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

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain
rendered on May 2, 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 70450 (CT head/brain) and 70496 (computed tomography
angiography of the head). Code 70450 is a column II code with a modifier indicator of 1 when billed with
column I code 70496. Code 70450 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 computed tomography (CT) scan of the
head/brain rendered on May 2, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided on April 28, 2021.

You asked the Plan to pay for genetic testing. You say that this testing is recommended to help distinguish patients at increased risk for clinically significant prostate cancer from those at very low risk for disease. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the Plan cannot determine how the enrollee can to this provider for testing.

The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. 

We looked at the file and Medicare rules. The documentation submitted does not include a physician order or clear intent to order the specific lab service billed on this claim. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided on April 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics. 
 
You asked the Plan to pay for foot orthotics. You say that you got foot orthotics to help with healing after 
surgery. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided May 13, 2021. 
 
You asked the Plan to waive the copayment for the office visit. You say that the copayment should be waived. 
The Plan denied your request. The Plan says the correct cost-sharing 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 $50 
copayment for in-network specialist visits.  
 
You have been asked to pay a $50 copayment for the office visit. The office visit falls within the in-network 
specialist 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 an office visit provided 
May 13, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the office visit and the electrocardiogram reporting rendered by the out-of-network (OON) provider on February 16, 2021.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the services were rendered by an out of network provider without prior authorization. Additionally, the services were not urgent nor emergent.

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 did not provide medical records to our organization to support their claim that the services provided in this case were not urgent or emergent in nature. Additionally, the services were provided in a contracted facility with the health plan. Medicare rules state that services and referrals obtained from a plan provider are viewed as plan-approved. Therefore, we decided that the Plan has to pay for the office visit and the electrocardiogram reporting rendered by the out-of-network (OON) provider on February 16, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
May 4, 2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must 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 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 out of network physician services provided to the 
enrollee on May 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial observation care services provided on December 
25, 2020 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the initial observation care services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered 
benefit.

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 initial observation care services provided on 
December 25, 2020 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the endoscopy retrograde cholagiopancreatipgraphy (ERCP) procedure you had at an outpatient hospital on May 12, 2021.
You asked the Plan to waive the coinsurance for the ERCP procedure. You say that you would like the Plan to reconsider payment because this was an essential service. The Plan denied your request. The Plan says you were charged this coinsurance correctly.
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 outpatient surgery or other services at an outpatient hospital facility. You have been asked to pay 20% coinsurance for the ERCP procedure. The ERCP procedure falls within the outpatient surgery or other services at an outpatient hospital facility 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 the endoscopy retrograde cholagiopancreatipgraphy (ERCP) procedure you had at an outpatient hospital on May 12, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant360 testing (81406, 81405, 81405, 81404, 81403, 
81402, 81401, 81400, 81321, 81314, 81311, 81310, 81293, 81276, 81275, 81272, 81270, 81235, 81210, 81201, 
81121, 81120) provided on January 4, 2021. 
 
You asked the Plan to pay for Guardant360 testing. You say that this is a covered service. The Plan denied your 
request. The Plan says this cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say that code 81479 is used to 
report Guardant360 testing. 

We find that CPT codes 81406, 81405, 81405, 81404, 81403, 81402, 81401, 81400, 81321, 81314, 81311, 
81310, 81293, 81276, 81275, 81272, 81270, 81235, 81210, 81201, 81121, and 81120 are not supported in the 
medical record. Specifically, these codes were used to report Guardant360 testing, which should be billed with 
81479. Based on this information, we decided that Medicare rules for coverage of Guardant360 testing have 
not been met. Therefore, we decided that the Plan does not have to pay for Guardant360 testing (81406, 81405, 
81405, 81404, 81403, 81402, 81401, 81400, 81321, 81314, 81311, 81310, 81293, 81276, 81275, 81272, 81270, 
81235, 81210, 81201, 81121, 81120) provided on January 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for prophylaxis (D1110), topical application of fluoride (D1206) and an unspecified preventive procedure (D1999) provided on May 13, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for prophylaxis, topical application of fluoride and an unspecified preventive procedure. You say that you request a full reimbursement, as well as a full and complete reason for the cost share and a schedule of what procedures are allowed and the cost share of each item. The Plan denied your request. The Plan says you received dental services from an OON provider, and you are responsible for paying the full cost of services that aren't covered by the Plan. The Plan also says that they found and verified network providers in the area to provide the 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 covers prophylaxis and topical application of fluoride when services are received from an in-network provider. An unspecified preventive procedure is not a covered benefit. 

We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of prophylaxis, topical application of fluoride and an unspecified preventive procedure have not been met. Specifically, the services were rendered by an OON provider. The unspecified preventive procedure is not a covered benefit of Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for prophylaxis (D1110), topical application of fluoride (D1206) and an unspecified preventive procedure (D1999) provided on May 13, 2021, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and (b). 

The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that enrollees must pay an $85 copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in a physician's office or at a free-standing facility. You can find this information on page 4-33 of the Plan's 2021 Evidence of Coverage (EOC).

Your contract with the Plan clearly says that you must pay an $85 copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in a physician's office or at a free-standing facility. 

You have been asked to pay an $85 copayment for the duplex scan of extremity veins. The duplex scan 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 the duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited study (93971) provided January 29, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee from July 15, 2020, to July 31, 2020.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says due to the enrollee's hospice status at the time of service, this claim should be submitted to Original Medicare first.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for medical services provided to the enrollee from July 15, 2020, to July 31, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the extractions (D7210) for teeth # 27 and 28, and inhalation of nitrous oxide (D9230) provided on June 8, 2021.
You asked the Plan to pay an additional amount for the dental services. You say that you feel this claim should have been submitted as medical instead of dental. You say that the provider did not do a prior authorization. You also say that you have not had any dental procedures done this year. The Plan denied your request. The Plan says there is a $2,000 allowance for preventive and comprehensive dental services. The Plan also says that the allowance was exhausted in the processing of this claim.
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 annual allowance of $2,000 has been exhausted. The record shows that the Plan paid $2,000 towards the dental services that you received on the date of service in this case. The Evidence of Coverage clearly states that you are responsible for any amount over and above the allowance amount. Therefore, we decided that the Plan does not have to pay an additional amount for the extractions (D7210) for teeth # 27 and 28, and inhalation of nitrous oxide (D9230) provided on June 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the periodic oral evaluation (D0120) provided on May 13, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay more for the periodic oral evaluation. You say that you would like to be reimbursed for this service. The Plan denied your request. The Plan says the cost share was applied correctly per you plan benefits. The Plan also says that cost sharing is a contractual obligation of the Plan and cannot be waived.
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, you are responsible for the difference between the billed amount and allowed amount for covered dental services received OON. Therefore, we
decided that the Plan does not have to pay more for the periodic oral evaluation (D0120) provided on May 13, 2021 by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ground mileage (A0425) and non-emergency ambulance transport (A0428) from the enrollee's residence to a medical office/clinic provided on February 23, 2021.

You asked the Plan to pay for the ground mileage and non-emergency ambulance transport.

You say that this is a valid transport that the patient could not have gotten at origin, and you would like this to be reprocessed for payment. The Plan denied your request. The Plan says ambulance transport to or from an outpatient office or facility is not a Medicare covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when they meet certain origin and destination requirements. A doctor's office is not a covered destination. 

The services you have asked the Plan to pay for are ambulance transport services to a doctor's office. The records show that the enrollee was transported to a doctor's office for a follow up visit. Therefore, we decided that the Plan does not have to pay for the ground mileage (A0425) and non-emergency ambulance transport (A0428) from the enrollee's residence to a medical office/clinic provided on February 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the podiatry services provided on May 10, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were 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 requested provider in this case is not a network provider with the Plan. The referring provider 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 podiatry services provided on May 10, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for gingival irrigation (D4921) provided on May 18, 2021.

You asked the Plan to reimburse you for gingival irrigation. You say that you would like to appeal the denied coverage. The Plan denied your request. The Plan says the service at issue in this appeal is not covered by your contract.

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 reimburse you for gingival irrigation (D4921) provided on May 18, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided by an out-of-network provider on March 25, 2021.
You asked the Plan to pay for out-of-network physical therapy. The Plan denied your request. The Plan says out-of-network services are not authorized.
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 physical therapy provided by an out-of-network provider on March 25, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic casts (D0470) and consultation (D9310)
provided on July 27, 2021.

You asked the Plan to pay for the diagnostic casts and consultation. You say that you were not aware that these
services would not be covered. You also say that you may not be able to afford to pay for these services. The
Plan denied your request. The Plan says these services are not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
diagnostic casts (D0470) and consultation (D9310) provided on July 27, 2021.