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

We decided that the Plan does not have to waive the deductible for a diagnostic mammogram provided on October 15, 2021.
You asked the Plan to waive the deductible for a diagnostic mammogram. You say that you are being charged because the mammogram is being billed as diagnostic and not a screening. The Plan denied your request. The Plan says the claims were processed correctly, and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $750 deductible which applies to outpatient diagnostic tests and therapeutic services and supplies.
The medical records show that you received a diagnostic mammogram on October 15, 2021. Therefore, you are responsible to pay your share of the cost-sharing charges. The record shows that you had only paid $186.10 toward the $750 deductible prior to receiving the services. Therefore, you are responsible to pay the total allowed amount of $215.90. The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which applies to outpatient diagnostic tests and therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time a diagnostic mammogram was received on October 15, 2021. Therefore, we decided that the Plan does not have to waive the deductible for a diagnostic mammogram provided on October 15, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for radiation therapy provided from August 25, 2021, to August 27, 2021.
You asked the Plan to waive the coinsurance for radiation therapy. You say that you should owe less than the provider is charging and you did not go in on August 27, 2021. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for radiation therapy. The medical records show that you received radiation therapy on August 25, 2021. The total allowed amount is $165.30 and 20% of that is $33.06. The medical records show that you received radiation therapy on August 27, 2021. The total allowed amount is $781.50 and 20% of that is $156.30.
The total amount you owe is: $189.36. You have been asked to pay the total coinsurance amount of $189.36 for radiation therapy. Radiation therapy 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 coinsurance for radiation therapy provided from August 25, 2021, to August 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care rendered on October 12, 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 99231 (subsequent hospital care) and 01630 (anesthesia for surgery on humeral head and neck of shoulder joint). Code 99231 is a column II code with a modifier indicator of 1 when billed with column I code 01630. Code 99231 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 subsequent hospital care rendered on October 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection rendered on September 20, 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. Medicare rules say that in order for code 62320 to be covered, certain documentation requirements must be met. The medical records in this case do not meet Medicare's documentation requirements. Specifically, the record is not signed and there is no notation of the percent of pain relief achieved either before or after the injection. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of procedure code 62320 have not been met. Therefore, we decided that the Plan does not have to pay for the injection rendered on September 20, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (96372, 96361, 96374, 36415) provided October 11, 2021, to October 25, 2021.
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation provided does not support the billed services.
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 find that CPT codes 96372, 96361, 96374, & 36415 are not supported in the medical record. Specifically,
the claim did not include a valid provider type. A corrected claim was requested, and none was received. Based
on this information, we decided that Medicare rules for coverage of the physician services have not been met.
Therefore, we decided that the Plan does not have to pay for physician services (96372, 96361, 96374, 36415)
provided October 11, 2021, to October 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the three removals of residual tooth roots (D7250 x3)
provided on September 21, 2021.
You asked the Plan to pay for the removals of residual tooth roots. You say that you thought the $350 you paid
at the time of service would be sufficient and the Plan would cover the remainder. The Plan denied your
request. The Plan says this service is not a covered expense under your dental 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 the three
removals of residual tooth roots (D7250 x3) provided on September 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (62320) provided on October 18, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the records do not support the billed services.
The Plan must follow Medicare rules. Medicare rules say that in order for code 62320 to be covered, certain documentation requirements must be met. The documentation must include the legible signature of the physician or non-physician practitioner responsible for providing the care to the patient. In addition, the procedure report should clearly document the indications and the medical necessity for the blocks along with the pre and post percent pain relief achieved immediately post-injection. The medical records in this case do not meet Medicare's documentation requirements. Specifically, the record is not signed and there is no notation of the percent of pain relief achieved either before or after the injection. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of procedure code 62320 have not been met. Therefore, we decided that the Plan does not have to pay for the services (62320) provided on October 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (74176) provided September 7, 2021.
You asked the Plan to pay for the radiology services. You say that the radiology services were medically
necessary. The Plan denied your request. The Plan says the code billed shares a bundled relationship with
another code billed and is not separately payable.
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 74177. 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 radiology services (74176) provided September 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral x-rays (D0220, D0230) provided on October 12, 2021.
You asked the Plan to pay for the intraoral x-rays. You say that these services are listed as covered by your dental benefit. The Plan denied your request. The Plan says these x-rays are not covered by your dental 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. Please note that the pages of the contract cited in your appeal describe the benefits offered by the Plan's additional optional dental rider, which is available for an additional monthly premium. The Plan has confirmed that you were not enrolled in these additional benefits at the time of service. The intraoral x-rays are not listed as covered under the Plan's mandatory dental benefits. Therefore, we decided that the Plan does not have to pay for the intraoral x-rays (D0220, D0230) provided on October 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (62320) provided on August 16, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says records were not provided to support coverage.
The Plan must follow Medicare rules. Medicare rules say that in order for code 62320 to be covered, certain documentation requirements must be met. The documentation must include the legible signature of the physician or non-physician practitioner responsible for providing the care to the patient. In addition, the procedure report should clearly document the indications and the medical necessity for the blocks along with the pre and post percent pain relief achieved immediately post-injection.
The medical records in this case do not meet Medicare's documentation requirements. Specifically, the record is not signed and there is no notation of the percent of pain relief achieved either before or after the injection. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of procedure code 62320 have not been met Therefore, we decided that the Plan does not have to pay for the services (62320) provided on August 16, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for infusion services (S1015, S8301) provided July 8, 2021.

You asked the Plan to pay for the infusion services. You say that the services were medically necessary. The Plan denied your request. The Plan says the billed codes are not eligible for Medicare payment.

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 find that CPT code S1015 and S8301 is not supported in the medical record. Specifically, per the National Physician Fee Schedule, the billed codes have a status of "I" and are invalid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the infusion services have not been met. Therefore, we decided that the Plan does not have to pay for infusion services (S1015, S8301) provided July 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periapical radiographic imaging (D0230 and D0220) provided by a participating provider on September 29, 2021, to October 5, 2021.
You asked the Plan to pay for periapical radiographic imaging. You say that you were told this provider was in-network and that these services would be covered. The Plan denied your request. The Plan says the rendered dental 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 periapical radiographic imaging (D0230 and D0220) provided by a participating provider on September 29, 2021, to October 5, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the inpatient hospital stay provided by an out-of-network provider from January 5, 2020, to January 13, 2020.

You asked the Plan to pay for the inpatient hospital stay. You say that you were unaware of the enrollee's insurance and unable to follow the normal authorization process. The Plan denied your request. The Plan says that no prior authorization was obtained.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not submit the 2020 Evidence of Coverage. This means we cannot determine if the Plan's denial of non-emergent services is supported. Therefore, we decided that the Plan has to pay for the inpatient hospital stay provided by an out-of-network provider from January 5, 2020, to January 13, 2020.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an epidural steroid injection (62320) provided on October 18, 2021.  You asked the Plan to pay for an epidural steroid injection. You say that this treatment is part of a pain management program. The Plan denied your request. The Plan says this is not supported in the records.  The Plan must follow Medicare rules. Medicare rules say that in order for epidural steroid injections to be covered, the procedural report should clearly document the indications and medical necessity for the blocks along with the pre and post percent (%) pain relief achieved immediately post-injection.  We looked at the file and Medicare rules. The percent pain relief achieved immediately post-injection is not documented in the submitted records. Based on this information, we decided that Medicare rules for coverage of an epidural steroid injection have not been met. Therefore, we decided that the Plan does not have to pay for an epidural steroid injection (62320) provided on October 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital outpatient clinic visit provided on October 22, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the hospital outpatient clinic visit. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent.
Therefore, we decided that the Plan does not have to pay for the hospital outpatient clinic visit provided on October 22, 2021, 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 services (62320) provided on August 23, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the records do not support the billed service.
The Plan must follow Medicare rules. Medicare rules say that in order for code 62320 to be covered, certain documentation requirements must be met. The documentation must include the legible signature of the physician or non-physician practitioner responsible for providing the care to the patient. In addition, the procedure report should clearly document the indications and the medical necessity for the blocks along with the pre and post percent pain relief achieved immediately post-injection.
The medical records in this case do not meet Medicare's documentation requirements. Specifically, the record is not signed and there is no notation of the percent of pain relief achieved either before or after the injection. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of procedure code 62320 have not been met. Therefore, we decided that the Plan does not have to pay for the services (62320) provided on August 23, 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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
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 you do not require treatment by multiple therapies, including either physical therapy
or occupational therapy, at an intensive rehabilitation therapy program. You are ambulating short distances
with minimal assistance. You can receive services at a lower level of care.
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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for an automatic external defibrillator with electrocardiogram analysis (K0606) provided on September 29, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for an automatic external defibrillator with electrocardiogram analysis. You say that due to the opaque process of the Plan, you could not reasonably have known a prior authorization was required or secure a prior authorization. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not referred by a network provider or rendered in a participating facility. The Plan has also determined that these services were not urgent or emergent, nor were they approved in advance.  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 an automatic external defibrillator with electrocardiogram analysis (K0606) provided on September 29, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup (D2950) provided on October 19, 2021.

You asked the Plan to pay for the core buildup. You say that this service should be included with the covered
crowns. The Plan denied your request. The Plan says this service may only be covered once per year. You had
two core buildups provided on the date in question. The first core buildup is covered, but the second exceeds
the frequency limitations for this 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. The Plan can cover one core
buildup, including pins (D2950) per year.

Though the Plan offers a dental benefit in excess of Medicare coverage, the core buildup is requested in a
frequency that exceeds what is covered under this benefit. Therefore, we decided that the Plan does not have to
pay for the core buildup (D2950) provided on October 19, 2021.