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

We decided that the Plan does not have to pay for molecular genetic screening testing provided on February 4, 2021.
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because molecular genetic screening testing is not a Medicare benefit for the diagnoses listed and was performed for screening purposes.
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, genetic testing, was requested for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for molecular genetic screening testing provided on February 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on February 22, 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 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 February 22, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided on January 27, 2021.

You asked the Plan to waive the copayment for physical therapy. You say that a letter was sent approving 10 visits for therapeutic exercises. You say that you need the Plan to pay for the necessary medical treatment. 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 $40 copayment for physical therapy at an in-network outpatient hospital.

You have been asked to pay a $40 copayment for physical therapy. Physical therapy falls within the "Outpatient rehabilitation services" 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 physical therapy provided on January 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visits coded 99213 provided on December 2, 2020 and December 30, 2020.

You asked the Plan to pay for the office visits. You say that you feel thee services should be billed. The Plan denied your request. The Plan says the services billed are not payable.

The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or feet or have fungal nails. 

Records do not show that any of these conditions are present. The services you are asking the Plan to pay for are routine foot care services. Based on this information, we decided that Medicare rules for coverage of the office visits have not been met. Therefore, we decided that the Plan does not have to pay for the office visits coded 99213 provided on December 2, 2020 and December 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), bitewing radiographic images (D0274), and a teeth cleaning (D1110) provided on March 10, 2021.
You asked the Plan to pay for a periodic oral evaluation, bitewing radiographic images, and a teeth cleaning. You say that you were not aware that the provider was out-of-network. The Plan denied your request. The Plan says you are not covered for these services when seen by an out-of-network 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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a periodic oral evaluation, bitewing radiographic images, and a teeth cleaning have not been met. Specifically, services were provided by an out-of-network provider without prior authorization.
The Plan has contracted providers available to provide these services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation (D0120), bitewing radiographic images (D0274), and a teeth cleaning (D1110) provided on March 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99202) provided January 28, 2021.
You asked the Plan to pay for the office visit. You say that please consider approving these services and reversing the denial on this appeal. The Plan denied your request. The Plan says this service is not covered when rendered by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99202) provided January 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a skin substitute graft (15275) provided on March 9, 2021, by an out-of-network provider.

You asked the Plan to pay for a skin substitute graft. You say that the requested service was a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for out of network care have not been met.

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 a skin substitute graft (15275) provided on March 9, 2021, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve six additional chiropractic visits.

You asked the Plan to pre-approve the additional visits. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance care. 

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 additional visits. Our reviewer says that the requested chiropractic visits are not medically reasonable and necessary. Our physician reviewer found that the enrollee has low back pain. The medical records provided indicate that the enrollee has reached a clinical baseline without further improvement. The enrollee has chronic conditions. The record indicates that further treatment would be maintenance therapy. 

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 additional visits have not been met. Therefore, we decided that the Plan does not have to pre-approve six additional chiropractic visits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on April 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 services are not covered.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid. 

In this case, the MUE for CPT code 87798 is 13. You billed 17 units of this code, exceeding the MUE. 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 laboratory services rendered on April 10, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.

You asked the Plan to pre-approve the SNF care. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 pre-approve the SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found this enrollee does not require skilled nursing or therapy services.

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 SNF care have not been met. Specifically, medically necessary services can be obtained at a lower level of care. This means SNF care is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for computed tomography (CT) abdomen and pelvis (74176) provided February 4, 2021.

You asked the Plan to waive the copayment for the CT scan. You say that this copay should be reduced to something more reasonable like $25. When making the appointment you were told there would be no copay. Your referring physician also told you there would be no copay. The Plan denied your request. The Plan says the claim was processed with the correct copayment 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 $125 copayment for Medicare covered radiological diagnostic services. 

You have been asked to pay $125 copayment for the CT scan. The CT scan 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 computed tomography (CT) abdomen and pelvis (74176) provided February 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for fillings (D2391 x2, D2331) provided
on March 16, 2021.

You asked the Plan to pay an additional amount for fillings. You say that the services should be covered. The
Plan denied your request. The Plan says the services are a covered benefit, but you have exceeded the
frequency limit of two every calendar year. The provider was paid at the Medicare allowed rate therefore no
additional payment can be made.

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 looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of fillings have not been met. Specifically, the record shows that you had exceeded the frequency
limit. Additionally, the allowed amount of these services for an out-of-network provider were paid by the plan.
Therefore, we decided that the Plan does not have to pay an additional amount for fillings (D2391 x2, D2331) provided on March 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2740) and core buildup (D2950) provided on March 22, 2021.
You asked the Plan to pay for the dental services. You say that you have not met your maximum allowance yet. The Plan denied your request. The Plan says they paid part of the cost for these services; however, you have met your annual $2,000 limit for dental services and are responsible for the uncovered cost.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers up to $2,000 per year for supplemental dental care. You are responsible for any amount over and above this limit. Though the Plan offers a dental benefit in excess of Medicare coverage, items or services that exceed the $2,000 annual limit are not covered under this benefit. Documentation shows that the Plan has covered $2,000 of dental care for you in 2021. Therefore, we decided that the Plan does not have to pay an additional amount for the crown (D2740) and core buildup (D2950) provided on March 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for chiropractic services provided on March 9, 2021.
You asked the Plan to waive the copayment for chiropractic services. You say that you did not receive the services you requested and feel that you should not be responsible for the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are 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). Your contract with the Plan clearly says that you must pay a $20 copayment for chiropractic services. You have been asked to pay a $20 copayment for chiropractic services. Chiropractic services fall within the chiropractic services 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 chiropractic services provided on March 9, 2021.
We note your complaint that you did not receive the services you requested. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on February 12, 2021.
You asked the Plan to waive the copayment for emergency care. You say that you have been unable to work and cannot afford the services. The Plan denied your request. The Plan says the claims were processed correctly and you are 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). Your contract with the Plan clearly says that you must pay a $50 copayment for emergency care. You have been asked to pay a $50 copayment for emergency care. Emergency care falls within the emergency 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 emergency care provided on February 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 power operated vehicle (POV).
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 these services. Our reviewer says that you do not meet the criteria for coverage. Our physician reviewer found the records do not show that you have a personal mobility deficit that significantly impairs your participation in mobility-related activities of daily living (MRADLs) in the home. There is no documentation of a detailed physical exam. It is not clear that you cannot use a walker, cane, or manual wheelchair or that you can safely operate the requested POV in your home. The services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 2 power operated vehicle (POV).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Hyaluronan or derivative, gel-one, for
intra-articular injection, per dose (J7326) provided on February 12, 2021.
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to
the service 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 20%
coinsurance for each Medicare-covered Part B drug.
You have been asked to pay $473.80 ($2,369 x 20% coinsurance) for the Medicare Part B drug injection
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 coinsurance for the Hyaluronan or derivative, gel-one, for
intra-articular injection, per dose (J7326) provided on February 12, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic mammography, including
computer-aided detection (CAD) when performed; bilateral (77066) provided on November 9, 2020.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to
the service 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 $50
copayment for diagnostic radiology.
You have been asked to pay a $50 copayment for the diagnostic radiology 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 copayment for the diagnostic mammography, including computer-aided detection (CAD) when performed; bilateral (77066) provided on November 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two periodontal scalings and root planings (D4341 x2), eleven localized deliveries of antimicrobial agents (D4381 x11), two gingival irrigations (D4921 x2), and two drugs or medicaments dispensed in the office for home use (D9630 x2) provided on February 11, 2021 by an OON provider.
You asked the Plan to pay for the scalings and planings, localized deliveries of antimicrobial agents, gingival irrigations, and drugs or medicaments. You say that the provider was faxed your benefit information on January 5, 2021. The Plan denied your request. The Plan says payments for these services are denied because your plan does not cover services from a provider who is not 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 two periodontal scalings and root planings (D4341 x2), eleven localized deliveries of antimicrobial agents (D4381 x11), two gingival irrigations (D4921 x2), and two drugs or medicaments dispensed in the office for home use (D9630 x2) provided on February 11, 2021 by an OON provider
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement provided on March 22, 2021 by an out of network (OON) provider.

You asked the Plan to pay for the debridement. You say that the service is medically necessary. The Plan denied your request. The Plan says no prior authorization was 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 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 debridement provided on March 22, 2021 by an out of network (OON) provider.