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

We decided that the Plan does not have to waive the copayment for the sleep study performed on April 23, 2021.

You asked the Plan to waive the copayment for the sleep study. You say that you are wondering why you are being billed $100 twice for the same service when you only had one sleep study done on January 23, 2021, and the other on April 23, 2021, was a follow up visit. The Plan denied your request. The Plan says the claim was processed accordingly with your 2021 EOC 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). 

Review of the file show that you received two (2) separate sleep studies were conducted on January 23, 2021, and April 23, 2021. You were asked to pay a $100 copayment for the sleep study. Your 2021 EOC states that enrollees must pay a $100 copayment per visit for Medicare-covered sleep studies in an outpatient facility setting. 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 sleep study performed on April 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on June 25, 2021.
You asked the Plan to pay for a limited oral evaluation. You say that this was your first evaluation dental visit with this provider, and you do not understand why the office visit is not a covered expense. The Plan denied your request. The Plan says there is no coverage for a limited oral evaluation problem focused 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, 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 limited oral evaluation (D0140) provided on June 25, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aduhelm.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has dementia diagnosed by positron emission tomography (PET) scan and magnetic resonance imaging (MRI). The neurology note dated September 17, 2021 states he has memory issues but is able to shop, pay bills, and perform all activities of daily living. A mini-mental state exam (MMSE) of 25 out of 30 is documented, which correlates with normal cognition. The MRI imaging in this case suggests the presence of cerebrovascular disease, which is evidence of a mixed etiology for the enrollee's symptoms. It has not been sufficiently demonstrated that Aduhelm is at least as beneficial as the existing and medically appropriate alternatives that this enrollee is taking. Aduhelm is therefore not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Aduhelm.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health skilled nursing service needs.

You asked the Plan to pre-approve home health services. The Plan denied your request. The Plan says the enrollee's care does not require the skills of a licensed nurse.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy.

A doctor must certify the need for home health care services. 

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 home health services. Our physician reviewer found that in this case, the documentation does not support that the enrollee requires additional skilled nursing services to effectively provide treatment in order to improve his condition, or to perform a maintenance program to maintain his condition or prevent deterioration. He has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. He has had skilled nursing services for education and medication management. Therefore, the requested home health services are not medically necessary at this time. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health skilled nursing service needs.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for limited oral evaluation - problem focused (CPT code D0140), cone beam CT capture and interpretation with field of view of one full dental arch - maxilla, with or without cranium (CPT code D0366), guided tissue regeneration - resorbable barrier, per site (CPT code D4266) for tooth #13, surgical placement of implant body: endosteal implant (CPT code D6010) for tooth #13, bone graft at time of implant placement (CPT code D6104) for tooth #13, extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (CPT code D7210) for tooth #13, and collection and application of autologous blood concentrate product (CPT code D7921) provided on April 13, 2021, and April 15, 2021, by a non-contracted provider.

You asked the Plan to pay for the dental services. You say that you believed this provider was in-network. The Plan denied your request. The Plan says the claims were processed accordingly with your 2021 EOC 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. Review of the file show that the Plan has decided to reprocess both claims at an in-network level, and in accordance with your 2021 benefits due to incorrect provider network information being provided to you. You were reimbursed the Plan's share of the covered services which totaled to $1,788.50. The Plan approved reimbursement in full for D0140, D0366 and D4266 in the amount of $370.00. Reimbursement was also approved for the Plan's 50% cost share of D6010 at $1,091.50 ($2183 X .50) and D7210 at $197.00 ($394 X .50). In addition, an extra $130.00 was also included in the reimbursement as it was deducted from your share of $1091.50, reducing your share to $961.50 for D6010), this exhausted your $500.00 dental allowance; the dental allowance can be used for covered comprehensive services ($95.00 (D0140) + $75.00 (D0366) + $200.00 (D4266) + $130.00 (D6010) = $500.00 dental allowance). You are responsible for your 50% cost share of D6010 at $1,091.50 - $130.00 allowance = $961.50 ($2183.00 X .50 - $130.00) and D7210 at $197.00 ($394 X .50), and are also responsible for the charges for D6104 and D7921 as these services are not listed as covered benefits per pages 125-133 of your 2021 EOC. Therefore, we decided that the Plan does not have to pay for the dental services provided on April 13, 2021, and April 15, 2021, by a non-contracted provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and a cone beam computed tomography (CT) image (D0383) provided on June 25, 2021.
You asked the Plan to pay for a comprehensive oral evaluation and a cone beam CT image. You say that this was a medical examination of your tongue and should be handled that way. The Plan denied your request. The Plan says the requested provider 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. We have confirmed that the provider opted out of Medicare on October 4, 2016.
This means that the provider was opted out of Medicare for the date of service at issue. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and a cone beam computed tomography (CT) image (D0383) provided on June 25, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the perfusionist services provided on May 10, 2021.

You asked the Plan to pay for the perfusionist services. You say that the services were ordered by the in-network surgeon as a surgical requirement and were provided at an in-network facility. You say that you are requesting reprocessing of the claim under ancillary provider rules based on the surgeon's requirement for the services. The Plan denied your request. The Plan says these are inpatient only services.

The Plan must follow Medicare rules. Medicare rules say that no Medicare payment can be made to a provider that is not enrolled in the Medicare program and all items and non-physician services furnished to inpatients must be furnished directly by the hospital or billed through the hospital under arrangements. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the perfusionist services have not been met. Therefore, we decided that the Plan does not have to pay for the perfusionist services provided on May 10, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on March 15, 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 procedure codes 95955, 95937, 95908, and 95927 are not supported.

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 95955 is electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery). The definition of code 95937 is neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method. The definition of code 95908 is nerve conduction studies; 3-4 studies. The definition of code 95927 is short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in the trunk or head. 

We find that CPT codes 95955, 95937, 95908, and 95927 are not supported in the medical record. Specifically, there is no documentation of an EEG during nonintracranial surgery to support code 95955. There is no documentation of neuromuscular junction testing to support code 95937. There is no documentation of 3-4 nerve conduction studies to support code 95908. There is no documentation of a short-latency somatosensory evoked potential study to support code 95937.

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 testing services rendered on March 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a personal emergency response system.
You asked the Plan to pre-approve 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 items that do not contribute meaningfully to the treatment of an illness or injury or the functioning of a malformed body member are not covered. The item at appeal is a medical life alert system. While this item may be of benefit to you, it is not covered by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve a personal emergency response system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for frames, purchases (CPT code V2020), spherocylinder, bifocal, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per lens (CPT code V2203) and anti-reflective coating, per lens (CPT code V2750) purchased on May 11, 2021.
You asked the Plan to pay for the eyewear. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says you exhausted your benefit allowance.
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. We looked at the file and the Plan's rules. You exhausted your benefit allowance. The Plan paid $100 for the eyewear. Your 2021 EOC states that if the eyewear you purchase costs more than $100, you pay the difference. Therefore, we decided that the Plan does not have to pay for frames, purchases (CPT code V2020), spherocylinder, bifocal, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per lens (CPT code V2203) and anti-reflective coating, per lens (CPT code V2750) purchased on May 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown rendered on May 25, 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.

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 crown rendered on May 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for apicoectomy/periradicular surgery - molar (first root) (CPT code D4325) and Retrograde filling - per root (CPT code D3430) provided to the enrollee on April 27, 2021.
You asked the Plan to pay for the dental services. You say that the only option to save the tooth was by completing the apicoectomy. The Plan denied your request. The Plan says the services are not a covered benefit under the 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. The services are not listed in the enrollee's EOC as a covered benefit; therefore, they are not covered. Therefore, we decided that the Plan does not have to pay for apicoectomy/periradicular surgery - molar (first root) (CPT code D4325) and Retrograde filling - per root (CPT code D3430) provided to the enrollee on April 27, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit on April 1, 2021.

You asked the Plan to waive the copayment for the emergency room visit. You say that the copayment should be $75 and not $110 because when you went to the emergency room, they did a procedure, and your benefits say a procedure has a $75 copayment. You state that you did not have $110 at the time and your daughter paid a copayment at the hospital front desk. You state you should not have to pay the $110 copayment bill you received in the mail. The Plan denied your request. The Plan says the $75 copayment for outpatient procedures does not apply towards emergency room services. The Plan states the $110 copayment does apply since this is not an outpatient visit but an emergency room visit. The Plan states they made an error processing the claim and corrected the claim. The Plan states there is a reprocessed claim showing that one copayment of $110 was removed and there is only one $110 copayment you owe for the emergency room visit on April 1, 2021.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). 

Review of the file show that you had an emergency room visit on April 1, 2021. You were asked to pay a $110 copayment for the emergency care you received. Your 2021 EOC states enrollees must pay a $110 for each covered emergency room visit. If you paid the $110 copayment for the services, please talk to your Plan regarding the payment. 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 emergency room visit on April 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gastrointestinal tract imaging.

You asked the Plan to pre-approve gastrointestinal tract imaging. You say that the enrollee is elderly and in extreme pain. You say that the medical records show that the enrollee still needs treatment and that the requested testing is necessary. The Plan denied your request. The Plan says there are no clinical notes showing that the bleeding source cannot be identified at colonoscopy or upper endoscopy. The Plan says that the records do not show persistent GI bleeding after the treatment noted was performed.

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 gastrointestinal tract imaging. Our reviewer says that gastrointestinal tract imaging is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has undergone recent upper gastrointestinal endoscopy (EGD) and colonoscopy, at which time colonic arteriovenous malformations (AVM's) were ablated and gastritis was identified and treated (with resolution of epigastric pain). No subsequent clinical notes were provided that show the enrollee has demonstrate persistent gastrointestinal (GI) bleeding after the treatments performed above. No laboratory studies were provided to corroborate ongoing iron deficiency nor progressive anemia to warrant the requested services as medically necessary at this time. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of gastrointestinal tract imaging have not been met. Therefore, we decided that the Plan does not have to pre-approve gastrointestinal tract imaging.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the hip x-ray (CPT code 73502) provided on June 4, 2021.
You asked the Plan to waive the copayment for the hip x-ray. You say that you were told your copayment would only be $40 and you feel the claim should be reprocessed since you feel you were misrepresented. The Plan denied your request. The Plan says there is a $100 copayment for radiology services performed in an outpatient hospital. The Plan states since the allowable amount is less than the copayment, your responsibility is 100% of the allowable amount which is $74.59. The Plan states you did not make outreach to the Health Plan to verify benefits for this service until after the services were rendered.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance).
Review of the file show that you received a hip x-ray at the outpatient department of the hospital on June 4, 2021. The Medicare-allowed amount for the x-ray is less than the set $100 copayment; therefore, you have been asked to pay the lesser amount of $74.59 for the hip x-ray. 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 hip x-ray (CPT code 73502) provided on June 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on March 9, 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 were not billed correctly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on March 9, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on October 7, 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 were not billed correctly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results.
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on October 7, 2020.