Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for pain management services (procedure code 62320) provided to the enrollee on August 30, 2021.
You asked the Plan to pay for the services. You say that the services were billed correctly and should be paid for. The Plan denied your request. The Plan says the records are insufficient to support payment for the services.
The Plan must follow Medicare rules. Medicare rules say that in order for code 62320 to be covered, certain documentation requirements must be met. The documentation must include the legible signature of the physician or non-physician practitioner responsible for providing the care to the patient. In addition, the procedure report should clearly document the indications and the medical necessity for the blocks along with the pre and post percent pain relief achieved immediately post-injection. The medical records in this case do not meet Medicare's documentation requirements. Specifically, the record is not signed and there is no notation of the percent of pain relief achieved either before or after the injection. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of procedure code 62320 have not been met. 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 pain management services (procedure code 62320) provided to the enrollee on August 30, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided on September 30, 2021.
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that you have never been charged for a colonoscopy before. You say that this was a screening colonoscopy. The Plan denied your request. The Plan says this was a diagnostic colonoscopy and the copayment applied was correct.
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 a screening
colonoscopy can become a diagnostic colonoscopy when a physician removes a polyp during the procedure.
Your contract with the Plan also clearly says that you must pay a $260 copayment for each Medicare-covered
outpatient hospital services.
Medical records show that polyps were removed during your colonoscopy. You have been asked to pay a $260
copayment for a diagnostic colonoscopy. A diagnostic colonoscopy falls within the outpatient hospital 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 a diagnostic colonoscopy
provided on September 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) and knee orthotics (L1833) provided on July 16, 2021.  You asked the Plan to pay for a lumbar-sacral orthosis and knee orthotics. You say that the enrollee needed this equipment. The Plan denied your request. The Plan says this equipment was provided following unsolicited outreach to the enrollee.  The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances.  We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the past 15 months. Based on this information, we decided that Medicare rules for coverage of a lumbar-sacral orthosis and knee orthotics have not been met. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) and knee orthotics (L1833) provided on July 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the prophylaxis (D1110) provided on November 9, 2021.

You asked the Plan to pay an additional amount for the dental service. You say that you received a bill for $36. You say that you were not aware that the provider was no longer in network. You also say that you should not have to pay this bill. The Plan denied your request. The Plan says the claim was processed correctly.

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 provider in this case is out of network. The record shows that the member liability of $36 was correctly applied. This is a contractual obligation you agreed to when you enrolled in the Plan's dental coverage. Therefore, we decided that the Plan does not have to pay an additional amount for the prophylaxis (D1110) provided on November 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy (90832) provided on July 21, 2021, to September 9, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for psychotherapy. You say that the treatment provided was medically necessary to manage the consumer's illness and prevent episodes decompensation. The Plan denied your request. The Plan says there is no referring provider involved in these services and the rendering provider is a non-participating provider. The Plan also says that they did not authorize any services for this 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 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 had network providers
available who could have provided the items/services at issue in this appeal. 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 psychotherapy (90832) provided on July 21, 2021,
to September 9, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the fluoride application (D1208), and periapical x-ray (D0220) provided on July 12, 2021.
You asked the Plan to pay for the dental services. You say that the services should be covered. The Plan denied your request. The Plan says fluoride treatments are not covered. The Plan also says the periapical x-ray is not covered either.
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 fluoride treatment and periapical x-ray are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the fluoride application (D1208), and periapical x-ray (D0220) provided on July 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for pain management services (procedure code 62320) provided to the enrollee on September 20, 2021.  

You asked the Plan to pay for the services. You say that the services were billed correctly and should be paid for. The Plan denied your request. The Plan says the records are insufficient to support payment for the services.  

The Plan must follow Medicare rules. Medicare rules say that in order for code 62320 to be covered, certain documentation requirements must be met. The documentation must include the legible signature of the physician or non-physician practitioner responsible for providing the care to the patient.  In addition, the procedure report should clearly document the indications and the medical necessity for the blocks along with the pre and post percent pain relief achieved immediately post-injection.  

The medical records in this case do not meet Medicare's documentation requirements.  Specifically, the record is not signed and there is no notation of the percent of pain relief achieved either before or after the injection. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of procedure code 62320 have not been met. 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 pain management services (procedure code 62320) provided to the enrollee on September 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1851) and suspension sleeve (L2397) provided September 28, 2021.
You asked the Plan to pay for the orthoses. You say that the claim was prescribed by the enrollee's PCP on file and is currently covered under the coverage criteria for knee orthosis per the CMS LCD. The Plan denied your
request. The Plan says there is no documented medical necessity for this brace and sleeve. The doctor listed as the ordering provider by the DME company denies ordering this item for the enrollee.
The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances. We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the past 15 months. Based on this information, we decided that Medicare rules for coverage of the orthoses have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1851) and suspension sleeve (L2397) provided September 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the dental filling (D2335) provided on October 4, 2021.

You asked the Plan to waive the copayment for the filling. You say that this service was pre-approved, and you do not understand why you have to pay this amount. The Plan denied your request. The Plan says this claim was processed correctly, and your copayment was assessed in accordance with your contract and dental schedule of benefits. This type of filling requires a $68 copayment when performed by a general dentist.

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 $68 copayment for a resin-based composite, four or more surfaces, involving incisal angle (D2335) performed by a general dentist.

You have been asked to pay a $68 copayment for the filling billed with code D2335. 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 dental filling (D2335) provided on October 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection rendered on August 9, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. Medicare rules say that for code 62320 to be covered, certain documentation requirements must be met.

The medical records in this case do not meet Medicare's documentation requirements. Specifically, the record is not signed and there is no notation of the percent of pain relief achieved either before or after the injection. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of procedure code 62320 have not been met. Therefore, we decided that the Plan does not have to pay for the injection rendered on August 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a CT scan provided on November 17, 2021.  

You asked the Plan to waive the copayment for a CT scan. You say that you were told that your cancer treatments 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 $100 copayment for CT scans.   

You have been asked to pay a $100 copayment for a CT scan. A CT scan 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 a CT scan provided on November 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the porcelain/ceramic crown (D2740) provided on August 25, 2021.
You asked the Plan to pay for the crown. You say that you believed your benefits included a $2,500 limit and 2 crowns and a root canal at no cost to you in addition to this allowance. The Plan denied your request. The Plan says all supplemental dental services are subject to the $2,500 annual maximum. You met your maximum for dental care in 2021 on the date in question and are responsible for the remaining cost. In addition, the Plan says that they have reviewed your call logs and found that you only called the Plan after this service was rendered.
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 up to $2,500 per year for supplemental dental care. Though the Plan offers a dental benefit in excess of Medicare coverage, the services were provided in excess of the Plan's annual maximum for dental care. Documentation shows that you met this maximum on the date in question after the Plan issued partial payment for services. You are responsible for the remaining cost.
Therefore, we decided that the Plan does not have to pay for the porcelain/ceramic crown (D2740) provided on August 25, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance transportation services provided on September 28, 2021.
You asked the Plan to waive the copayment for the ambulance transportation. You say that you feel that you do not owe the copayment because the transportation was necessary since your wife was unable to take you. 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 $265 copayment per date of service for ground ambulance transportation.
You have been asked to pay a $265 copayment for the ambulance transportation. The ambulance transportation falls within the Ambulance 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 ambulance transportation services provided on September 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for handrails (A9270).

You asked the Plan to pay for handrails. You say that your occupational therapist recommended them so they should be covered by the Plan. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pay for handrails (A9270).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206) provided on November 4, 2021.
You asked the Plan to pay for the topical application of fluoride varnish. You say that you were not advised that this service would not be covered by your insurance. The Plan denied your request. The Plan says this service is not a covered expense under your dental plan. The Plan also says that you did not contact the Plan prior to the date of service to verify benefits and provider eligibility.
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 topical application of fluoride varnish (D1206) provided on November 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services (U0003) provided July 13, 2020 to July 14, 2020.  

You asked the Plan to pay for the lab services. You say that the lab services were 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 providers must report services correctly. Providers must report services with the appropriate CPT code.  

We find that CPT code U0003 is not supported in the medical record. Specifically, the patient was an inpatient in a skilled nursing facility at the time services were rendered. This service is not eligible for separate payment. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (U0003) provided July 13, 2020 to July 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a bladder procedure, physician's services and
laboratory services provided on April 13, 2021, a consultation provided on May 1, 2021, pre-anesthesia,
laboratory testing, a Coronavirus test provided on May 27, 2021, and surgery provided on May 29, 2021.
You asked the Plan to reimburse you for a bladder procedure, physician's services and laboratory services
provided on April 13, 2021, a consultation provided by on May 1, 2021, pre-anesthesia, laboratory testing, a
Coronavirus test provided on May 27, 2021, and surgery provided on May 29, 2021. You say that these
medical services were urgently needed. The Plan denied your request. The Plan says Plan covers worldwide
emergency and urgently needed services outside the United States under the following circumstances:
emergency services, including emergency or urgently needed care and emergency ambulance transportation
from the scene of an emergency to the nearest medical treatment facility. Pre-scheduled and/or elective
procedures are not covered.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and
pre-approved care. The Plan contract also says that the Plan covers worldwide emergency and urgently needed
services outside the United States under the following circumstances: emergency services, including
emergency or urgently needed care and emergency ambulance transportation from the scene of an emergency
to the nearest medical treatment facility. Transportation back to the United States from another country is not
covered. Pre-scheduled and/or elective procedures are not covered.
We looked at the file, the Medicare rules and the Plan's rules. The file shows that the services were prescheduled
and/or elective procedures, which are a Plan contract exclusion for worldwide coverage outside of
the United States. Based on this information, we decided that the Plan does not have to reimburse you for a
bladder procedure, physician's services and laboratory services provided on April 13, 2021, a consultation
provided on May 1, 2021, pre-anesthesia, laboratory testing, a Coronavirus test provided on May 27, 2021, and
surgery provided on May 29, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on October 26, 2020.
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 the denied codes remain not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.
We find that the denied codes are not supported in the medical record. Specifically, the place of service on the
CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a
place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of skilled nursing
facility. (POS 31) Based on this information, we decided that Medicare rules for coverage of the services have
not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the
enrollee on October 26, 2020.