Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the amalgam filling and intraoral x-ray provided on September 30, 2020 and the intraoral x-ray and full mouth debridement provided on October 7, 2020.

You asked the Plan to pay for the amalgam filling, intraoral x-rays, and full mouth debridement. You say that you thought this would be covered because an x-ray is an x-ray, and a cleaning is a cleaning. You say that you went to this dentist because he accepts your insurance. 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 amalgam filling and intraoral x-ray provided on September 30, 2020 and the intraoral x-ray and full mouth debridement provided on October 7, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the intravenous ultrasound and related procedures (CPT code(s): 75820, 75822, 36012, 37252, 37253, 75822, 76937, 36011, and sedation codes, 99152 & 99153), for the enrollee.

You asked the Plan to pre-approve the services. You say that the procedure is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does have signs and symptoms consistent with venous insufficiency, but not iliac vein compression. The Plan states the enrollee has had no surgical treatment for venous insufficiency and they have not had initial testing such as computed tomographic (CT) or magnetic resonance (MR) venography.

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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support the medical necessity of the invasive vein procedures in question. There is no documentation of leg edema on physical examination, there is no evidence of left greater than right leg edema as leg measurements is symmetric bilaterally. There is no evidence of proximal venous occlusive disease on noninvasive imaging. As there is no evidence of May-Thurner syndrome or proximal vein occlusive disease, the documentation does not support the appropriateness or medical necessity of the procedures in question. 

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve the intravenous ultrasound and related procedures (CPT code(s): 75820, 75822, 36012, 37252, 37253, 75822, 76937, 36011, and sedation codes, 99152 & 99153), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for urgent care services you received on May 5, 2021.  You asked the Plan to waive the copayment for the urgent care services. You say that after consulting with your primary care doctor, you were directed to the walk-in clinic for care. The Plan denied your request. The Plan says you were charged this copayment 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 copayment for urgent care or walk-in clinic services.   You have been asked to pay a $20 copayment for the urgent care services. 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 urgent care services you received on May 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids provided on March 25, 2021.
You asked the Plan to reimburse you for hearing aids. The Plan denied your request. The Plan says hearing aids are not a Medicare covered benefit. Your Plan offers hearing aids as an extra benefit, but only through contracted hearing aid providers.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when provided by the network hearing aid provider. We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided by the network hearing aid provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids provided on March 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit you had with an orthopedic
surgeon on August 11, 2021.
You asked the Plan to waive the copayment for the orthopedic surgery visit. You say that this visit was needed
as a result of after-effects from COVID-19, so the copayment should be waived. The Plan denied your request.
The Plan says you were charged this copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40
copayment for visits with a specialist.
Plan documentation shows that copayments are only waived for COVID-19 testing and treatment. According
to the records, this visit was to treat you for arthritis, not COVID-19. That is why this copayment applies. You
have been asked to pay a $40 copayment for the orthopedic surgery visit. The orthopedic surgery visit falls
within the visits with a specialist 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 office visit you had with an orthopedic
surgeon on August 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an unspecified preventive procedure (D1999) provided on September 13, 2021.
You asked the Plan to pay for an unspecified preventive procedure. You say that you do not agree with the denial of payment for necessary services. You visited your dentist because of a fallen filling in one of your teeth, this you understand is not an out of ordinary visit and understand that services should be covered. The Plan denied your request. The Plan says the service at issue is not covered under your benefit Plan.
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 an unspecified preventive procedure (D1999) provided on September 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services you received on June 8, 2021.
You asked the Plan to waive the copayment for the lab services. You say that these lab services were done in
preparation for your annual physical scheduled a few days later. The Plan denied your request. The Plan says
this copayment was charged 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 $10
copayment for lab services.
Your Evidence of Coverage explicitly says that an annual physical includes the following services: bodily
systems examinations, measurement and recording of vital signs, a complete prescription medication review,
and a review of recent hospitalizations. It does not include lab services, so a separate copayment can apply.
You have been asked to pay a $10 copayment for the lab services. 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 lab services you received on June 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the CT scan of the head or brain (CPT code 70450) provided to the enrollee on July 13, 2021.  You asked the Plan to pay for the CT scan. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not covered as billed.  The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met. Our records indicate a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 70450 and 70496. This PTP edit has a modifier indicator of 1, which indicates modifiers associated with NCCI are allowed, however, an appropriate NCCI modifier was not billed with this PTP code edit. Therefore, we decided that the Plan does not have to pay for the CT scan of the head or brain (CPT code 70450) provided to the enrollee on July 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), extraction (D7140), and take-home drug (D9630) provided on June 15, 2021.
You asked the Plan to pay for the dental services. You say that every time you call the plan you are advised the services should have been paid. The Plan denied your request. The Plan says you pay 100% for extractions received out of network.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the limited oral evaluation and take-home drug are not among those covered under this benefit. Additionally, the record shows that the Plan reprocessed the extraction to be paid at 100% of the allowable amount. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), extraction (D7140), and take-home drug (D9630) provided on June 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for office visits you had with a pulmonology
specialist on February 1, 2021, and August 2, 2021.
You asked the Plan to waive the copayments for the specialist visits. You say that these visits were needed as a
result of after-effects from COVID-19, so the copayments should be waived. The Plan denied your request. The
Plan says these copayments were charged correctly. The Plan says that the diagnosis billed on these claims
(pulmonary nodule) is not a COVID-19 diagnosis, so the copayments apply.
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 visits.
According to the Plan's documentation, the Plan is only waiving cost sharing for COVID-19 testing and
treatment. The claims for these services do not indicate that these visits were related to COVID-19 tests or
treatment. You have been asked to pay a $40 copayment for the specialist visits. 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 office visits you had with a pulmonology specialist on February 1, 2021, and
August 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a complete maxillary and mandibulary denture (D5110 and D5120) provided by a participating provider on July 12, 2021.

You asked the Plan to pay for a complete maxillary and mandibulary denture. You say that you needed new dentures, and you are very pleased with your new dentures. The Plan denied your request. The Plan says the dental services provided are not a covered benefit.

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 a complete maxillary and mandibulary denture (D5110 and D5120) provided by a participating provider on July 12, 2021.
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.
You asked the Plan to pre-approve IRF care. You say that it is felt that this is medically necessary. The Plan
denied your request. The Plan says the criteria for IRF admission 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 in the Medicare rules section.
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 enrollee was admitted to acute care after a fall which caused a left hip fracture.
This was surgically treatment, and the enrollee is weight-bearing as tolerated. The records show that the
enrollee is medically stable with no acute medical problems. She has no acute rehab nursing needs. Based upon
the enrollee's current level of function, she does not require intensive therapies, consisting of at least 3 hours of
therapy per day at least 5 days per week with multidisciplinary approach to daily therapy.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 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.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy services provided from May 25, 2021 through June 29, 2021.
You asked the Plan to waive the copayment for physical therapy services. You say that you were under the assumption that three back-to-back visits was one payment of $20. You say that you had no say in the number of appointments scheduled and you should have been advised that this would result in frequent $120 copayments. The Plan denied your request. The Plan says the copayments 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 $20 for each Medicare-covered physical therapy visit.
You have been asked to pay a $20 copayment for each physical therapy visit. The total amount you owe is $240 ($20/visit x 12 visits = $240). Physical therapy services fall within the "Outpatient rehabilitation services" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for physical therapy services provided from May 25, 2021 through June 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99203) radiologic examination,
spine, cervical (72040) radiologic examination, spine, lumbosacral (72100) radiologic exam, spine; thoracic
(72070) electrical stimulation (unattended) (97014) therapeutic ultrasound (97035) therapeutic procedures
(97110) mechanical traction (97012) hot/cold packs (97010) provided July 16, 2021 to August 2, 2021.
You asked the Plan to pay for the chiropractic services. You say that you are asking for payment of at least half
of the invoice since this was a trial just like all doctor visits. The Plan denied your request. The Plan says these
services are not covered when rendered by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that
the Plan does not have to pay for the outpatient office visit (99203) radiologic examination, spine, cervical
(72040) radiologic examination, spine, lumbosacral (72100) radiologic exam, spine; thoracic (72070) electrical
stimulation (unattended) (97014) therapeutic ultrasound (97035) therapeutic procedures (97110) mechanical
traction (97012) hot/cold packs (97010) provided July 16, 2021 to August 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections.
You asked the Plan to pre-approve facet joint injections. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that one to two levels, either unilateral or bilateral, are allowed per session per spine region. 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 facet joint injections. Our reviewer says that the services are not medically necessary. Our physician reviewer found the record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service at more than two levels for the same date of service. The elements of the coverage criteria are not satisfied. The requested service is not recommended.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for occupational therapy provided by a participating provider on June 25, 2021.
You asked the Plan to waive the copayment for occupational therapy. You say that these services were never provided. The Plan denied your request. The Plan says services were rendered on the date of service in question.
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 pay a $40 copayment for outpatient rehabilitation services/in-network/occupational therapy services. The enrollee has been asked to pay a $40 copayment for occupational therapy. The correct copayment has been applied to the services that were provided. Occupational therapy falls within the outpatient rehabilitation services/in-network/occupational therapy services benefit category. 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 for occupational therapy provided by a participating provider on June 25, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for magnetic resonance angiography (MRA) of the head (70544) and MRA of the neck blood vessels (70547) provided on March 15, 2021.

You asked the Plan to pay for the MRA of the head and MRA of the neck blood vessels. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says these codes are included in services that have been processed and paid.

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 codes 70544 and 70547 are column II codes to column I codes 70551 and 76376. This claim has not been billed with an appropriate modifier to bypass these edits. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for magnetic resonance angiography (MRA) of the head (70544) and MRA of the neck blood vessels (70547) provided on March 15, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for famotidine 20MG injection (CPT code S0028) provided to the enrollee on December 9, 2020.
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not covered as billed.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the service have not been met. Per Medicare guidelines this code is not a valid code for Medicare purposes as CPT code S0028 is assigned a status code I = Not valid for Medicare purposes. Therefore, we decided that the Plan does not have to pay for famotidine 20MG injection (CPT code S0028) provided to the enrollee on December 9, 2020.