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

We decided that the Plan does not have to pay for the digital breast tomosynthesis rendered on July 24, 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 procedure code 77062 is not payable.
The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes. We looked at the file and Medicare rules. Billed procedure code 77062 has a status indicator of I and is not valid for Medicare purposes. Therefore, we decided that the Plan does not have to pay for the digital breast tomosynthesis rendered on July 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe inpatient mental health services provided on June 12, 2020 to July 1, 2020 by an out of network (OON) provider.You asked the Plan to pay forinpatient mental health. You say that the service was medically necessary.The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services rendered by an out-of-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 had network providersavailable 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 forthe inpatient mental health services provided on June 12, 2020 to July 1, 2020 by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment applied toemergency room services provided on October 12, 2020.You asked the Plan to waive the copayment applied tothe emergency room services. You say that you took the enrollee to this emergency room, but they were unable to treat her prolapsed uterus because they did not have a gynecologist on staff. You say that this provider recommended the enrollee go to adifferent hospital because they were unequipped and unable to help her. You say that this provider should not be paid because they did not provide any assistance.The Plan denied your request. The Plan says the copayment was appropriately applied to theservices in dispute.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must paya $90 copayment per emergency department visit for Emergency Care. The enrollee has been asked to pay a $90 copayment for the emergency room services. The emergency room services fall within the Emergency Care benefit category. The documentation provided shows that the enrollee did present to this emergency room on this date of service, she was seen by a doctor andan assessment was done.This justifies billing for an emergency room visit.This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.Therefore, we decided that the Plan does not have to waive the copayment applied toemergency room services provided on October 12, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share amount for the complete series x-ray provided on October 29, 2020.
You asked the Plan to waive the cost share amount for the dental service. You say that you called the dental office prior to your appointment. You say that they advised the cleaning would be covered at 100%. You say that you were advised there was a new patient special of $79 for an exam, cleaning, and x-rays. You say that you are not being charged for the x-rays. You also say that if you had just had the bitewing x-rays, you would have been covered at 100%. The Plan denied your request. The Plan says there is a 50% coinsurance for Class 2 Basic Services, including the complete series x-ray.
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, there is a 50% coinsurance for Class 2 Basic Services, including the complete series x-ray. This is a contractual obligation you agreed to when you enrolled in the Plan's dental coverage. Therefore, we decided that the Plan does not have to waive the cost share amount for the complete series x-ray provided on October 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the resin-based composite on tooth #13 provided.

You asked the Plan to waive the cost share for the resin-based composite. You say that your enhanced dental package states that fillings are covered at 100%.The Plan denied your request. The Plan says this claim was 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 requested items or services are not among those covered under this benefit. Tooth #13 is a posterior tooth, and resin-based composites are not covered for posterior teeth. The record shows that the Plan paid for an amalgam filling. You are responsible for the difference in cost.Therefore, we decided that the Plan does not have to waive the cost share for the resin-based composite on tooth #13 provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the portable oxygen concentrator purchased on July 31, 2020.
You asked the Plan to reimburse you for the portable oxygen concentrator. You say that you assumed you would be reimbursed for the medially needed device. The Plan denied your request. The Plan says per Medicare guidelines payment is not made for purchases of oxygen and oxygen equipment.
The Plan must follow Medicare rules. Medicare rules say that only rented oxygen equipment is eligible for coverage. We looked at the file and Medicare rules. Purchased oxygen equipment is statutorily non-covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the portable oxygen concentrator have not been met. Therefore, we decided that the Plan does not have to reimburse you for the portable oxygen concentrator purchased on July 31, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on June 8, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not approved in advance.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan saysthat the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on June 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on March 24, 2020 by an out of network (OON) provider.
You asked the Plan to pay for physician 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. The Plan says that the rendering assisted living facility is also out-of-network.
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 physician services provided on March 24, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe panoramic x-ray (D0330) provided on October 5, 2020.You asked the Plan to pay forthe dental service. You say that your previous dentist is no longer in network. You say that you were having issues with a tooth and you went to a new dentist. You say that when you went for your appointment she did a new panoramic x-ray. You say that you thought this was a normal part of the procedure. You also say that you would like the frequency limitation for this service to be waived.The Plan denied your request. The Plan says 1 panoramic x-ray is covered every 3 plan years. The Plan says that the frequency limit for this service 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.Though the Plan offers a dental benefit in excess of Medicare coverage, the frequency limit of 1 panoramic x-ray every 3 plan years has been exceeded. The record shows that the Plan paid for a panoramic x-ray that you received on April 2, 2019.Therefore, we decided that the Plan does not have to pay forthe panoramic x-ray (D0330) provided on October 5, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided by you on March 29, 2020.
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive order for treatment in place. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on March 29, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided by you on March 29, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for targeted genomic sequence analysis panel (CPT Code 81455) provided on August 11, 2020.
You asked the Plan to pay for the testing. You say that the service was necessary and the claim should be processed as in-network since you are the sole provider for the testing. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. As Comprehensive Genomic Profile (CGP) testing is not defined as a targeted panel by MolDX; and it is a test not currently satisfactorily described by any existing CPT code; to report a CGP, service providers should use CPT code 81479 (used for the entire bundled multi-test panel) at this time, in addition to the approved DEX Z-CodeTM entered adjacent in the comment/narrative field for the test; not unbundled to separate codes. Medicare non-coverage applies to both contracted and non-contracted providers and cannot be overridden by plan directed care. This is an administrative determination for coding and is not based on clinical criteria for medical necessity. Any and all codes on this claim are denied, and in addition, previous payments to these providers for this member are subject to recoupment. Therefore, we decided that the Plan does not have to pay for targeted genomic sequence analysis panel (CPT Code 81455) provided on August 11, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided on August 7, 2020.You asked the Plan to pay forthe ambulance services. You say that you were treated in place by the medics.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on August 7, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services provided  on August 7, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on June 10, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says it cannot be determined that the services were medically necessary.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. The documentation submitted does not contain medical records from the non-contract provider. Without records, it cannot be determined that Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for the services provided on June 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient office visit (99213) provided October 2, 2020.
You asked the Plan to waive the copayment for the office visit. You say that you feel you should not owe the copay because you did not get any help from the doctor. The Plan denied your request. The Plan says the claim was processed and the correct copayment has been 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 $50 copayment for specialist visits. You have been asked to pay $44.34 for the office visit. Since the allowed amount was less than the copayment amount, you are responsible for the lesser amount. The office visit falls 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 copayment for the outpatient office visit (99213) provided October 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the visit to urgent care (S9088, 99214) provided on October 17, 2020.
You asked the Plan to waive the copayment for the urgent care visit. You say that you were told you would not be billed if you could not be treated. The Plan denied your request. The Plan says urgent care services have a $50 copay.
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 urgently needed services. You have been asked to pay a $50 copayment for an urgent care visit. You saw a physician in the urgent care department and had an evaluation. An urgent care visit falls within the urgently needed 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 the visit to urgent care (S9088, 99214) provided on October 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 28, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the nursing facility care. You say that you would like reconsideration because the member required attention. The Plan denied your request. The Plan says prior authorization was not obtained as is required by the Plan contract.
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 medical services provided on February 28, 2020 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 medical services provided on January 2, 2020 to February 14, 2020 by an out of network (OON) 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 an out-of-network 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 medical services provided on January 2, 2020 to February 14, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that IRF admission is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the documentation does not support that the complexity of the enrollee's nursing, medical and rehabilitation needs requires an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require at least 3 hours a day /5 day a week of therapy services. Medicare coverage criteria are not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray (72100) provided on July 14, 2020.
You asked the Plan to pay for an x-ray. You say that this code is supported. The Plan denied your request. The Plan says this procedure is not documented.
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 72100 is radiologic examination, spine, lumbosacral; 2 or 3 views. We find that CPT code 72100 is not supported in the medical record. Specifically, although the submitted records note that "multiple plain film x-rays of the lumbar spine were taken," there is no documentation of the specific number of views taken. Without this information, this code cannot be verified. Based on this information, we decided that Medicare rules for coverage of an x-ray have not been met. Therefore, we decided that the Plan does not have to pay for an x-ray (72100) provided on July 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on February 27, 2020, and September 1, 2020.
You asked the Plan to pay for periodontal maintenance. You say that the services were medically necessary. The Plan denied your request. The Plan says they are unable to make payment for any services received from a provider that has opted out of Medicare.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 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. Specifically, you received services from a provider that has opted out of Medicare. This means the service is not covered under your benefit plan. Therefore, we decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on February 27, 2020, and September 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gingival irrigation, per quadrant (D4941) provided on September 14, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit under your contractual policy.
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 service provided is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the gingival irrigation, per quadrant (D4941) provided on September 14, 2020.