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

We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy with specimen
collection (45378) provided on July 29, 2021.
You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that this should be a $0
copayment for a colorectal cancer screening. The Plan denied your request. The Plan says this claim was
processed correctly, and your copayment was assessed in accordance with your contract. The Plan contacted
the facility to investigate the codes billed and found that you have a history of colonic polyps.
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 $275
copayment for outpatient surgery services. When a colonoscopy is considered diagnostic rather than screening,
the outpatient surgery cost sharing applies.
You have been asked to pay a $275 copayment for the diagnostic colonoscopy. The diagnostic colonoscopy
was billed with code 45378. This service included specimen collection and is classified as a diagnostic
colonoscopy. Therefore, the colonoscopy falls within the outpatient surgery services benefit category. This
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that
the Plan does not have to waive the copayment for the diagnostic colonoscopy with specimen collection
(45378) provided on July 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the periodontal maintenance (D4910) and oral hygiene instructions (D1330) provided September 8, 2021. 

You asked the Plan to pay for the periodontal maintenance and oral hygiene instructions. You say that your oncologist has advised that it is medically necessary for you to go to the dentist every three months for periodontal maintenance. The Plan denied your request. The Plan says you have exceeded the frequency limit for cleanings and oral hygiene instructions are not 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. The Plan covers the periodontal maintenance once every 6 months.   

We looked at the file and Medicare rules. In this case the Plan provided documentation showing that periodontal maintenance was previously covered on June 7, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of the periodontal maintenance has been exceeded. Though the Plan offers dental benefits in excess of Medicare coverage, oral hygiene instructions are not among those covered services. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910) and oral hygiene instructions (D1330) provided September 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for ophthalmological services, medical examination provided on September 10, 2021.  

You asked the Plan to pay for ophthalmological services, medical examination. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.  

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 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 ophthalmological services, medical examination provided on September 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient hospital services.  

You asked the Plan to pay for inpatient hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there is no documentation provided to support the expectation you will require a greater than 2 midnight stay.  

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.   

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 inpatient hospital services. Our reviewer says that inpatient hospital services are not medically reasonable and necessary. You are undergoing a planned right total knee arthroplasty. You are medically stable and have been provided medical clearance to undergo this elective procedure. The planned procedure is not listed on the Inpatient Only List. The procedure is currently approved as an ambulatory procedure. There is no documentation provided to support the expectation you will require a greater than 2 midnight stay. Our physician reviewer found that your condition does not meet criteria for coverage of inpatient hospital 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 inpatient hospital services have not been met. Therefore, we decided that the Plan does not have to pay for inpatient hospital services.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on August 4, 2021.  

You asked the Plan to pay for ambulance response and treatment, no transport. The Plan denied your request. The Plan says Medicare and the Plan do not cover ambulance services without transportation.  

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.   

The ambulance company did not provide transport services on August 4, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on August 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses purchased on June 22, 2021, from an out-ofnetwork
provider.
You asked the Plan to pay for the eyeglasses. You say that you were told that you could buy these glasses and
would receive reimbursement from the Plan for them. You went to your doctor who is not part of the Plan's
routine vision network, and you would have gone somewhere cheaper if you knew these would not be covered.
The Plan denied your request. The Plan says routine eyewear must be purchased through a provider in the
specified routine vision network. The benefit allowance is applied at the point of sale, and you are responsible
for any amount over the annual benefit maximum. These eyeglasses were purchased through an out-of-network
provider, and therefore are denied. The Plan also states that they have reviewed your call logs and did not
identify any calls you made to the plan prior to purchasing these glasses.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers these services when they are purchased through a provider in the Plan's specified
routine vision network.
We looked at the file and the Plan's rules. The provider in this case is not part of the Plan's specified network.
Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met.
Therefore, we decided that the Plan does not have to pay for the eyeglasses purchased on June 22, 2021, from
an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physician's services for an eye examination 
provided on August 31, 2021.

You asked the Plan to waive the copayment for physician's services for an eye examination. The Plan denied 
your request. The Plan says the claim processed 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 $40 
copayment for Vision Care (Medicare-covered). 

You have been asked to pay $40 copayment for physician's services for an eye examination. The physician's 
services for an eye examination falls within the Vision Care (Medicare-covered) 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 physician's services for an eye examination provided on 
August 31, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient behavioral health services provided by a Licensed Marriage and Family Therapist (LMFT) from June 1, 2021 to July 20, 2021
You asked the Plan to pay for the outpatient behavioral health services provided by a LMFT. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says a LMFT is ineligible to enroll in the Medicare program.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. The services you received in this case were provided by a Licensed Marriage & Family Therapist (LMFT).
This provider type is not eligible to enroll in Medicare. No provider shall receive payment for services furnished to a Medicare beneficiary unless the provider is enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the outpatient behavioral health services provided by a Licensed Marriage and Family Therapist (LMFT) from June 1, 2021 to July 20, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and pulp vitality test (D0460) provided on September 3, 2021.
You asked the Plan to pay for the dental services. You say that you did not know these services would not be covered, and you cannot afford to pay for them. The Plan denied your request. The Plan says the pulp vitality test is not a covered service under your dental benefit. The limited exam is an eligible service that may be covered once per plan year, but you had a previous limited exam on September 2, 2021, which was covered by the Plan at that time. Therefore, the limited exam provided on September 3, 2021, was provided in excess of what is covered by your 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. Services and codes which are not listed in the Plan's dental benefits chart are not covered. Eligible services may be subject to limitations in frequency or other exclusions. The Plan can cover one limited exam to evaluate a problem (D0140) per plan year. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested pulp vitality test is not among those covered under this benefit. The limited exam is a covered service, but documentation shows that the Plan has already paid for one limited oral exam for you in the 2021 Plan year. This means that you have exceeded the frequency limitation for this service. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) and pulp vitality test (D0460) provided on September 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the root amputation (D3450) provided on August 5, 2021.
You asked the Plan to pay for the dental service. You say that you received a root canal. You say that you thought this service would be covered. You say that your dentist did their best to save your tooth. You also say that the service was medically necessary. The Plan denied your request. The Plan says root amputation 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 root amputation is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the root amputation (D3450) provided on August 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 19 extractions (D7140) and intravenous sedation 
provided from October 20, 2020, to December 18, 2020.

You asked the Plan to pay for the dental services. You say that the services were medically necessary. You also 
say that you were hospitalized for treatment of an infection. The Plan denied your request. The Plan says 
fillings and intravenous sedation are not covered by the Plan or Medicare.

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 extractions and intravenous 
sedation are not among those covered under this benefit. Additionally, the services you are asking the Plan to 
pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly 
supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we 
decided that the Plan does not have to pay for the 19 extractions (D7140) and intravenous sedation provided 
from October 20, 2020, to December 18, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for wound care services (29581) provided from 
May 21, 2021, to June 1, 2021.

You asked the Plan to waive the copayment for the wound care services. You say that the services should be 
covered as they are very expensive and would cause financial hardship. The Plan denied your request. The Plan 
says the cost-sharing applied correctly based on 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 $300 
copayment for Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers. 

You have been asked to pay a $79.38 copayment per visit for four visits of wound care services at an 
ambulatory surgery center, which is less than the $300 per visit based on the Plans contract ($79.38 x 4 = 
$317.52). Wound care services fall within the Outpatient surgery, including services provided at hospital 
outpatient facilities and ambulatory surgical centers 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 wound care services (29581) provided from May 21, 2021, to June 1, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the abdominal ultrasound (76705) provided on August 2, 2021.  

You asked the Plan to pay for the abdominal ultrasound. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says an edit exists between CPT codes 76705 and 93976.  

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 76705 is a column II code to column I code 93976. 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 the abdominal ultrasound (76705) provided on August 2, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.  

You asked the Plan to pre-approve SNF services. You say that the enrollee needs additional treatment before he can go home. The Plan denied your request. The Plan says that the enrollee has no skilled nursing needs.  

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for radiology services (procedure code 76140) provided to the enrollee on July 23, 2021.  

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this code is not valid 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 76140 is "Consultation on X-ray examination made elsewhere, written report."  

We find that CPT code 76140 is not supported in the medical record. Specifically, this code has a status indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for Medicare purposes. 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 radiology services (procedure code 76140) provided to the enrollee on July 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laser treatment for inflammatory skin disease (psoriasis) services coded 96920 provided on August 20, 2021.  

You asked the Plan to pay for the laser treatment for inflammatory skin disease. 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.  

In this case, the CPT Code Manual definition of code 96920 is laser treatment for inflammatory skin disease (psoriasis); total area less than 250 sq cm.   

We find that CPT code 96920 is not supported in the medical record. Specifically, this code is only reportable for psoriasis per the code description. This code was not billed with a diagnosis code to support psoriasis on the claim. Based on this information, we decided that Medicare rules for coverage of the laser treatment for inflammatory skin disease have not been met. Therefore, we decided that the Plan does not have to pay for the laser treatment for inflammatory skin disease (psoriasis) services coded 96920 provided on August 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve genetic testing (81425).  

You asked the Plan to pre-approve the genetic testing. You say that the testing is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.  

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 genetic testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found to consider the request for genetic testing, clear documentation showing how those results will be used to treat the condition is required. This information has not been provided. Additionally, testing for purposes where the results will not directly influence the treatment or testing for informational purposes only, is not considered 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 the genetic testing have not been met. Therefore, we decided that the Plan does not have to pre-approve genetic testing (81425).