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

 We decided that the Plan does not have to pre-approve removal of lateral exostosis (D7471), guided tissue regeneration (D4266) and placement of intra-socket biological dressing to aid in homeostastis or clot stab (D7922).  You asked the Plan to pre-approve dental services. You say that you wish to appeal the denial reason. The Plan denied your request. The Plan says the requested services are not listed in the contract and therefore, are not covered service with your Plan.  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 pre-approve removal of lateral exostosis (D7471), guided tissue regeneration (D4266) and placement of intra-socket biological dressing to aid in homeostastis or clot stab (D7922).
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for an ultrasound (76942) provided June 29, 2021.  You asked the Plan to pay for the ultrasound. You say that the services were medically necessary. The Plan denied your request. The Plan says the code billed shares a bundled relationship with another code billed and is 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 CPT code. In this case, we have confirmed that code 76942 has a bundled relationship with code 49423.   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 an ultrasound (76942) provided June 29, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for occupational therapy services provided on June 8, 2021.  You asked the Plan to pay for the occupational therapy services. You say that plans are required to pay non-contracted providers at the preferred provider rate when services are not available from preferred providers in the service area. You say that the in-network benefits should be honored, and the claim processed for payment. The Plan denied your request. The Plan says the records do not support the service billed.  The Plan must follow Medicare rules. Medicare rules say that therapy services billed as services incident to a physician/non-physician practitioner's service must meet all incident requirements. Medicare rules also say that the services of an occupational therapy assistant (OTA) shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the occupational therapy services have not been met. Specifically, the records do not indicate if the rendering provider was an occupational therapist or an OTA. A nurse practitioner is not able to bill for the services of an OTA because the nurse practitioner is not a therapist. There is no evidence that the nurse practitioner was on the premises to be able to bill for occupational therapy services. Additionally, the record does not include the rendering providers credentials, so we are unable to verify the billed services. Therefore, we decided that the Plan does not have to pay for occupational therapy services provided on June 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for dermatology services provided on June 16, 2021.  You asked the Plan to waive the copayment for the dermatology services. You say that the dermatologist didn't provide any services on this date.  You said that the doctor simply came in when your wife had surgery for moral support.  You said that he just sat in a chair and watched, so there should be no bill. The Plan denied your request. The Plan says you were charged this copayment 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 $35 copayment for medical care or surgery services in a specialty physician's office.   You have been asked to pay a $35 copayment for the dermatology services. We looked at the medical records from this date of service.  The records show that you were seen for skin lesions on your left ear.  The doctor examined your head and upper body on this date and treated three lesions with liquid nitrogen.  Because the records confirm that you received dermatology services on this date, the copayment was charged correctly. The dermatology services fall within the medical care or surgery services in a specialty physician's office 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 dermatology services provided on June 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for inpatient hospital care from May 27, 2021, through June 2, 2021.  You asked the Plan to waive the copayment for inpatient hospital care. You say that the Plan should pay all the charges. The Plan denied your request. The Plan says the copayment was applied 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 $325 copayment each day for days 1-5 and $0 each day for days 6 - discharge for inpatient hospital care.   You have been asked to pay a $1625 ($325 x 5 = $1625) copayment for inpatient hospital admission. The services at issue fall within the inpatient hospital 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 inpatient hospital care from May 27, 2021, through June 2, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for psychotherapy services (90832) provided on July 15, 2021.  You asked the Plan to pay for psychotherapy services. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.  The Plan must follow Medicare rules. Medicare rules say that the CP will attempt to consult with the enrollee's attending or primary care physician.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of psychotherapy services have not been met. Specifically, the provided records do not document an attempt to consult with, nor a referral from, the enrollee's attending or primary care physician. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90832) provided on July 15, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve ten (10) additional OT visits.  You asked the Plan to pre-approve ten (10) additional OT visits. You say that additional OT visits are medically necessary. The Plan denied your request. The Plan says additional OT visits are not medically necessary.  The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.  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 ten (10) additional OT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the enrollee has previously been treated with outpatient therapies and should be independent with a home exercise program. There is no documentation of a recent injury or decline in function. The additional therapy services are not an appropriate duration and frequency for treatment of the enrollee's medical condition and therefore are not medically necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ten (10) additional OT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve ten (10) additional OT visits.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on February 23, 2021.  You asked the Plan to pay for the laboratory services. 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 covered as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on February 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a mammogram provided on November 10, 2020.  You asked the Plan to waive the copayment for the mammogram. You say that you should not be charged for your yearly checkup. 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 $0 copayment for screening mammograms.   Your contract also clearly says that you must pay a $100 copayment for each diagnostic test, except allergy tests. You have been asked to pay $40 for the mammogram, which is less than the $100 copayment for diagnostic mammograms. The record shows that you had other diagnostic tests done at the same time, which makes the mammogram a diagnostic test instead of a screening. Diagnostic mammograms fall 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 a mammogram provided on November 10, 2020.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for ultrasound behind abdominal cavity (76770 x3), and ultrasound of pelvis (76856 x3) provided from February 6, 2020, through November 19, 2020.  You asked the Plan to waive the copayments for ultrasound behind abdominal cavity, and ultrasound of pelvis. You say that you should have only been charges $20 per service. The Plan denied your request. The Plan says the copayments were applied 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 $85 copayment for outpatient diagnostic tests.   You have been asked to pay a $378.46 ($77.42 + 48.38 + 77.70 x2 + 48.63 x2 = $378.46) copayment for ultrasound behind abdominal cavity, and ultrasound of pelvis. The services at issue fall within the outpatient diagnostic tests benefit category. Since the Allowed Amount for these services is less than the required copayment of $85, you have been asked to pay only $77.42 + 48.38 + 77.70 x2 + 48.63 x2 = $378.46. 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 copayments for ultrasound behind abdominal cavity (76770 x3), and ultrasound of pelvis (76856 x3) provided from February 6, 2020, through November 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and interpretation and problem focused limited oral evaluation, or pay more for the root canal, and core buildup provided on August 5, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the cone beam CT capture and interpretation and problem focused limited oral evaluation, and to pay more for the root canal, and core buildup. You say that you feel that a higher reimbursement would be justified since no in-network endodontist was available for a lengthy period of time. The Plan denied your request. The Plan says the cone beam CT capture and interpretation is not a covered service, and your benefits for the problem focused limited oral evaluation have been exceeded. The Plan also says that 50% of the allowed amount for the root canal was paid after the $75 deductible was applied, and 30% of the allowed amount for the core buildup was paid.  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 cone beam CT capture and interpretation is not among those covered under this benefit. The contract says that oral examinations are limited to two per calendar year. The record shows that you received oral exams on May 19, 2021, and August 2, 2021 and your oral exams benefit has been exhausted. The contract also says that you are responsible for a $75 dental deductible per year, plus a 50% coinsurance of the Plan's dental fee schedule for root canal therapy, and a 70% coinsurance of the Plan's dental fee schedule for core buildups. You are also responsible for the difference between the billed amount and allowed amount for services received OON. Therefore, we decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and interpretation and problem focused limited oral evaluation, or pay more for the root canal, and core buildup provided on August 5, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve chiropractic services to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve these OON services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services can be provided by a network provider.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.  The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve chiropractic services to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the surgical repair services provided on February 6, 2021.  You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says an appropriate modifier was not billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.  In this case, the CPT Code Manual definition of code 13132 is repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 2.6 cm to 7.5 cm. We find that CPT code 13132 was billed with code 36556. Code 13132 may be eligible for payment when billed with this code pair. However, the claim provided does not show the code at issue was billed with a modifier suitable for payment. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the surgical repair services provided on February 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the pharmacogenetic testing provided on May 21, 2021.  You asked the Plan to pay for the testing services. You say that the testing can affect clinical decisions for the enrollee. The Plan denied your request. The Plan says the billed codes cannot be verified.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.  We looked at the file and the rules. The claim provided lists a place of service as an independent laboratory. The records do not indicate that the specimen was obtained at an independent laboratory. Furthermore, if one laboratory procedure evaluates multiple genes, the lab shall report only one code with one unit of service. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the pharmacogenetic testing provided on May 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a (presbyopia correcting function of intraocular lens.  You asked the Plan to pre-approve the lens. You say that this is medically necessary. The Plan denied your request. The Plan says Medicare covers a basic intraocular lens after removing a cataract.  The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a conventional IOL.   While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatism-correcting feature of an IOL. Therefore, we decided that the Plan does not have to pre-approve a (presbyopia correcting function of intraocular lens.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for arthroscopy and inpatient hospital care provided from August 12, 2021, to August 27, 2021.  You asked the Plan to waive the copayments for arthroscopy and inpatient hospital care. You say that you suffered a series of complications after the surgery and you feel that for this reason you should not be responsible for 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 a $125 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. Your contract with the Plan also clearly says that you must pay a $250 copayment for inpatient hospital care.  The record shows that you received arthroscopy on August 12, 2021, at an outpatient hospital facility. Therefore, you are responsible to pay the $125 copayment.   The record shows that you received inpatient hospital care from August 25, 2021, to August 27, 2021. Therefore, you are responsible to pay the $250 copayment.    The total amount you owe is: $375.   You have been asked to pay the total copayment amount of $375 for arthroscopy and inpatient hospital care. Arthroscopy falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. Inpatient hospital care falls within the inpatient hospital 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 copayments for arthroscopy and inpatient hospital care provided from August 12, 2021, to August 27, 2021.   We note your complaint that you suffered through complications following a surgical procedure. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an automatic blood pressure monitor (A4670).  You asked the Plan to pre-approve an automatic blood pressure monitor. You say that this device is medically necessary for your condition. The Plan denied your request. The Plan says this item is a non-covered item according to Medicare rules.  The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension.   The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. Therefore, we decided that the Plan does not have to pre-approve an automatic blood pressure monitor (A4670).
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home infusion therapy coded as S9338 provided from May 13, 2021, through May 14, 2021.  You asked the Plan to pay for the home infusion therapy. You say that this is medically reasonable and necessary. The Plan denied your request. The Plan says this code is not a valid code for Medicare purposes.  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 S9338 is home infusion therapy, immunotherapy, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.  We find that CPT code S9338 is not eligible for payment. Specifically, this code has a status indicator of "I" which is not valid for Medicare purposes. Specifically, Medicare uses another code for reporting of, and payment for, these services. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy coded as S9338 provided from May 13, 2021, through May 14, 2021.