to waive the copayment forthe endoscopy. You say that the service needed to be done. You say that you didn't realize there would be a copayment.The Plan denied your request. The Plan says the copayment 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 $350 per day for outpatient procedures and services.You have been asked to pay a $350 copayment for the endoscopy. The endoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 forthe endoscopy provided on October 30, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe cardiac MRI provided on November 13, 2019.You asked the Plan to waive the copayment forthe cardiac MRI. You say that the copayment is higher than expected. You say that if you were aware of the copayment you would have declined the service.The Plan denied your request. The Plan says the copayment 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 $250 per day for Medicare-covered diagnostic radiology services. You havebeen asked to pay a $250 copayment for the cardiac MRI. The cardiac MRI 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 forthe cardiac MRI provided on November 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services (G0127) provided to the enrollee on August 19, 2019.You askedthe Plan to pay forthe services. The Plan denied your request. The Plan says the supporting documentation received does not support CPT G0127-59,Q8.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 G0127 is "Trimming of dystrophic nails, any number".We asked our coding reviewer to carefully review the case file andapply 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 use of code G0127 is not supported. Our coding reviewer found that the medical records provided do not meet criteria for billing HCPCS code G0127-59-Q8.We looked at this coder'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 forthe services (G0127) provided to the enrollee on August 19, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe CT scan provided on September 26, 2019.You asked the Plan to waive the coinsurance forthe CT scan. You say that you should not be responsible for the coinsurance because it is required for your surgery. You say you have never had to pay a copayment for diagnostic services. 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 $20 coinsurance for up to a maximum of $75 per day for Medicare-covered diagnostic radiology services. You have been asked to pay a $27.29 which is 20% of the allowed amount for the CT scan. The allowed amount is $136.44. ($136.44 x 20% = $27.29). The CT scan falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have beenasked 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 forthe CT scan provided on September 26, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvemagnetic resonance imaging (MRI) of the brain.You asked the Plan to pre-approvethe MRI. The Plan denied your request. The Plan says this is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file andapply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that an MRI is not medically necessary. Our physician reviewer found that the enrollee had brief dizziness while at thegym exercising which resolved, but repeats when getting up quickly. A residual mild headache was present the day after these symptoms started. Physical findings were unremarkable. Meclizine and Zofran prescribed as well as recommendations to drink more water. Cardiology ruled out cardiac cause. In the case of this enrollee, the sudden dizziness symptoms which resolved and were more likely to be related to dehydration, vertigo, blood pressure medication, or other metabolic cause should be considered and treated, and ongoing symptoms reported prior to considering advanced brain imaging. There were no other records provided which might support this request. Therefore, this request for brain MRI will be considered not medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the MRI have not been met.Therefore, we decided that the Plan does not have to pre-approvemagnetic resonance imaging (MRI) of thebrain.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forperiodontal maintenance (D4910) adjunctive pre-diagnostic test (D0431) localized delivery of antimicrobial agents (D4381) provided July 9, 2019.You asked the Plan to pay forthe dental services. You say that you would like to appeal for payment as this was the provider's office error with scheduling your routine cleaning too early.The Plan denied your request. The Plan says services are not covered by the plan and the benefit maximum has been exceeded.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Periodontal maintenance is covered once every 6 months. Records show that you received periodontal maintenance on February 4, 2019, therefore this service was provided prior to 6 month's time period of eligibility. Additionally, the adjunctive pre-diagnostic test and localized delivery of antimicrobial are not listed under the description of benefits and therefore are not covered.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 forperiodontal maintenance (D4910) adjunctive pre-diagnostic test (D0431) localized delivery of antimicrobial agents (D4381) provided July 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe CMT provided on June 27, 2019 by an OON provider.You asked the Plan to pay forthe CMT. You say that you have been seeing this provider for over twenty years.The Plan denied your request. The Plan says you received services from a non-contracted provider. The Plan also says that prior authorization was not obtained.Medicare rules saythat plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe CMT provided on June 27, 2019 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe dental extractions (D7140 x4, D7210 x2) provided on August 13, 2019.You asked the Plan to pay forthe dental extractions. You say that you were in a lot of pain due and had 8 infected and decayed teeth that needed to be pulled. You were told that the plan would pay the oral surgeon $1,000 instead the plan paid the lowest amount.The Plan denied your request. The Plan says this request exceeds the benefit limitations of 2 covered extractions per year.Medicare generally does not cover dental services. However, the Plan offers a dentalbenefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The health plan contract allows 2 extractions a year.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 forthe dental extractions (D7140 x4, D7210 x2) provided on August 13, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forintraoral-periapical first x-ray (D0220) provided November 11, 2019.You asked the Plan to pay forthe x-rays. You say that this was a bitewing x-ray and this should be covered with $0 copay.The Plan denied your request. The Plan says this service is not covered under the benefit package.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 forintraoral-periapical first x-ray (D0220) provided November 11, 2019.