Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray provided on June 29, 2021.

You asked the Plan to pay for the panoramic x-ray. You say that you returned to the original dentist because you were not getting the quality of care from the new dentist. You say that you are being penalized for obtaining good care out-of-network and you expect payment for the dental exam and prophylaxis. The Plan denied your request. The Plan says the periodic oral evaluation and prophylaxis will be paid. The Plan also says that the panoramic x-ray remains denied as a non-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 panoramic x-ray is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray provided on June 29, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic exercises (97110) rendered by the out-of-
network (OON) provider on April 28, 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 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 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 services 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 the therapeutic exercises (97110) rendered by the out-of-network (OON) provider
on April 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for duplex scan of arterial inflow and venous outflow of
abdominal, pelvic, scrotal contents and/or retroperitoneal organs; limited study (93976) provided June 9, 2021.
You asked the Plan to pay for the diagnostic service. You say that the medical records provided will show
proof of medical necessity. The Plan denied your request. The Plan says no separate payment is allowed.
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 the
diagnostic service is a column II code to column I code 76856. 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 duplex scan of arterial inflow and venous
outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; limited study (93976) provided
June 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided on
June 4, 2021, and June 18, 2021.
You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you cannot afford the
charges. 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 Medicare Part B prescription drugs.
You received Medicare Part B drugs on June 4, 2021. The total allowed amount is $6,105 and 20% of that is
$1,221.
You received Medicare Part B drugs on June 18, 2021. The total allowed amount is $6,105 and 20% of that is $1,221. The total amount you owe is: $2,442. You have been asked to pay the total coinsurance amount of $2,442 for Medicare Part B drugs. Medicare Part B drugs 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 coinsurance for Medicare Part B drugs provided on June 4, 2021, and June 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Moh's micrographic surgery with would repair provided on August 12, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the Moh's micrographic surgery with wound repair. You say that you should not have to pay for the visit because the provider told you they accepted your plan. The Plan denied your request. The Plan says no prior authorization was obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the Moh's micrographic surgery with would repair provided on August 12, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aduhelm solution.
You asked the Plan to pre-approve Aduhelm solution. You say that the requested drug is medically necessary.
The Plan denied your request. The Plan says the enrollee does not meet the guidelines for coverage of the
requested drug.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve Aduhelm solution. Our reviewer says
that the criteria for coverage have not been met. Our physician reviewer found the record indicates that the
enrollee has a diagnosis of progressive cognitive decline and mild to moderate abnormalities on mental status
testing that do not met criteria for a dementia condition. The Food and Drug Administration has not stated that
the requested drug is indicated for the enrollee's condition. The Medicare approved drug compendia do not
contain a supportive citation for the use of the requested drug in the enrollee's clinical situation.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Aduhelm solution have not been met. Therefore, we decided that the Plan does
not have to pre-approve Aduhelm solution.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on September 6, 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 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 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 September 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (70450) provided July 22, 2021.
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The
Plan denied your request. The Plan says the billed code shares a bundled relationship with another code 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. In this case, we have confirmed that code 70450
has a bundled relationship with code 70496. This claim has not been billed with an appropriate modifier to
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we
decided that the Plan does not have to pay for radiology services (70450) provided July 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug services rendered on May 26, 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 Plan must follow Medicare rules. The rules say that the applicable payments made under the prospective
payment systems are payment in full for all inpatient hospital services.
We looked at the file and Medicare rules. The file shows that the services at issue were billed while the enrollee
was inpatient at the hospital. Payment is included in the facility payment to the hospital. Therefore, we decided
that the Plan does not have to pay for the drug services rendered on May 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on June 7, 2021.
You asked the Plan to pay for the services. You say that the enrollee would like to be better informed of any
further risks to themselves and/or family members by understanding genetic composition. The Plan denied your
request. The Plan says there is no documentation of a face to face encounter of the provider with the enrollee.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the review has determined that there is no specific clinical rationale for genetic cardiac testing. The
enrollee has a known history of hypercholesterolemia and no history of cardiac disease. The review has
determined that the enrollee does not meet the criteria for this request.
We looked at this physician's review, the file, and Medicare rules. 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 laboratory services provided to the enrollee on June 7, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for laboratory services provided on July 8, 2021.

You asked the Plan to waive the deductible for laboratory services. You say that you disagree with the charges because you received the laboratory services as part of your annual wellness exam. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $250 deductible which applies to outpatient diagnostic tests and therapeutic services and supplies. 

The record shows that you received laboratory services on July 8, 2021. Laboratory services are not included in the annual wellness exam. You had paid $0 toward the $250 deductible prior to receiving the services. Therefore, you are responsible to pay the total allowed amount of $44.28. 

The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $250 deductible which applies to outpatient diagnostic tests and therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time laboratory services were received on July 8, 2021. Therefore, we decided that the Plan does not have to waive the deductible for laboratory services provided on July 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on April 27, 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 procedure code 81479 is 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 81479 is unlisted molecular pathology procedure.
We find that CPT code 81479 is not supported in the medical record. Specifically, the documentation does not
support the performance of an unlisted molecular pathology procedure. 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 April 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal scaling and root planing - four or more teeth per quadrant (D4341) provided June 25, 2021.
You asked the Plan to pay for the periodontal scaling and root planing. You say that you were unaware of the frequency limit and cannot afford the cost of the services. The Plan denied your request. The Plan says you have exceeded the frequency limit for this service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the periodontal scaling and root planing once per quadrant every three years. We looked at the file and Medicare rules. The Plan provided documentation showing that periodontal and root planing was previously covered on September 10, 2019.
Based on this information, we decided that the Plan's frequency limit for coverage of the periodontal scaling and root planing has been exceeded. Therefore, we decided that the Plan does not have to pay for the periodontal scaling and root planing - four or more teeth per quadrant (D4341) provided June 25, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on June 17, 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 procedure code 81345 is 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 81345 (TERT gene analysis) and 0089U (oncology
[melanoma] gene expression profiling). Code 81345 is a column II code with a modifier indicator of 1 when
billed with column I code 0089U. Code 81345 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 laboratory services rendered on June
17, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the two resin-based composites provided on May 17, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay more for the resin-based composites. You say that you have been going to this dentist for several years and were not aware they were in-network or OON. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that OON providers are allowed to balance bill you for the difference between their billed amount and the Plan's paid amount.
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 a 20% coinsurance of the covered plan allowance after the $100 deductible is met, plus the difference between the billed amount and allowed amount for covered dental services that are received OON.
Therefore, we decided that the Plan does not have to pay more for the two resin-based composites provided on May 17, 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 prophylaxis - adult (D1110) provided July 29, 2021.
You asked the Plan to pay for the dental cleaning. You say that this is your second of two covered dental
cleanings. The Plan denied your request. The Plan says you have exhausted your dental benefit for the year
2021.
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 two dental
cleanings per year, up to a $500 annual maximum for dental benefits.
We looked at the file and Medicare rules. The Plan provided documentation showing that the full $500 annual
maximum had been applied to your dental services prior to the dental cleaning on July 29, 2021. Based on this
information, we decided that the Plan's dental benefit has been exhausted. Therefore, we decided that the Plan
does not have to pay for the prophylaxis - adult (D1110) provided July 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electrical osteogenesis stimulator.
You asked the Plan to pre-approve an electrical osteogenesis stimulator. The Plan denied your request. The
Plan says the request is not medically necessary.
The Plan must follow Medicare rules. The rules say that an electrical bone stimulator is covered for nonunion
of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs
have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the
electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs
separated by a minimum of 90 days.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve an electrical osteogenesis stimulator.
Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the record
does not indicate that the enrollee has a failed spinal fusion or is undergoing a multi-level spinal fusion surgery.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of an electrical osteogenesis stimulator have not been met. Therefore, we decided
that the Plan does not have to pre-approve an electrical osteogenesis stimulator.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for chemotherapy provided on August 13,
2021.
You asked the Plan to waive the coinsurance for chemotherapy. You say that you were not informed that you
would owe anything for chemotherapy. 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 chemotherapy.
You received chemotherapy on August 13, 2021. The total allowed amount is $10,244.65 and 20% of that is
$2,048.93.
You have been asked to pay the total coinsurance amount of $2,048.93 for chemotherapy. Chemotherapy falls
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 coinsurance
for chemotherapy provided on August 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on June 29, 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 procedure code 81345 is 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 81345 (TERT gene analysis) and 0089U (oncology
[melanoma] gene expression profiling). Code 81345 is a column II code with a modifier indicator of 1 when
billed with column I code 0089U. Code 81345 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 laboratory services rendered on June
29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care provided on May 18, 2021.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the records
do not support the services were unrelated.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
In this case, the CPT Code Manual definition of code 99223 is initial hospital care, per day, for the evaluation
and management of a patient. We find that CPT code 99223 was billed along with another evaluation and
management service. If more than one evaluation and management service is provided on the same day to the
same patient by the same physician or more than one physician in the same specialty in the same group, only
one evaluation and management service may be reported unless the evaluation and management services are
for unrelated problems. The records provided do not indicate the services were provided for unrelated
problems. Based on this information, we decided that Medicare rules for coverage of the services provided
have not been met. Therefore, we decided that the Plan does not have to pay for the initial hospital care
provided on May 18, 2021.