Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the laboratory services (80048, 80076, 83615, 85025, 85651) rendered by the out-of-network (OON) provider on June 21, 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.
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 contract states that through the Point of Service (POS) benefit option members may receive certain services from out-of-network providers. However, the Plan contract does not state what services are covered under this benefit. Therefore, we decided that the Plan has to pay for the laboratory services (80048, 80076, 83615, 85025, 85651) rendered by the out-of-network (OON) provider on June 21, 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the mandibular partial denture - flexible base (including retentive/clasping materials, rests, and teeth) (D5226) provided May 27, 2021.  You asked the Plan to pay for the partial lower denture. You say that this service was essential and should be covered. The Plan denied your request. The Plan says this service is not covered under your benefits.  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 mandibular partial denture - flexible base (including retentive/clasping materials, rests, and teeth) (D5226) provided May 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the cystourethroscopy procedure you had at an outpatient hospital facility on February 25, 2021.
You asked the Plan to waive the cost sharing for the cystourethroscopy procedure. You say that you didn't realize there was a deductible with this plan. You said that you cannot afford this cost sharing. The Plan denied your request. The Plan says you were charged this cost sharing 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 a $1250 deductible and a $350 copayment once the deductible is met for outpatient surgery at an outpatient hospital. You have been asked to pay a $1250 deductible and a $350 copayment once the deductible was met for the
cystourethroscopy procedure. The cystourethroscopy procedure falls within the outpatient surgery at an outpatient hospital 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. The deductible was clearly disclosed in your Evidence of Coverage to you and you had not met your deductible at the time of these services. Therefore, we decided that the Plan does not have to waive the cost sharing for the cystourethroscopy procedure you had at an outpatient hospital facility on February 25, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for an additional molecular pathology procedure (G0452) provided on July 20, 2021.

You asked the Plan to pay for code G0452. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not supported.

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 confirm that Medicare coverage criteria have been met. 

We looked at the file and Medicare rules. In this case, there were no medical records provided confirming that two separate molecular pathology procedures (G0452) were provided July 20, 2021 by this provider. The file shows that the Plan paid for one claim submitted with code G0452 by this provider.

Therefore, we decided that the Plan does not have to pay for an additional molecular pathology procedure (G0452) provided on July 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that the enrollee is appropriate for an LTACH admission. The Plan denied your request. The Plan says based on Medicare guidelines, the requested LTACH services do not meet the requirements for approval.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  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 the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the providers believe the enrollee can be discharged to a skilled nursing facility after additional acute care services. The record indicates that the enrollee is improving but still requires acute care services. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be recommended.  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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the unspecified preventive services (D1999 x 2) provided 
from August 27, 2021, to September 10, 2021.

You asked the Plan to pay for the dental services. You say that you were not advised you would have to pay for 
the services. The Plan denied your request. The Plan says unspecified preventive services are not listed as 
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 services are not among those 
covered under this benefit. The record shows that the unspecified preventive service was reported for the 
coronavirus fee. This is not listed as a covered benefit.

Therefore, we decided that the Plan does not have to pay for the unspecified preventive services (D1999 x 2) 
provided from August 27, 2021, to September 10, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the positron emission tomography (PET) with concurrently acquired computed tomography (CT) coded 78815 provided on June 7, 2021.  

You asked the Plan to pay for the positron emission tomography (PET) with concurrently acquired computed tomography (CT). You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable 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.  

In this case, the CPT Code Manual definition of code 78815 is positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid-thigh.  

We find that CPT code 78815 is not supported in the medical record. Specifically, this service was billed with diagnosis code C50.911 (Malignant neoplasm of unspecified site, right female breast). Review of the file shows there is a more appropriate site to be billed for the services rendered. This means this service was billed with an inappropriate diagnosis code. Based on this information, we decided that Medicare rules for coverage of the positron emission tomography (PET) with concurrently acquired computed tomography (CT) have not been met. Therefore, we decided that the Plan does not have to pay for the positron emission tomography (PET) with concurrently acquired computed tomography (CT) coded 78815 provided on June 7, 2021.
Appeal type: Imaging
Decision: Favorable

 We decided that the Plan has to waive the deductible for a bone density scan provided on July 27, 2021.  You asked the Plan to waive the deductible for a bone density scan. You say that this was preventative service and you should not be responsible for the charges. The Plan denied your request. The Plan says that the claims were processed correctly and you are being charged the correct amount.  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. The Plan did not provide medical records. Without medical records we cannot determine whether or not diagnostic services took place. Furthermore, the Plan did not provide proof that the bone mass measurement benefit had been exhausted.   The Plan says that you must pay $132.12 for a bone density scan. However, you cannot be asked to pay anything for bone mass measurements. Therefore, we decided that the Plan has to waive the deductible for a bone density scan provided on July 27, 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 waive the coinsurance for an out-of-network office visit (99214, 1159F, 1160F) rendered on July 22, 2021.
You asked the Plan to waive the coinsurance for an out-of-network office visit. You say that you normally only pay a copayment. You also say that your doctor had left the clinic you normally go to and the clinic told you to go to the urgent care to get your medicine renewed. You also say that you do not feel you should have to pay the full cost. The Plan denied your request. The Plan says you were 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 50% coinsurance of the total allowed amount, per provider per day for each Out-of-Network, Medicare-covered primary care provider office visit. You have been asked to pay $62.89 in coinsurance, which is 50% of the total allowed amount for an out-of-network office visit ($126.22 allowed amount x 50% = $62.89). An out-of-network office 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 coinsurance for an out-of-network office visit (99214, 1159F, 1160F) rendered on July 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for hereditary cancer screening panel testing provided on January 4, 2021.

You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this panel constitutes a single procedural service so much be billed with a single procedure code.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. 

The test at issue in this appeal, genetic testing, was requested for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for hereditary cancer screening panel testing provided on January 4, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation mileage.
You asked the Plan to pre-approve additional mileage. You say that you need to see this surgeon as soon as possible and need this transportation to get there. The Plan denied your request. The Plan says the requested providers office is more than 50 miles from your home. Routine transportation may only be covered when trips are to or from plan-approved locations and do not exceed 50 miles of driving distance.
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 up to 48 one-way routine ground transportation trips per year. Trips must be to or from Plan-approved locations and must not exceed 50 miles of driving distance. We looked at your request, the records in the case file, and the rules. The requested location is greater than 50 miles away. 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 pre-approve additional routine transportation mileage.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided on July 1, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the OON lab services. You say that these services were medically necessary, and the referring provider is a contracted provider. The Plan denied your request. The Plan says neither your organization nor the referring provider is a contracted provider with the Plan. The Plan says that unauthorized, non-plan care is not covered.
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.
You are 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 lab services provided on July 1, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We de
cided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on August 24, 
2021.
You asked the Plan to pay for the dental service. You say that you went to see your dentist about a toothache. 
You say that your dentist referred you to an endodontist for further evaluation. You say that the endodontist 
determined the tooth could not be repaired and needed to be extracted. You also say that you understand you 
have $1,000 for dental services per year. The Plan denied your request. The Plan says 1 limited oral evaluation 
is covered per plan year. The Plan also says that the frequency limit has been exceeded.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage and the service is listed as covered, the 
frequency limit has been exceeded. The record shows that the Plan paid for a limited oral evaluation that you 
received on August 10, 2021. Therefore, we decided that the Plan does not have to pay for the limited oral 
evaluation (D0140) provided on August 24, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate for the gingival irrigation (D4921 x 2) 
provided from October 5, 2020, to November 5, 2020.

You asked the Plan to pay the in network rate for the gingival irrigation. You say that you were not aware that 
the dentist was out of network. You also say that you feel you are not responsible for this bill. The Plan denied 
your request. The Plan says gingival irrigation is not listed as a covered 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.

Though the Plan offers a dental benefit in excess of Medicare coverage, the gingival irrigation are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay the in network rate 
for the gingival irrigation (D4921 x 2) provided from October 5, 2020, to November 5, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cyclobenzaprine HCL.

You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Cyclobenzaprine HCL.

Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wheelchair modifications.

You asked the Plan to pre-approve wheelchair modifications. You say that this is medically necessary for your condition. The Plan denied your request. The Plan says this is requested for use in a SNF.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. 

Records show that wheelchair modifications is being requested for use in a SNF or hospital. Therefore, we decided that the Plan does not have to pre-approve wheelchair modifications.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit (99284) provided on August 27, 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 $90 copayment per emergency room visit within or outside the service area. You have been asked to pay a $90 copayment for the emergency room visit 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 emergency room visit (99284) provided on August 27, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on 
April 29, 2021.

You asked the Plan to waive the copayment for the ER visit. You say that the copayment is always absorbed by 
the hospital if you are admitted. The Plan denied your request. The Plan says you were charged this copayment 
correctly. The Plan says that you were not admitted to the hospital as an inpatient, rather, you were just kept in 
observation. There is no copayment waiver for the ER visit if you stay in observation.

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 per visit for emergency room services. 

You have been asked to pay a $50 copayment for the ER visit. Records show that you were seen in the ER and 
then kept in observation. You were never admitted to the hospital as an inpatient, so there is no provision in 
your contract for a waiver of the ER copayment. 

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 emergency room (ER) visit you had on April 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee.
You asked the Plan to pre-approve these services. You say that the member's pain is debilitating and is affecting their quality of life. The Plan denied your request. The Plan says that this service is considered experimental and investigational.
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 pre-approve these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The Intracept procedure remains experimental for back pain. More research is needed to show safety and efficacy. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services. We looked at this physician's review, the file, and Medicare rules. 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 pre-approve the Intracept procedure for the enrollee.