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

 We decided that the Plan does not have to waive the copayment for the computed tomography of the abdomen and pelvis (74178) provided on August 4, 2021.  You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.  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 $140 copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in a network physician's office or at a network free standing facility (such as a radiology center or medical clinic).    You have been asked to pay a $140 copayment for the Medicare-covered radiological diagnostic service provided. 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 computed tomography of the abdomen and pelvis (74178) provided on August 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cytopathology, concentration technique, smears and interpretation (CPT code 88108) provided to the enrollee on June 25, 2021.

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. Review of the shows the claim was billed with an inappropriate place of service 22 (outpatient). According to claims history, the enrollee was inpatient during this date of service per another claim, dates of service June 21, 2021, through June 29, 2021. Therefore, we decided that the Plan does not have to pay for the cytopathology, concentration technique, smears and interpretation (CPT code 88108) provided to the enrollee on June 25, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy evaluation and therapeutic activities
provided on June 3, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the physical therapy evaluation and therapeutic activities. You say that the
treating provider is in-network with the Plan, and prior authorization was not required. You also say that the
services rendered were medically necessary. The Plan denied your request. The Plan says the treating provider
is not a network provider with the Plan. The Plan also says that that these services are 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 did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the physical therapy evaluation and therapeutic
activities provided on June 3, 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 monaural hearing aids (V5050) provided on June 17, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for hearing aids. You say that a customer service representative from the Plan told you that you could use this provider because the hearing aids would be cheaper. The Plan denied your request. The Plan says the hearing aid services in this case were not urgent or emergent, nor were they pre-approved. These services could have been received from in-network providers.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the monaural hearing aids (V5050) provided on June 17, 2021, by an out-of-network (OON) provider.   Your complaint about potential misinformation from a Plan representative is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional intraoral periapical x-ray (D0230) provided on
September 16, 2021.
You asked the Plan to pay for the additional intraoral periapical x-ray. You say that you went to the dentist for
a cleaning and the did not tell you that they were doing x-rays. You also say that you feel you should owe
nothing because you did not get the service you wanted. The Plan denied your request. The Plan says your
benefits for this service have been satisfied and the frequency limitation 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, intraoral x-rays are limited to one
procedure code per calendar year. The record shows that you received a first intraoral periapical x-ray (D0220)
on September 16, 2021 which was covered by the Plan and your intraoral x-rays benefit has been exhausted.
Therefore, we decided that the Plan does not have to pay for the additional intraoral periapical x-ray (D0230)
provided on September 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the osseous surgery (D4261), bone replacement grafts (D4263), and guided tissue regeneration (D4266) provided on August 23, 2021.
You asked the Plan to pay for the dental services. You say that you have already paid most of this bill. You say that you did not know a treatment plan was not filed with the plan until now. You also say that you feel you should not be charged for these services based on errors. The Plan denied your request. The Plan says the osseous surgery, bone replacement graft, and guided tissue regeneration are not listed as covered dental services.
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 services you received are not among those covered under this benefit. Additionally, the record shows that you signed a financial agreement taking responsibility for the amount due. The financial agreement also states that it is an estimate and may differ from your actual coverage. Therefore, we decided that the Plan does not have to pay for the osseous surgery (D4261), bone replacement grafts (D4263), and guided tissue regeneration (D4266) provided on August 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network
(OON) provider on August 4, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network
provider, without prior authorization.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the service 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 this service. Therefore, we decided that the Plan
does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on August 4,
2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergency transportation; taxi (A0100) provided May 24, 2021.
You asked the Plan to pay for the taxi transportation. You say that this should be a covered benefit. The Plan denied your request. The Plan says routine transportation must be pre-scheduled through the Plan's transportation vendor in order to be covered.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine transportation when you arrange transportation in advance through the Plan's transportation vendor. We looked at your request, the records in the case file, and the rules. In this case your transportation was not arranged through the Plan's transportation vendor. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pay for the non-emergency transportation; taxi (A0100) provided May 24, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (82310, 82728, 83540, 83550, 83970,
84100) provided on March 3, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says the laboratory tests that are related to ESRD
treatment are considered integral to dialysis services and may only be reported by the dialysis facility.
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate.
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for
the laboratory services (82310, 82728, 83540, 83550, 83970, 84100) provided on March 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for intraoral images (D0230 and D0220), and bitewings (D0274) provided by a participating provider on October 27, 2021.  You asked the Plan to pay for intraoral images and bitewings. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says the services that were 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 intraoral images (D0230 and D0220), and bitewings (D0274) provided by a participating provider on October 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the bath set, oversized diabetic socks, and denture kit (CPT
code E1399 x 3) provided on June 23, 2021.
You asked the Plan to pay for the items. You say that the claim should be paid. The Plan denied your request.
The Plan says these items are non-covered items.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
These items are not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the bath
set, oversized diabetic socks, and denture kit (CPT code E1399 x 3) provided on June 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a tooth extraction (D7210) provided by an opt out provider on August 6, 2021.
You asked the Plan to pay for a tooth extraction. You say that you were referred to this dentist. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says the rendering dentist has opted-out of Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. The rendering dentist has opted out of Medicare until April1, 2023. Therefore, we decided that the Plan does not have to pay for a tooth extraction (D7210) provided by an opt out provider on August 6, 2021
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a 3-dmensional rendering with interpretation and reporting of imaging services (76377) provided on July 31, 2021.
You asked the Plan to pay for a 3-dmensional rendering with interpretation and reporting. You say that the service at issue was a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.
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 76377 is a column II code to column I code 71275. 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 a 3-dmensional rendering with interpretation and reporting of imaging services (76377) provided on July 31, 2021
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for a 3-dimensional radiotherapy plan (77295) provided on March 8, 2021,
and a therapeutic radiology field setting (77280) provided on March 9, 2021.
You asked the Plan to pay for radiological services. You say that the services at issue were a medical necessity
for the enrollee. The Plan denied your request. The Plan says that rules for payment have not been met because
the services at issue are considered included in code 77301.
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. Specifically, the Plan states that the provider billed 77301 but has not forwarded
any documentation to support this assertion. The Plan has not supplied additional evidence as to why codes
77295 and 77280 are not supported. It is the burden of the Health Plan to substantiate their denial with
evidence. In this case, the denial has not been substantiated, so we must find in your favor. Therefore, we
decided that the Plan has to pay for a 3-dimensional radiotherapy plan (77295) provided on March 8, 2021, and
a therapeutic radiology field setting (77280) provided on March 9, 2021.
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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a scooter (K0010) and related supplies and fees provided on June 22, 2021.  You asked the Plan to pay for a scooter and supplies/fees. You say that the items at issue were a necessity for you. The Plan denied your request. The Plan says rules for payment have not been met because the supplier of the items at issue is not enrolled in the Medicare program.  The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for a scooter (K0010) and related supplies and fees provided on June 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI provided on September 18, 2021.
You asked the Plan to waive the copayment for an MRI. You say that you should have been informed of the copayment beforehand. 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 $325 copayment for diagnostic radiology services that are not ultrasounds. You have been asked to pay the allowed amount of $196.13, which is less than the $325 copayment for an MRI. An MRI falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an MRI provided on September 18, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the portable oxygen concentrator (E1392) provided on
August 6, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the portable oxygen concentrator. You say that you would like reconsideration
because you need the portable oxygen concentrator at work and at home. The Plan denied your request. The
Plan says you did not receive this equipment from an in-network provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan 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.
Additionally, the record does not include a physician order for the purchased durable medical equipment.
Therefore, we decided that the Plan does not have to pay for the portable oxygen concentrator (E1392)
provided on August 6, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for podiatry services provided on September
27, 2021.
You asked the Plan to waive the copayment for podiatry services. You say that the copayment should not be
charged. The Plan denied your request. The Plan says the proper copayment was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35
copayment for Medicare Covered Podiatry Services in a Specialist's office.
You have been asked to pay a $35 copayment for podiatry services. Podiatry services falls within the Podiatry
services benefit category. This means that you have been asked to pay the correct amount based on your
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the
Plan. Therefore, we decided that the Plan does not have to waive the copayment for podiatry services provided
on September 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for magnetic resonance angiography, head; without contrast material(s) (CPT code 70544) provided to the enrollee on September 8, 2021.  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. Our records indicate a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 70551 and 70544. 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 magnetic resonance angiography, head; without contrast material(s) (CPT code 70544) provided to the enrollee on September 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crowns (D2740) provided on May 27, 2021.

You asked the Plan to pay for the crowns. You say that you say that your understanding is that your policy covers crowns, except when employed for bite or height adjustment. You also say that as a result of grinding your teeth, additional crowns were required. The Plan denied your request. The Plan says this service is not a covered expense under your dental plan. The Plan also says that you did not contact the Plan prior to this date of service to verify benefits and 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, 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 crowns (D2740) provided on May 27, 2021.