Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments and coinsurance for transfusion with red blood cells, computed tomography (CT) scans, a catheter insertion procedure, ferric carboxymaltose injections, and an octreotide injection provided from January 14, 2021, to August 12, 2021.
You asked the Plan to waive the copayments and coinsurance for the transfusion, CT scans, catheter insertion, and injections. You say that you have never received bills for lab work or preventive injections before. The Plan denied your request. The Plan says the correct copayments and coinsurance were 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 $0 copayment for blood services. In addition, for the administration of blood infusion, you will pay the cost sharing for the location of the services. Your contract with the Plan clearly says that you must pay a $125 copayment for surgery or other services provided at an outpatient hospital. Your contract with the Plan clearly says that you must pay an $85 copayment for radiological diagnostic services, including CT scans. Your contract with the Plan clearly says that you must pay a 20% coinsurance for each Part B drug, including injectable drugs. You have been asked to pay a $125 copayment for each transfusion. The transfusions fall within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. You have also been asked to pay an $85 copayment for each CT scan. The CT scans fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. You have also been asked to pay a $125 copayment for the catheter insertion. The catheter insertion falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. You have also been asked to pay 20% of the allowed amount for each injection. The injections fall within the Medicare Part B Prescription Drugs 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 and coinsurance for transfusion with red blood cells, computed tomography (CT) scans, a catheter insertion procedure, ferric carboxymaltose injections, and an octreotide injection provided from January 14, 2021, to August 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) therapy rendered on August 30, 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 TENS therapy for chronic low back pain (CLBP) is covered when the beneficiary is enrolled in an approved clinical study meeting specific requirements.
We looked at the file and Medicare rules. The file shows that the TENS therapy was not provided for CLBP in the setting of an approved clinical study. 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 transcutaneous electrical nerve stimulation (TENS) therapy rendered on August 30, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (88312, 88305) provided on October 7, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says there were network providers available.
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 services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for lab services (88312, 88305) provided on October 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on March 8,
2021.
You asked the Plan to pay for the dental service. You say that you were advised to opt out of Medicare because
you had no interactions with Medicare at all since 2007. You say that you are now receiving notification that
your patient's reimbursements are being denied. You also say that the services should be covered until you are
able to opt back in to the Medicare program. The Plan denied your request. The Plan says the provider in this
case has opted out of Medicare. The Plan also says payment cannot be made to a provider that has opted out of
Medicare.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, dental services performed by a dentist
that has opted out of Medicare are not among those covered under this benefit. Therefore, we decided that the
Plan does not have to pay for the periodontal maintenance (D4910) provided on March 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2740) and core buildup (D2950) provided on May 13, 2021.
You asked the Plan to pay for the crown and core buildup. You say that you would not have had these services done if you knew they would not be covered. The Plan denied your request. The Plan says there is a $1,000 annual maximum for dental care every year. You have previously exceeded this limit and are responsible for the excess charges. In addition, the core buildup is not a covered service under 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. The Plan does not cover services which are not listed in the dental benefits chart in the contract. The Plan covers a maximum of $1,000 for dental care each year. Though the Plan offers a dental benefit in excess of Medicare coverage, the record shows that you have previously exhausted your $1,000 annual limit for dental care. In addition, the core buildup is not listed as a
covered service under this benefit. Therefore, we decided that the Plan does not have to pay for the crown (D2740) and core buildup (D2950) provided on May 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (G0483) provided to the enrollee on March 10, 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 G0483 remains 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 G0483 is "Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed."
We find that CPT code G0483 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). 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 pay for drug testing services (G0483) provided to the enrollee on March 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for radiation therapy provided from August 27, 2021, to September 14, 2021.  

You asked the Plan to waive the coinsurance for radiation therapy. You say that you feel that you are being overcharged. 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.  

You received radiation therapy from August 27, 2021, to September 14, 2021. Therefore, you are responsible to pay your share of the cost-sharing charges. Please see the chart below.
   
Date of Service Service Allowed Amount Amount You Owe 
8/27/2021 Radiation Therapy $7,653.20 $1,530.63 
9/8/2021 Radiation Therapy $3,780.84 $756.17 
9/9/2021 Radiation Therapy $3,993.83 $798.77 
9/10/2021 Radiation Therapy $3,780.84 $756.17 
9/13/2021 Radiation Therapy $1,828.99 $365.80 
9/14/2021 Radiation Therapy $1,828.99 $365.80  

The total amount you owe is: $4,573.34.  

You have been asked to pay the total coinsurance amount of $4,573.34 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 27, 2021, to September 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for injections (62320) provided October 4, 2021.

You asked the Plan to pay for the injections. 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 for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.

We looked at the file and Medicare rules. Insufficient clinical records were provided to support the billed code. Additional records were requested by the plan, and none were provided. Based on this information, we decided that Medicare rules for coverage of the injections have not been met. Therefore, we decided that the Plan does not have to pay for injections (62320) provided October 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services 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.

The Plan must follow Medicare rules. The rules say that genetic testing procedures submitted under CPT code 81455 are denied as not medically necessary.

We looked at the file and Medicare rules. The services are billed under code 81455. 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 laboratory services rendered on May 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the fixed partial denture sectioning (D9120) provided on October 26, 2021.  

You asked the Plan to pay for fixed partial denture sectioning. You say that this service was necessary. The Plan denied your request. The Plan says this service is 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. Therefore, we decided that the Plan does not have to pay for the fixed partial denture sectioning (D9120) provided on October 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the comprehensive oral evaluation (D0150), complete series x-ray (D0210), and extraction (D7140) provided from July 26, 2021, to August 3, 2021, by the out of network dentist.

You asked the Plan to pay an additional amount for the dental services. You say that it is your understanding that your plan allows you to receive treatment in and out of network at 100%. You say that when you looked up your plan, it was covered 100% out of network. You say taht The Plan denied your request. The Plan says out of network dentists may bill you for any amount greater than what the plan pays. The Plan also says that you did not contact them to verify benefits or provider eligibility.

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 services are listed as covered, out of network dentists may bill you for any amount greater than what the Plan pays. Therefore, we decided that the Plan does not have to pay an additional amount for the comprehensive oral evaluation (D0150), complete series x-ray (D0210), and extraction (D7140) provided from July 26, 2021, to August 3, 2021, by the out of network dentist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an intraoral image (D0210) provided by a participating provider on November 8, 2021.
You asked the Plan to pay for an intraoral image. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says the benefit limit for D0210 has already been exhausted.
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 covers an intraoral image once every five years. We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of an intraoral image have already been met. Therefore, we decided that the Plan does not have to pay for an intraoral image (D0210) provided by a participating provider on November 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (87496, 87498, 87502, 87486) provided September 22, 2021.
You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan denied your request. The Plan says this service was for screening purposes and is non-covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal, genetic testing, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for genetic testing (87496, 87498, 87502, 87486) provided September 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

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

We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on October 13, 2021.

You asked the Plan to pay for the panoramic x-ray. You say that the panoramic x-ray was covered the last time you had it. You also say that you would like the Plan to pay for the charge as this service is assumed to be covered in 2022. 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 panoramic x-ray (D0330) provided on October 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient mental health care provided from September 22, 2021, to September 24, 2021.
You asked the Plan to waive the copayment for inpatient mental health care. You say that you feel that the charges should be paid due to how you were treated. 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 a $318 copayment for days 1-5 for inpatient mental health care. You have been asked to pay $318, which is less than the total copayment amount for inpatient mental health care. Inpatient mental health care 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 inpatient mental health care provided from September 22, 2021, to
September 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for orthotics (L0650, L1833) provided July 21, 2021.
You asked the Plan to pay for the orthotics. You say that the medical equipment was medically necessary. The Plan denied your request. The Plan says this equipment was provided following an unsolicited telephonic consult and there was no physical exam.
The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances. We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an
unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the past 15 months. Based on this information, we decided that Medicare rules for coverage of the orthotics have not been met. Therefore, we decided that the Plan does not have to pay for orthotics (L0650, L1833) provided July 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on October 21, 2021.

You asked the Plan to pay for the dental service. You say that you do not remember going to the dentist in 2019. You also say that you cannot afford to pay $75. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 3 plan years. 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 service is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation that you received on October 11, 2019, less than 3 years ago. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on October 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for urgently needed services provided on November 17, 2021.  You asked the Plan to waive the copayment for urgently needed services. You say that they were unable to treat your condition so you went to the emergency room. 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 a $65 copayment for urgently needed services.   You have been asked to pay a $65 copayment for urgently needed services. Urgently needed services fall within the urgently needed services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for urgently needed services provided on November 17, 2021.