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

We decided that the Plan does not have to pay for the duplex scan (93880) provided on February 12, 201.
You asked the Plan to pay for the duplex scan. The Plan denied your request. The Plan says this service has already been paid.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. In this case, the records show that only one duplex scan was provided
on the date of service in question. The Plan has already processed and paid for one duplex scan. A second unit of code 93880 was not provided and therefore is not payable. Based on this information, we decided that Medicare rules for coverage of the duplex scan have not been met. Therefore, we decided that the Plan does not have to pay for the duplex scan (93880) provided on February 12, 201
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 87496, 87498, 87631, 87798, 87486, 87541, 87581, and 87640 provided on October 8, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes 87496, 87498, 87631, 87798, 87486, 87541, 87581, and 87640 are not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in a Skilled Nursing Facility setting, place of service 31.
Based on this information, we decided that Medicare rules for coverage of the laboratory services have not
been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 87496,
87498, 87631, 87798, 87486, 87541, 87581, and 87640 provided on October 8, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140)
provided September 23, 2021.
You asked the Plan to pay for the limited oral exam. You say that this service was necessary, and you would
like it covered. 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 limited
oral exam once per plan year.
We looked at the file and Medicare rules. The Plan provided documentation showing that a limited oral exam
was previously covered on July 19, 2021.
Based on this information, we decided that the Plan's frequency limit for coverage of the limited oral exam has
been exceeded. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation -
problem focused (D0140) provided September 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve surgical extractions (D7210) for teeth # 7, 8, 9, 10, 23, and 26.  You asked the Plan to pre-approve surgical extractions. You say that you need these services. The Plan denied your request. The Plan says the requested surgical extractions are not medically necessary.  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 surgical extractions when the services are medically necessary and reasonable.   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 surgical extractions. Our reviewer says that the requested surgical extractions are not medically necessary. Our physician reviewer found the documentation provided shows adequate coronal tooth structure of the indicated teeth allowing removal via elevation and/or forceps. Therefore, the reviewer found that the requested surgical extractions are not medically necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of surgical extractions have not been met. Therefore, we decided that the Plan does not have to pre-approve surgical extractions (D7210) for teeth # 7, 8, 9, 10, 23, and 26.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for an echocardiography (93306) and duplex scan (93970) provided on June 4, 2021.  You asked the Plan to waive the coinsurance for the echocardiography and duplex scan. You say that you should only be assessed a $95 copayment The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.    You have been asked to pay a 20% coinsurance for an echocardiography and duplex scan (the total allowed amount is $677.60 x 20% = $135.52).  Echocardiography's and duplex scans 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 coinsurance for an echocardiography (93306) and duplex scan (93970) provided on June 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98940) rendered by the out-of-network (OON) provider on July 28, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the chiropractic manipulative treatment (98940) rendered by the out-of-network (OON) provider on July 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (81206, 81210, 81235, 81275, 81276, 81292, 81295, 81298, 81301, 81317 and 81401) provided on April 22, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says Medicare denies coverage when a laboratory assays two or more genes in a patient in parallel
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Specifically, the documentation submitted does not include a lab report or any clinical information. We are unable to determine why this testing was ordered or if it will affect the member's treatment. There is insufficient information to determine if Medicare criteria for coverage have been met. Therefore, we decided that the Plan does not have to pay for the laboratory services (81206, 81210, 81235, 81275, 81276, 81292, 81295, 81298, 81301, 81317 and 81401) provided on April 22, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for a group behavioral health intervention (96165) provided on September 16, 2021.
You asked the Plan to pay for a group behavioral health intervention. You say that the service at issue was 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 a group behavioral health intervention (96165) provided on
September 16, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) care provided from September 1, 2021, through September 30, 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 services 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 $0 copayment for days 1 through 20 and a $184 copayment per day, for days 21 through 100, for skilled nursing facility care.
You have been asked to pay $4,232 ($184 copayment x 23 days) for the skilled nursing facility care provided.
You initially received skilled nursing facility care from August 19, 2021, through August 31, 2021 which
applied a $0 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 skilled nursing facility (SNF)
care provided from September 1, 2021, through September 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services coded 99153 provided on
August 19, 2021.
You asked the Plan to pay for the moderate sedation services. 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 99153 is moderate sedation services provided by the
same physician or other qualified health care professional performing the diagnostic or therapeutic service that
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of
the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (list
separately in addition to code for primary service).
We find that CPT code 99153 is not supported in the medical record. Specifically, this code has a Professional
Component (PC)/Technical Component (TC) indicator of 3. This means that this code may not be paid if
furnished to a hospital inpatients or patients in a hospital outpatient department. Based on this information, we
decided that Medicare rules for coverage of the moderate sedation services have not been met. Therefore, we
decided that the Plan does not have to pay for the moderate sedation services coded 99153 provided on August
19, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided on August 3, 2021.
You asked the Plan to waive the copayment for the ultrasound. You say that you should have paid 20% of what your insurance pays toward the ultrasound. The Plan denied your request. The Plan says the proper copayment 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 $125 copayment for Medicare-covered radiological diagnostic services, not including X-rays, performed in a physician's office or at a free-standing facility (such as a radiology center or medical clinic). The total allowed amount was $92.34 which is less than the copayment amount of $125. Since the total allowed amount was less than the copayment only $92.34 is allowed to be paid for a copayment.
You have been asked to pay a $92.34 copayment for the ultrasound. An ultrasound 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 an ultrasound provided on August 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient hospital services provided on May 17, 2021.
You asked the Plan to pay for the outpatient hospital services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 38724 has a status indicator of C.
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule. The service at issue in this appeal was billed with CPT code 38724. This code is listed with a status indicator of "C" on Addendum B of the 2021 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission. Therefore, we decided that the Plan does not have to pay for the outpatient hospital services provided on May 17, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the comprehensive oral evaluation (D0150), complete series of intraoral x-rays (D0210), and scaling in presence of generalized moderate or severe gingival inflammation (D4346) provided on September 28, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay more for the comprehensive oral evaluation, complete series of intraoral x-rays, and scaling. You say that your guide stated that annual exam and cleanings were covered. The Plan denied your request. The Plan says you saw a dentist outside of the Plan's network and are responsible for the difference between the dentist's fees and the Plan's dental fee schedule. The Plan also says that all calls between you and the Plan were reviewed and no misquotes regarding coverage were found.
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 more for the comprehensive oral evaluation (D0150), complete series of intraoral x-rays (D0210), and scaling in presence of generalized moderate or severe gingival inflammation (D4346) provided on September 28, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from May 14, 2021, to June 22, 2021.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you were told that any coronavirus related services would be fully covered. 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 $295 copayment for days 1-5 for inpatient hospital care. You received inpatient hospital care form May 14, 2021, to June 22, 2021. The record shows that this stay does not qualify for the coronavirus waiver. Therefore, you are responsible to pay a $295 copayment for days 1-5 (May 14, 2021, to May 18, 2021). The total amount you owe is: $295 (copayment) x 5 (inpatient days) = $1,475.
You have been asked to pay the total copayment amount of $1,475 for inpatient hospital care. 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 copayment for inpatient hospital care provided from May 14, 2021, to June 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician (D9310) provided September 17, 2021.
You asked the Plan to pay for the dental consultation. You say that you feel this service should be covered because switching to an in-network provider would potentially save money. 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 consultation - diagnostic service provided by
dentist or physician other than requesting dentist or physician (D9310) provided September 17, 2021
Appeal type: Testing
Decision: Unfavorable

You asked the Plan to pay for ultrasonic guidance for needle placement. The Plan denied your request. The
Plan says the ultrasonic guidance for needle placement is experimental or investigational and not covered.
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 ultrasonic guidance for needle placement.
Our reviewer says that the requested ultrasonic guidance for needle placement is not considered medically
reasonable and necessary in this case.
Our physician reviewer found that the enrollee is a 79-year-old female who underwent trigger point injections
to the iliotibial band tendon for pain. Ultrasonic guidance for needle placement was requested. The provided
documentation did not reveal evidence that this particular enrollee's clinical situation required assistance with
needle placement such as with obstruction of view due to body fat or sensitive areas being injected such as an
epidural or facet joint injection. An Iliotibial band injection does not typically require ultrasound guidance and
manual tactile anatomical placement should have sufficed. Therefore, this request for ultrasonic guidance for
needle placement for the trigger point injections will be considered 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 ultrasonic guidance for needle placement have not been met. Therefore, we
decided that the Plan does not have to pay for ultrasonic guidance for needle placement provided on
August 6, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Caris MI profile for the enrollee.
You asked the Plan to pre-approve the testing. You say that this is medically necessary to see if the results can help with the treatment of the cancer. The Plan denied your request. The Plan says many of tests in the panel are not related to treating the cancer.
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 the testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found although some of the tests in this panel are targeted therapy, not all of them are medically necessary for a diagnosis of metastatic cholangiocarcinoma. 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 testing have not been met. Therefore, we decided that the Plan does not have to pre-approve the Caris MI profile for the enrollee.