Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services you received from June 1, 2019, to September 3, 2019.
You asked the Plan to pay for the chiropractic services. The Plan denied your request. The Plan says these services are not covered when provided 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 services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the chiropractic services you received from June 1, 2019, to September 3, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for ultrasounds provided on January 6, 2020
and January 13, 2020.
You asked the Plan to waive the copayments for ultrasounds. You say that you thought that you would only
owe specialist copayments. 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 $100
copayment for radiological diagnostic services.
You received an ultrasound on January 6, 2020. Therefore, you are responsible to pay the allowed mount of
$82.94, which is less than the $100 copayment.
You received an ultrasound on January 13, 2020. Therefore, you are responsible to pay the $100 copayment.
The total amount you owe is: $182.94.
You have been asked to pay the total copayment amount of $182.94 for ultrasounds. Ultrasounds fall 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 copayments for ultrasounds provided on January 6, 2020 and January 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab tests provided on September 30, 2019 by an out of
network (OON) provider.
You asked the Plan to pay for lab tests. You say that you would like this claim reprocessed and approved for
payment. 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 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 for lab tests provided on September 30, 2019 by an
out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180), the periodontal scaling and root planing (D4342) for all 4 quadrants, and the topical application of fluoride varnish (D1206) provided on December 13, 2019.
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says the comprehensive periodontal evaluation, periodontal scaling and root planing, and topical application of fluoride varnish are not listed as covered services. The Plan also says that any services not specifically listed are not covered.
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 dental services you received are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180), the periodontal scaling and root planing (D4342) for all 4 quadrants, and the topical application of fluoride varnish (D1206) provided on December 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the special pump services rendered on January 16, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not separately payable.
The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are statutorily excluded. The provider submitted a claim for procedure code 99190 (special pump services). This code has a status indicator of X and no separate Medicare payment. Payment is included in the payment to the facility. Therefore, we decided that the Plan does not have to pay for the special pump services rendered on January 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you on July 30, 2019.
You asked the Plan to pay for the services. You say that this should be covered. The Plan denied your request.
The Plan says this provider does not accept Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items or services provided directly by a physician or practitioner who has opted out of the program except
in cases involving emergencies or urgently needed care.
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider that
has opted out of the Medicare program. The file shows that this provider entered into a private contract with
you regarding payment. Therefore, we decided that the Plan does not have to pay for the services provided to
you on July 30, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a Computed Tomography (CT) scan provided on December
11, 2019.
You asked the Plan to pay for CT scan. You say that the service performed was appropriate for this date of
service. The Plan denied your request. The Plan says the denial of payment for this service is correct, because
the Plan is the secondary payer for this enrollee and the claim must be submitted to the primary payer first.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for
services until the claim for those services has gone to the primary insurer. However, plans are still required to
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a
bill for reimbursement to the primary insurer.
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has advised you
to submit this claim to the primary payer. As the secondary insurer, the Plan cannot be held responsible for CT
scan until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does
not have to pay for a Computed Tomography (CT) scan provided on December 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the skin peel therapy provided on January 14, 2020.
You asked the Plan to pay for the skin peel therapy. You say that the treatment was for cystic boils on your
back. The Plan denied your request. The Plan says the service is considered a cosmetic procedure and not
covered.
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 skin peel therapy. Our physician
reviewer found that the documentation indicates that your acne condition was unresponsive to topical therapy,
but declined antibiotic therapy. A course of antibiotics would be indicated prior to the use of a chemical peel.
The review has determined the provided skin peel therapy was not medically reasonable or necessary to treat
your condition.
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 skin peel therapy have not been met. Therefore, we decided that the Plan
does not have to pay for the skin peel therapy provided on January 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder-elbow-wrist-hand orthosis provided on April
30, 2019.
You asked the Plan to pay for the shoulder-elbow-wrist-hand orthosis (L3960). You say that the orthosis was
medically necessary. The Plan denied your request. The Plan says there must be information in the enrollee's
medical record that supports the medical necessity for the item.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at the file and Medicare rules. No medical records were received to support the diagnosis on the
submitted order, therefore the billed codes cannot be supported. Based on this information, we decided that
Medicare rules for coverage of the shoulder-elbow-wrist-hand orthosis (L3960) have not been met. Therefore,
we decided that the Plan does not have to pay for the shoulder-elbow-wrist-hand orthosis provided on April 30,
2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray rendered on September 5, 2019.
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 claim was not billed correctly.
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis
code.
We looked at the file and Medicare rules. The file shows that the claim was billed with both a primary and
secondary diagnosis; however, the diagnosis can only be primary. 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 x-ray rendered on September 5, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the CIMZIA injections provided on
October 31, 2019 and December 3, 2019.
You asked the Plan to waive the coinsurance for the injections. You say that you believed the medication
would be paid in full. The Plan denied your request. The Plan says that the claim processed 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 20%
coinsurance for Medicare Part B prescription drugs.
You have been asked to pay a 20% coinsurance for the injections. The injections fall 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 the CIMZIA
injections provided on October 31, 2019 and December 3, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on
December 20, 2019.
You asked the Plan to waive the copayment for the ambulance transport. The Plan denied your request. The
Plan says that cost sharing is a contractual obligation under the plan and cannot be waived.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250
copayment for each one-way Medicare-covered ground trip.
You have been asked to pay a $224.33 copayment for the ambulance transport. The ambulance transport falls
within the one-way Medicare-covered ground trip benefit category. This means that you have been asked to
pay less than 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 ambulance transport provided on December 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for mechanical traction therapy (97012) provided by a
chiropractor from September 4, 2019 to October 7, 2019.
You asked the Plan to pay for mechanical traction therapy. You say that this should be covered. The Plan
denied your request. The Plan says this is not covered by Medicare or the Plan.
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 mechanical traction therapy (97012) provided by a chiropractor from
September 4, 2019 to October 7, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ER visit provided on February 14, 2020.
You asked the Plan to waive the copayment for an ER visit. You say that your doctor told you that you could get a CT scan faster if you went to the ER and you disagree with 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 $90 copayment for emergency care. You have been asked to pay a $90 copayment for an ER visit. An ER visit 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 an ER visit provided on February 14, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on
June 7, 2019.
You asked the Plan to pay for the pump assembly and operation. You say that you would like reconsideration
because it takes 30 minutes to set up the machine and the perfusionist is required to remain in the operating
room during the length of the procedure. The Plan denied your request. The Plan says payment for this service
is the responsibility of the facility to any vendor.
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier
other than the facility or hospital for services furnished to the beneficiary while an inpatient.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the pump assembly and operation have not been met. Specifically, payment for this service is
included in the DRG payment to the facility and is the responsibility of the facility to any vendor. Therefore,
we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on
June 7, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT scan of the heart with quantitative evaluation of
coronary calcium.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your
request. The Plan says coronary calcium scoring for use in asymptomatic patients for screening for CAD is not
a covered service.
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 was correct in denying the request to pre-approve the scan. Our reviewer says that the
requested scan is not medically reasonable or necessary. Our physician reviewer found you have increased
coronary risk but no documented cardiac disease. In this circumstance, guidelines for the management of
cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are
endorsed by several national organizations. These guidelines currently do not recommend routine performance
of specialized tests in the context of assessing coronary risk including coronary CT scanning and calcium
scoring. Treatment change or addition based on the results of screening with coronary CT scanning has not
been shown to improve cardiac outcome incremental to that achievable by treatment based on a combination of
standard risk factor profiling and basic lipid analysis. Moreover, aggressive risk factor modification and high
intensity -statin medication are recommended for you.
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 scan have not been met. Therefore, we decided that the Plan does not have
to pre-approve CT scan of the heart with quantitative evaluation of coronary calcium.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on April 10, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed,
however, 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. We find that payment for the lab services is not supported in the
medical record. We find that the issue of intent is not clear. There are no medical records in the case file in
regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided
that the Plan does not have to pay for the laboratory services provided on April 10, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of a lower
extremity (73720).
You asked the Plan to pre-approve an MRI of a lower extremity. You say that the service is 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. Medicare rules say that MRIs 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 was correct in denying the request to pre-approve an MRI of a lower extremity. Our
reviewer says that the service is not medically necessary. Our physician reviewer found while additional
diagnostics are likely necessary, better documentation from a neurologist (i.e. thorough neuro and
musculoskeletal examinations) would likely help clarify what diagnostics would be most beneficial to you (ex.
imaging, biopsy, electromyography/nerve conduction velocity). At present, the documentation does not show
that a lower extremity MRI is 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 an MRI of a lower extremity have not been met. Therefore, we decided that the
Plan does not have to pre-approve a magnetic resonance imaging (MRI) of a lower extremity (73720).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for antigen therapy services provided from
August 6, 2019 to September 23, 2019.
You asked the Plan to waive the copayments for antigen therapy services and immunotherapy injections. You
say that you were told that the services would be covered. 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 $40
copayment for specialist services.
You received antigen therapy services from August 6, 2019 to September 23, 2019 for a total of 20 visits.
Antigen therapy services are considered specialist services. Therefore, you are responsible to pay a $40
copayment per each visit. The total amount you owe is: $40 (copayment) x 20 (specialist services) = $800.
You have been asked to pay the total copayment amount of $800 for antigen therapy services. Antigen therapy
services fall within the physician/practitioner services, including doctor's office visits 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 copayments for antigen therapy services provided from August 6, 2019 to
September 23, 2019.