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

We decided that the Plan does not have to pay for the connective tissue gene panel provided on March 11,
2021.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says one CPT code
must be submitted for the panel.
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 looked at the file and the rules. The claim shows that the gene panel was billed with multiple codes. If a
single procedure is performed, only one code with one unit of service may be reported for the procedure. Based
on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that
the Plan does not have to pay for the connective tissue gene panel provided on March 11, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Cxbladder testing rendered on August 2, 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. The rules say that the Cxbladder testing is non-covered.
We looked at the file and Medicare rules. The test at issue is Cxbladder. This test is not covered by Medicare.
Therefore, we decided that the Plan does not have to pay for the Cxbladder testing rendered on August 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam (D0120) provided on September 7, 2021.

You asked the Plan to pay for the oral exam. You say that you have only had 1 teeth cleaning and 1 routine periodic evaluation paid for this year. You say that your plan covers 2 periodic evaluations and 3 cleanings due to your history of gum disease. You also say that these services should be covered. The Plan denied your request. The Plan says 2 periodic evaluations are covered per plan year. The Plan also says that the frequency limit 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 and the periodic evaluation is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a periodic evaluation that you received on January 12, 2021, and May 11, 2021. Therefore, we decided that the Plan does not have to pay for the oral exam (D0120) provided on September 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the routine vision services provided on August 24,
2021.
You asked the Plan to pre-approve the routine vision services. You say that you would like this claim
reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was
not obtained for these services rendered by an out-of-network (OON) provider.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers these services when they are rendered by an in-network provider.
We looked at the file and the Plan's rules. In this case, there is no exception that can be made for these services
rendered by an OON provider. Based on this information, we decided that the Plan's rules for coverage of the
routine vision services have not been met. Therefore, we decided that the Plan does not have to pre-approve the
routine vision services provided on August 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist telehealth visit provided on
November 8, 2021.
You asked the Plan to waive the copayment for a specialist telehealth visit. You say that you have used this
service before with no copayment. The Plan never informed you there would be a copayment. The Plan denied
your request. The Plan says the proper copayment was applied for this service.
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 for each office visit or telehealth visit to a specialist.
You have been asked to pay a $45 copayment for a specialist telehealth visit. A specialist telehealth 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 a specialist telehealth visit provided on November 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the orthosis provided on July 23, 2021.

You asked the Plan to pay for the orthosis. The Plan denied your request. The Plan says the documentation did not include a valid physician order.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.

The record does not contain a valid physician order or relevant medical records which support medical necessity for the supplies provided in this case. The medical records provided do not indicate that an orthosis was part of the enrollee's treatment plan for shoulder pain. The records do not show that an order for an orthosis was or would be placed for the enrollee to treat his condition. Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the orthosis provided on July 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan of the
abdomen and pelvis (74178) provided on September 8, 2021.
You asked the Plan to waive the copayment for a CT scan of the abdomen and pelvis. You say that no one
warned you about the cost of the procedure. The Plan denied your request. The Plan says the correct copayment
was applied.
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 category of test for each service date for CT scans, magnetic resonance imaging scans
(MRIs), position emission tomography (PET) scans, and nuclear cardiac imaging tests.
You have been asked to pay a $250 copayment for a CT scan of the abdomen and pelvis. A CT scan of the
abdomen and pelvis 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 a computed tomography (CT) scan of the
abdomen and pelvis (74178) provided on September 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the orthotics rendered on January 27, 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 there is no valid physician order.
The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating
physician before dispensing any durable medical equipment (DME) item to a beneficiary.
We looked at the file and Medicare rules. There is no valid physician order for the DME. 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 orthotics rendered on January 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for wound care services (unna boot strapping)
provided on September 15, 2021.
You asked the Plan to waive the copayment for the wound care services. You say that the dressing accidentally
got wet so you had to return the next day for a new one. The Plan denied your request. The Plan says you have
been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35
copayment for each podiatry visit.
You have been asked to pay a $35 copayment for the wound care services. The wound care services fall within
the Podiatry 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 wound care
services (unna boot strapping) provided on September 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the advance care planning rendered on May 21, 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 separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically
appropriate NCCI modifier is used to report the reason it should be paid as well.
The provider submitted a claim for procedure codes 99497 (advance care planning) and 99291 (critical care
services). Code 99497 is a column II code with a modifier indicator of 1 when billed with column I code
99291. Code 99497 was not billed with an appropriate modifier to allow for separate payment. Therefore, we
decided that the Plan does not have to pay for the advance care planning rendered on May 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual wellness visit rendered on August 19, 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 you exhausted the benefit limit.
The Plan must follow Medicare rules. Medicare rules say that an annual wellness visit is covered once every 12
months.
We looked at the file and Medicare rules. The file shows that you previously had an annual wellness visit on
February 5, 2021 that was covered by the Plan. The annual wellness visit on August 19, 2021 was performed
less than 12 months from your previously covered visit. Therefore, we decided that the Plan does not have to
pay for the annual wellness visit rendered on August 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the additional periapical x-rays (D0230 x 3) and scaling and root planing (D4342) for the upper right quadrant provided on September 21, 2021.  You asked the Plan to pay for the dental services. You say that you received confirmation 3 times that you had coverage. You say that you are on a very limited income. You also say that you cannot afford to pay this bill. The Plan denied your request. The Plan says 1 periapical x-ray is covered per calendar year. The Plan says that the frequency limit for this service has been exceeded. The Plan also says that scaling and root planing is not listed as a covered service.  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 and periapical x-ray is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for the initial periapical x-ray that you received on the date of service in this case. Additionally, scaling and root planing is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the additional periapical x-rays (D0230 x 3) and scaling and root planing (D4342) for the upper right quadrant provided on September 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the gel or gel-like pressure pad for mattress, standard mattress length and width (E0185) purchased on July 29, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the gel mattress pad. You say that you feel that this should have been covered by the Plan. The Plan denied your request. The Plan says no authorization on file for service in question.  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 gel or gel-like pressure pad for mattress, standard mattress length and width (E0185) purchased on July 29, 2021 by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit received on September 22,
2021.
You asked the Plan to waive the copayment for the services. You say that you did not want to go to this
appointment. The Plan denied your request. The Plan says the copayment was applied correctly in this case.
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 office visits.
You have been asked to pay a $40 copayment for the services. The services fall within the specialist 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 a specialist visit received on
September 22, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on August 16, 2021.
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that this was an emergency, and you feel you should not be responsible. The Plan denied your request. The Plan says the Medicare ambulance benefit is a transport benefit and if no transport of a Medicare beneficiary occurs, then there is no Medicare covered services. The Plan also says that the ambulance was called, and you were not transported to an emergency facility.
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 16, 2021. 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 response and treatment with no transport (A0998) provided on August 16, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on August 28, 2021.

You asked the Plan to pay for physical therapy services. The Plan denied your request. The Plan says prior authorization was not obtained by the 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 did not pre-approve the physical therapy 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 physical therapy services provided on
August 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided to the enrollee on September 6,
2021.
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 was not billed with the appropriate modifier.
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, we have confirmed that code 74176
is a column II code to column I code 74174. This claim has not been billed with an appropriate modifier to
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we
decided that the Plan does not have to pay for imaging services provided to the enrollee on September 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from
February 17, 2021, to February 20, 2021.
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 the DRG was reassigned.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the
reported principal and secondary diagnosis codes.
In this case, you billed the inpatient services provided with DRG 177 (Respiratory infections with MCC). 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 services. Our reviewer says that the
services at issue in this case were not supported by the medical records. Our physician reviewer found the
review indicates that the enrollee was a then 76 year old male with a history of diabetes, hypertension and
obesity who was admitted to the acute setting to manage a Covid-19 infection on February 17, 2021 and was
discharged February 20, 2021. He was treated with supplemental oxygen, Dexamethasone, Remdesivir, and
Albuterol as needed. He remained hemodynamically stable throughout the hospitalization. The review has
determined that the appropriate DRG is DRG 179: Respiratory infections and inflammations without CC/MCC.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay
for inpatient hospital services provided to the enrollee from February 17, 2021, to February 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for specialist office visit services received
from August 19, 2021, to October 1, 2021.
You asked the Plan to waive the copayments for the services. You say that the charges are excessive. The Plan
denied your request. The Plan says the claim was processed appropriately according to the services rendered
and your benefits.
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 office visits.
You have been asked to pay a $40 copayment for the services. The services fall within the specialist 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 specialist office visit services
received from August 19, 2021, to October 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient mental health admission and services provided November 13, 2019, to November 21, 2019.

You asked the Plan to waive the copayment for the inpatient mental health admission and services. You say that you were admitted against your will. The Plan denied your request. The Plan says the copayment 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 $245 copayment for each Medicare-covered day for days 1-6 for each inpatient hospitalization. 

You have been asked to pay a total of $1,470 ($245 copayment x 6 days = $1,470) for the inpatient mental health admission and services. the inpatient mental health admission and services falls within the Inpatient mental health 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 the inpatient mental health admission and services provided November 13, 2019, to November 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two custom fabricated abutments (D6057 x2), two abutment supported porcelain/ceramic crowns (D6058 x2), and pontic (D6245) provided on May 25, 2021.
You asked the Plan to pay for the custom fabricated abutments, abutment supported porcelain/ceramic crowns, and pontic. You say that [Enter appellant's argument from appeal letter, e.g. "...you need SNF care."] The Plan denied your request. The Plan says the custom fabricated abutments and abutment supported porcelain/ceramic crowns are not covered benefits under your dental plan. The Plan also says that the pontic is part of an implant supported bridge and is 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 custom fabricated abutment (D6057) and abutment supported porcelain/ceramic crown (D6058) are not among those covered under this benefit. The contract says that a pontic (D6245) is not covered for any part of an implant supported bridge. The provider's letter states that there are implants on tooth #'s 19 and 21, the pontic is needed due to a large space between the implants. Therefore, we decided that the Plan does not have to pay for the two custom fabricated abutments (D6057 x2), two abutment supported porcelain/ceramic crowns (D6058 x2), and pontic (D6245) provided on May 25, 2021.