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

We decided that the Plan does not have to pre-approve exercise classes, non-physician provider, per session
(CPT code S9451) provided from January 1, 2021, through August 1, 2021.

You asked the Plan to pre-approve the services. You say that you were not aware that your plan covered the membership until late August of this year. The Plan denied your request. The Plan says there was no conformation code obtained prior to the services being obtained.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. The plan confirmed you did not contact the plan prior to the dates of service January 1, 2021, February 1, 2021, March 1, 2021, April 1, 2021, May 1, 2021, June 1, 2021, July 1, 2021, August 1, 2021, to obtain the confirmation code needed as outlined in the Enrollment Requirements of your 2021 EOC. The plan has determined that the denial of reimbursement for items S9451 (Exercise classes, nonphysician provider, per session) you purchased on January 1, 2021, February 1, 2021, March 1, 2021, April 1, 2021, May 1, 2021, June 1, 2021, July 1, 2021, August 1, 2021, is correct per the plan benefits. Therefore, we decided that the Plan does not have to pre-approve exercise classes, non-physician provider, per session (CPT code S9451) provided from January 1, 2021, through August 1, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a telehealth psychotherapy visit provided on November 19, 2021.

You asked the Plan to waive the copayment for a telehealth psychotherapy visit. You say that these visits were for telehealth services and should be a $0 copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $40 copayment for an outpatient mental health telehealth visit.

The Plan confirmed this telehealth visit was not arranged through the Plan's telehealth service supplemental benefit. Therefore, a cost sharing amount applies. You have been asked to pay a $40 copayment for a telehealth psychotherapy visit. A telehealth psychotherapy visit falls within the an Outpatient 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 a telehealth psychotherapy visit provided on November 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist telehealth visit on January 14, 2022.

You asked the Plan to waive the copayment for a specialist telehealth visit. You say that this should be covered because you were unaware you had to enroll in the telehealth services to utilize the $0 copay benefit. The Plan denied your request. The Plan says the copay applied is correct.

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 $25 copayment for Physician/Practitioner services, including doctor's office visits. 

You have been asked to pay a $25 copayment for a specialist telehealth visit. Specialist telehealth visit falls within the Physician/Practitioner services, including doctor's office visits 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 a specialist telehealth visit on January 14, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the test provided to the enrollee on January 18, 2022.

You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. The Plan says this is not a covered service.

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 81599 is not supported in the medical record. Specifically, the service should be coded with CPT 81479. Additionally, it is statutorily not covered by Medicare at this time. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the test provided to the enrollee on January 18, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a telehealth psychotherapy visit provided on December 16, 2021.

You asked the Plan to waive the copayment for a telehealth psychotherapy visit. You say that these visits were for telehealth services and there should be a $0 copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $40 copayment for in-network outpatient mental health telehealth visit.

The Plan confirms that this visit was not arranged through the Plan's telehealth service supplemental benefit. Therefore, a cost sharing amount applies. You have been asked to pay a $40 copayment for a telehealth psychotherapy visit. A telehealth psychotherapy visit falls within the Outpatient 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 a telehealth psychotherapy visit provided on December 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for inpatient hospital stay on March 19, 2022, to March 22, 2022.

You asked the Plan to waive the coinsurance for inpatient hospital stay. You say that you are appealing the charges out of principle because you were bedridden during your stay so physical therapy was not given. The Plan denied your request. The Plan says the cost-sharing you are being charged is correct.

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 10% coinsurance for inpatient hospital stay. Includes inpatient acute, inpatient rehabilitation, long-term care hospitals, and other types of inpatient hospital services. Inpatient hospital care starts the day you are formally admitted to the hospital with a doctor's order. The day before you are discharged is your last inpatient day. Provider billed in the amount of $23,609.55 and the allowed amount is $8,538.82. The Plan paid $7,687.29. $8,538.82 - $7,687.29 = $851.53. Therefore, results in the total cost-sharing amount of $851.53.

You have been asked to pay 10% coinsurance for inpatient hospital stay. Inpatient hospital stay falls within the Inpatient hospital stays 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 inpatient hospital stay on March 19, 2022, to March 22, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for infectious agent antigen detection on January 12, 2022.

You asked the Plan to waive the cost-sharing for infectious agent antigen detection. You say that you do not agree with the charges. The Plan denied your request. The Plan says the cost-sharing amount you are being charged is correct.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 10% coinsurance for lab services, diagnostic procedures and tests, x-rays, and diagnostic radiology services including those performed in a freestanding lab, physicians office, or outpatient hospital facility. The allowed amounts for the 2 tests add to $96.04 + $70.38 = $166.42. This results in the full $125 deductible being applied to the claim. The remaining allowed amount is $166.42 - $125 = $41.42 meaning that a 10% coinsurance will be $4.14. Therefore, the $125 deductible + $4.14 coinsurance results in a total cost-sharing amount of $129.14. 

You have been asked to pay a $4.14 coinsurance and $125 deductible for infectious agent antigen detection. Infectious agent antigen detection falls within the Outpatient diagnostic tests and therapeutic service 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 cost-sharing for infectious agent antigen detection on January 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for a complete maxillary denture (D5110) and a 
complete mandibular denture (D5120) provided on May 23, 2022. 
 
You asked the Plan to waive the cost share for dentures. You say that you told the provider that you could not 
afford any services above your dental allowance amount. The Plan denied your request. The Plan says your 
annual dental allowance has been exhausted. 
 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 this benefit includes 
coverage up to $2,500 for supplemental preventive and comprehensive dental services. 
 
The record shows your annual dental allowance was exhausted during the processing of this claim. You have 
been asked to pay $2,992 for dentures received on May 23, 2022. These items/services fall within the dental 
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 cost share for a complete maxillary 
denture (D5110) and a complete mandibular denture (D5120) provided on May 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service April 8, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says procedure code 99100 is considered 
bundled and 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 procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service April 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the porcelain/ceramic crowns (D2740 x 3) and the core 
build-ups, including any pins when required (D2950 x 2) provided on April 9, 2021. 
 
You asked the Plan to pay for the dental items. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the dental items were received from an out-of-
network provider and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the dental items from an out-of-network provider. Though the Plan offers a 
dental benefit in excess of Medicare coverage, dental items/services received from an out-of-network provider 
are not covered. Therefore, we decided that the Plan does not have to pay for the porcelain/ceramic crowns  
(D2740 x 3) and the core build-ups, including any pins when required (D2950 x 2) provided on April 9, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the computer assisted navigation provided on March 25, 2022. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says that how the 
enrollee came to the provider is unable to be determined. 
 
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. 
 
We looked at the file and the rules. The Plan is inconsistent in their reasoning. The plan denied code 0054T 
because they could not determine how the enrollee came to the servicing provider. However, the Plan approved 
code 27130 which was billed on the same claim. The Plan has not made reasonable and diligent efforts to 
gather and forward to us information regarding their decision to deny your request.  Therefore, we decided that 
the Plan has to pay for the computer assisted navigation provided on March 25, 2022.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic x-ray (D0330) provided on May 3, 2022. 
 
You asked the Plan to pay for the dental services. You say that you cannot afford this payment. The Plan 
denied your request. The Plan says your benefit for the requested item or service 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service July 20, 2020. Therefore, 
we decided that the Plan does not have to pay for a panoramic x-ray (D0330) provided on May 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve scaling in presence of generalized moderate or severe 
gingival inflammation (D4346). 
 
You asked the Plan to pre-approve scaling. You say that you disagree with the denial of dental services. The 
Plan denied your request. The Plan says that the requested service is not covered due to the lack of full mouth 
x-rays. 
 
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. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of scaling in presence of generalized 
moderate or severe gingival inflammation (D4346) have been met. The Plan has made multiple attempts to 
obtain the medical records from the provider. The provider has not supported the need for this service. 
Therefore, we decided that the Plan does not have to pre-approve scaling in presence of generalized moderate 
or severe gingival inflammation (D4346).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vision services provided from November 1, 2021, to 
February 1, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the vision services. You say that the services should be covered. The Plan denied 
your request. The Plan says you must use an in-network provider for your services. 
   
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 vision services provided from November 1, 
2021, to February 1, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve resin-based composite - two surfaces, anterior tooth #8 
and 24. 
 
You asked the Plan to pre-approve the dental services. You say that you are having difficulty eating and pain 
due to fillings falling out. The Plan denied your request. The Plan says your benefit for the requested item or 
service 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested resin-based composite - two surfaces, anterior tooth #8 and 24 was 
exhausted on date of service April 06, 2022. Therefore, we decided that the Plan does not have to pre-approve 
resin-based composite - two surfaces, anterior tooth #8 and 24.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), intraoral imaging 
(D0220), and bitewings (D0274), provided by an out-of-network provider on January 24, 2022. 
 
You asked the Plan to pay for the dental services. You say that these services should be covered. The Plan 
denied your request. The Plan says the dental services were received from an out-of-network provider and are 
not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a limited oral evaluation (D0140), intraoral imaging (D0220), and bitewings (D0274), provided by 
an out-of-network provider on January 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the insertion of non-tunneled centrally inserted central 
venous catheter services coded 36556 and the arterial catheterization or cannulation for sampling, monitoring 
or transfusion services coded 33620-59 provided on December 29, 2021. 
 
You asked the Plan to pay for the insertion of non-tunneled centrally inserted central venous catheter services 
and the arterial catheterization or cannulation for sampling, monitoring or transfusion services. You say that 
you disagree with the Plan's denial. The Plan denied your request. The Plan says the services billed are not 
supported by the documentation. 
 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 36556 is insertion of non-tunneled centrally inserted 
central venous catheter; age 5 years or older. 
 
The CPT Code Manual definition of code 36620-59 is arterial catheterization or cannulation for sampling, 
monitoring or transfusion (separate procedure); percutaneous. 
 
We find that CPT codes 36556 and 36620-59 are not supported in the medical record. Specifically, the medical 
records submitted include an anesthesia record that a central venous catheter procedure was performed. 
However, the records didn't include documentation of the entry site and the final position of the tip of the 
central venous device. This means the validity and accuracy of the billed service cannot be verified. Therefore, 
code 36556 cannot be verified. 
 
The submitted medical records include an anesthesia record that indicated an arterial catheterization or 
cannulation for sampling, monitoring or transfusion (separate procedure); percutaneous, was performed. 
However, the submitted medical records do not include documentation of the entry site and does not include 
documentation of a cannula being inserted. Therefore, code 36620-59 cannot be verified. 
 
Based on this information, we decided that Medicare rules for coverage of the insertion of non-tunneled 
centrally inserted central venous catheter services and the arterial catheterization or cannulation for sampling, 
monitoring or transfusion services have not been met. Therefore, we decided that the Plan does not have to pay 
for the insertion of non-tunneled centrally inserted central venous catheter services coded 36556 and the arterial 
catheterization or cannulation for sampling, monitoring or transfusion services coded 33620-59 provided on 
December 29, 2021.