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

We decided that the Plan does not have to waive the copayment for the comprehensive hearing test provided on March 16, 2021.
You asked the Plan to waive the copayment for the comprehensive hearing test. You say that you are entitled to one hearing aid test per year and should not be charged a $10 copayment. The Plan denied your request. The Plan says you have been asked to pay 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 diagnostic laboratory services and diagnostic procedures and tests (per day, per facility). This excludes basic and advanced diagnostic imaging services.
You have been asked to pay a $10 copayment for the comprehensive hearing test. The comprehensive hearing test falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows a diagnosis of sensorineural hearing loss which makes the test diagnostic in nature.
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 comprehensive hearing test provided on March 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the periodic oral evaluation, prophylaxis and bitewing x-rays provided on January 12, 2021.

You asked the Plan to pay more for the periodic oral evaluation, prophylaxis and bitewing x-rays. You say that the letter said members pay nothing for in-network and out-of-network services. You say that you were told you should pay the difference, but the discrepancy should be resolved. The Plan denied your request. The Plan says the claim processed correctly.

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 contract says that members are responsible for the difference between the allowed amount and the billed amount for any out-of-network services.

Service
Billed Amount
Allowed Amount
Difference of Billed & Allowed Amount
Member Liability

Oral Evaluation
$50
$29.08
$20.92
$20.92

Prophylaxis
$70
$27.88
$42.12
$42.12

Bitewing X-Rays
$80
$58.15
$21.85
$21.85

TOTAL:
$84.89

Therefore, we decided that the Plan does not have to pay more for the periodic oral evaluation, prophylaxis and bitewing x-rays provided on January 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the ECG technology support provided on February 27, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the ECG tech support. You say that the member was unaware a procedure was performed outside of the enrollee's insurance plan. You say the in-network benefits should be applied. 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 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 ECG technology support provided on February 27, 2021 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 office visit provided on February 5, 2021 to February 7, 2021 by a non-participating provider.

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 were rendered by a non-participating provider without prior authorization.

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 office visit provided on February 5, 2021 to February 7, 2021 by a non-participating provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on October 15, 2020 by an
out-of-network (OON) provider.

You asked the Plan to pay for psychotherapy 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.

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 psychotherapy services provided on October 15, 2020 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on September 14, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this is not a covered benefit.

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, the services, 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 laboratory services provided to the enrollee on September 14, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on October 28, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for psychotherapy 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.

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 psychotherapy services provided on October 28, 2020 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided
from November 6, 2020, to November 16, 2020.
You asked the Plan to waive the copayment for the inpatient care. You say that this hospitalization was related
to a condition that you developed as a result of having COVID-19, and you feel it should be covered in full.
The Plan denied your request. The Plan says the cost sharing 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 $295
copayment for each of the first five days of an inpatient hospital stay. There is no additional copayment after
the fifth day.
You have been asked to pay a $1,475 copayment for a 10-day hospital stay. The total amount billed to the Plan
for the dates in question was $34,987.24. These services were found to be medically necessary, and the
remainder of the full bill is covered or waived by your Plan; however, you are responsible for your share of the
cost for medical services as outlined in the contract. You have been asked to pay $295 for each of the first five
nights of the stay ($295 copayment x 5 days = $1,475), and you are not being charged for any additional days.
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 inpatient hospital services provided from November 6,
2020, to November 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oscillation device with associated accessories to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the oscillation device with associated accessories. You say that this provider's device has special features unavailable with other devices. The Plan denied your request. The Plan says there were par provider's available.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an oscillation device with associated accessories to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on October 21, 2020.

You asked the Plan to pay for the genetic testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.

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 genetic testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Review of the file shows that the Plan reached out to the ordering provider and found that the genetic testing was not ordered/approved by the ordering provider. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on October 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for pulp vitality tests (D0460) and cone beam computed tomography (CT) capture and interpretation with limited field of view - less than one whole jaw (D0364) provided January 12, 2021.
You asked the Plan to pay for the pulp vitality tests and cone beam CT scan. You say that you confirmed that the provider was in network and the costs of service ahead of time and do not understand how the claims have processed. The Plan denied your request. The Plan says you have been given a one exception to process the claims from this provider on this date-of-service as in-network however these services are not covered under your dental benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for pulp
vitality tests (D0460) and cone beam computed tomography (CT) capture and interpretation with limited field
of view - less than one whole jaw (D0364) provided January 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient telemedicine specialist office visit provided on May 12, 2020.

You asked the Plan to waive the copayment for the outpatient telemedicine specialist office visit. You say that you were told the copayment for a telehealth visit would be waived. The Plan denied your request. The Plan says you have been asked to pay 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 $45 copayment per specialist visit.

You have been asked to pay a $45 copayment for the outpatient telemedicine specialist office visit. The outpatient telemedicine specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. Please note, there is no provision in the contract that a copayment would be waived.

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 telemedicine specialist office visit provided on May 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services coded 00840 provided on December 1, 2020.

You asked the Plan to pay for the anesthesia services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.

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 00840 is anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; not otherwise specified. 

We find that CPT code 00840 is not supported in the medical record. Specifically, this code was billed with diagnosis Z15.02 (Genetic susceptibility to malignant neoplasm of ovary) as the primary/first listed diagnosis code. The primary/first listed diagnosis should be coded as the underlying condition. This diagnosis has a code first note. A code first note provides sequencing instruction. This note indicates that an additional code should be reported to provider a more complete picture of that diagnosis. This means that this code was not billed with an appropriate primary diagnosis code. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services coded 00840 provided on December 1, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve placement of the Superion interspinous spacer device.

You asked the Plan to pre-approve the Superion procedure. You say that this procedure has been covered by several Original Medicare contractors and should not be denied by a Medicare Advantage plan. The Plan denied your request. The Plan says the current literature is not sufficient to support the medical necessity of this service.

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 pre-approve the Superion procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found Food and Drug Administration (FDA) indications include implantation of the Superion device at one or two adjacent lumbar levels in patients with moderate spinal stenosis in whom operative treatment is indicated at no more than two levels, from L1 to L5. This enrollee has multiple degrees of spinal stenosis, many not at FDA indicated levels of "moderate" spinal stenosis including at least one of the planned levels of implantation at L3-L4 and L4-L5. There are no updated imaging studies provided post previous interspinous spacer placement on 7/10/19 to indicate ongoing spinal stenosis. 

FDA contraindications include spinal instability, scoliosis, obesity, and osteoporosis, and have not been adequately addressed in the medical records. There is no discussion of spinal instability on flexion/extension films. There is no documentation of the enrollee's height, weight or body mass index. There is imaging evidence of mild convex leftward lumbar curvature, with no documentation of the Cobb angle. There is no discussion indicating that a bone density scan has demonstrated the lack of significant osteoporosis in this patient. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for Vertiflex Superion interspinous device at L3-L4 and L4-L5 is not medically reasonable or 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 Superion procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve placement of the Superion interspinous spacer device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composites provided on January 21, 2021.

You asked the Plan to pay for the resin-based composites. You say that you were advised twice you were covered before you had the work done. You say that you didn't do anything wrong and you shouldn't have to pay this bill. The Plan denied your request. The Plan says the services are not covered benefits.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the resin-based composites provided on January 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on January 8, 2021.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that coverage for all CV risk assessment panels, except the basic lipid panel, is denied for symptomatic (with signs and symptoms) patients with suspected or documented CV disease because panel testing is not specific to a given patient's lipid abnormality or disease. We looked at the file and Medicare rules. Per L36358, the requested cardiovascular risk assessment testing is not a covered service. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on January 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services coded 99291 provided on January 16, 2021.
You asked the Plan to pay for the critical care services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says this service is reported within the global period of a major procedure.
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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes.
We find that CPT code 99291 is not supported in the medical record. Specifically, this service is considered to be bundled as part of the global surgical fee because it was reported within the global period of the major procedure coded 44005 (Enterolysis (freeing of intestinal adhesion) (separate procedure)) billed on date of service January 5, 2021. Both providers are within the same group and have the same primary specialty-Surgery Surgical Critical Care. Based on this information, we decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services coded 99291 provided on January 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay this claim for the ophthalmology services provided on October 3, 2019.
You asked the Plan to pay this claim for the office visit (99213) and scanning computerized ophthalmic diagnostic imaging (92134). You say that the claim was denied for late filing, but the claim was not untimely. The Plan denied your request. The Plan says after careful review of the claim it was determined the claim processed as a duplicate. The original claim was paid on October 9, 2019 for same services, provider, and same date of service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes 99213 and 92134 were paid on October 9, 2019. Based on this information, we find that this claim, submitted on February 2, 2021 is a duplicate. Therefore, we decided that the Plan does not have to pay this claim for the ophthalmology services provided on October 3, 2019.