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

We decided that the Plan does not have to pay for radiology services (procedure code 73620.)

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 there is no modifier billed to indicate the services as separate/distinct.

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 73620 is "Radiologic examination, foot; 2 views." 

We find that CPT code 73620 is not supported in the medical record. Specifically, there was no modifier billed in this case to indicate that CPT 73620 is separate and distinct from other services billed on the same day by the same provider. 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 73620.)
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), initial periapical x-ray (D0220), additional periapical x-ray (D0230) provided on July 1, 2021.

You asked the Plan to pay for the dental services. You say that you were told the dentist was in network. You also say that the services should be covered. The Plan denied your request. The Plan says the limited oral evaluation is not listed as a covered service. The Plan says that periapical x-rays are not listed as covered services 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 limited oral evaluation and periapical x-rays are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), initial periapical x-ray (D0220), additional periapical x-ray (D0230) provided on July 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and prophylaxis (D1110) provided on June 1, 2021.
You asked the Plan to pay for the dental services. You say that you and your dentist were given information that the dental services would be covered at 100%. The Plan denied your request. The Plan says you have coverage for accidental dental and limited oral surgery services. The Plan says that preventive and diagnostic dental services are excluded from coverage. The Plan also says that oral exams and cleanings are considered preventive dental services and are not covered.
Medicare generally does not cover dental services. The Plan follows the same rule.
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 comprehensive oral evaluation (D0150) and prophylaxis (D1110) provided on June 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for OTC supplements, Oligomeric proanthocyanidins (OPC-3) provided on July 26, 2021.

You asked the Plan to reimburse you for OTC supplements, Oligomeric proanthocyanidins (OPC-3). The Plan denied your request. The Plan says the Medicare Managed Care Manual specifically prohibits Medicare
Advantage plans from covering "Alternative medicines" under an OTC benefit. The Managed Care Manual defines these items as "homeopathic and alternative medicines including botanicals, herbals, probiotics and nutraceuticals.

The Plan contract offers a supplemental Pick Your Perks program benefit. The benefit says over-the-counter items must be included on the Plan's allowed items list. Ineligible items include alternative medicines such as botanicals, herbals, probiotics and nutraceuticals.

We looked at the file and Medicare rules. The file shows that OTC items must be included on the Plan's allowed items list. Ineligible items include alternative medicines such as botanicals, herbals, probiotics and nutraceuticals. Therefore, we decided that the Plan does not have to reimburse you for over the counter (OTC) supplements, Oligomeric proanthocyanidins (OPC-3) provided on July 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental drugs (D9630) provided by an out-of-network provider on November 3, 2020.

You asked the Plan to pay for dental drugs. You say that this provider is in-network. The Plan denied your request. The Plan says D9630 is not a covered dental 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. 

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 dental drugs (D9630) provided by an out-of-network provider on November 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on September 8, 2021.
You asked the Plan to pay for the dental service. You say that your tooth broke. You say that you had your tooth repaired. You also say that the service was required to determine what repair was needed for the broken tooth. The Plan denied your request. The Plan says 1 limited oral evaluation is covered per plan year. The Plan also says that the frequency limit has been exceeded.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage and the services are listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a limited oral evaluation that you received on March 8, 2021. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on September 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee on June 10, 2021.

You asked the Plan to pay for acute inpatient hospital care. You say that this was medically necessary. The Plan denied your request. The Plan says this could have been provided in an alternate level of care, such as observation.

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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found based on there being no immediate signs or symptoms of complexity or severity that might warrant inpatient services as she was responding to conservative treatments at the time of admission, it was not expected that the enrollee would require hospital services that would likely cross 2 midnights. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee on June 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency oral evaluation (D0140) provided on August 17, 2021.

You asked the Plan to pay for the dental service. You say that you feel the service should be covered as it has been covered in the past. The Plan denied your request. The Plan says 1 emergency oral evaluation is covered every 12 months. The Plan says that the frequency limit has been exceeded.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage and emergency oral evaluation is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for an emergency oral evaluation that you received on February 22, 2021. Therefore, we decided that the Plan does not have to pay for the emergency oral evaluation (D0140) provided on August 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on June 21, 2021.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must 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 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 out of network physician services provided to the enrollee on June 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital care with diagnosis related group (DRG) 683 provided from June 22, 2020 to June 24, 2020.

You asked the Plan to pay for the inpatient hospital care. You say that the medical records support the billing of the principal diagnosis code N17.9: Acute kidney injury (nontraumatic) with DRG 683. The Plan denied your request. The Plan says the medical records do not support the billing of the principal diagnosis code N17.9: Acute kidney injury (nontraumatic) with DRG 683.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. 

In this case, you billed the inpatient services provided with N17.9. 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 the inpatient hospital care. Our reviewer says that the medical records do not support the billing of the principal diagnosis code N17.9: Acute kidney injury (nontraumatic) with DRG 683. Our physician reviewer found the review indicates that the enrollee is with a history of coronary artery disease with percutaneous intervention, congestive heart failure, hypertension, diabetes mellitus, chronic obstructive pulmonary disease, hiatal hernia with gastroesophageal reflux disease, peripheral arterial disease and hyperlipidemia, who presented for evaluation reporting generalized weakness, dyspnea, nausea, and pruritus. The review has determined that the medical records did not support the billing of the principal diagnosis code N17.9: Acute kidney injury (nontraumatic) with DRG 683. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital care with diagnosis related group (DRG) 683 provided from June 22, 2020 to June 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse an additional amount for the comprehensive oral evaluation (D0150) provided on May 13, 2021, by the out of network dentist

You asked the Plan to reimburse an additional amount for the dental service. You say that The Plan denied your request. The Plan says there is a 50% coinsurance for comprehensive oral evaluation received out of network.

The Plan says that dental services received out of network are paid based on the in network fee schedule. The Plan says out of network dentist may also bill you for any amount greater than what the Plan pays the provider.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage and the comprehensive oral evaluation is listed as covered, there is a 50% coinsurance when received out of network. Out of network dentists may also bill you for any amount greater than what the plan pays. Therefore, we decided that the Plan does not have to reimburse an additional amount for the comprehensive oral evaluation (D0150) provided on May 13, 2021, by the out of network dentist
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a FreeStyle Libre 2.
You asked the Plan to pre-approve a FreeStyle Libre 2. You say that the item is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan. We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a FreeStyle Libre 2 have not been met. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre 2.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency ambulance transportation services (A0427) provided on February 9, 2021.

You asked the Plan to waive the copayment for the ambulance transportation. You say that these services were necessary as the enrollee could not be taken privately to the hospital, and you feel this cost should be waived. The Plan denied your request. The Plan says Medicare-covered ambulance services require a $250 copayment per trip. These services have been covered and the enrollee is responsible for their share of the cost as indicated in the contract.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $250 copayment for each one-way Medicare-covered ground ambulance trip.

The enrollee has been asked to pay a $250 copayment for the ambulance transportation. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency ambulance transportation services (A0427) provided on February 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for puncture of the pleural space with the insertion of a needle or catheter placed for aspiration of fluid (32555) provided March 1, 2021.

You asked the Plan to pay for thoracentesis. You say that the enrollee had multiple exams on this date of service. Attached reports to support level of service. Please reconsider for processing. The Plan denied your request. The Plan says the claim has already been processed.

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 find that CPT code 32555-RT, 32555-LT is not supported in the medical record. Specifically, the documentation submitted supports 1 unit each of 32555-RT and 32555-LT, which was previously approved and paid. Based on this information, we decided that Medicare rules for coverage of thoracentesis have not been met. Therefore, we decided that the Plan does not have to pay for puncture of the pleural space with the insertion of a needle or catheter placed for aspiration of fluid (32555) provided March 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the telehealth visit you had with an out-of-network neuropsychiatry specialist on July 22, 2021.

You asked the Plan to waive the copayment for the telehealth visit with an out-of-network neuropsychiatry specialist. You say that there should not be a copayment for this since it was a 'telemed' visit. The Plan denied your request. The Plan says the $0 telehealth benefit is only available when you use network providers. This provider is out-of-network, so the out-of-network specialist visit copayment applies.

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 $70 copayment for out-of-network specialist visits.

You have been asked to pay a $70 copayment for the telehealth visit with an out-of-network neuropsychiatry specialist. Your contract explicitly states that the telehealth benefit at $0 copayment is only available if you use a network provider. The provider in this case is an out-of-network provider. That is why the out-of-network specialist visits copayment applies. 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 telehealth visit you had with an out-of-network neuropsychiatry specialist on July 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided on July 26, 2021
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says you did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must 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 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 out of network physician services provided on July 26, 2021
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency ambulance transportation services (A0427) provided on May 20, 2021.
You asked the Plan to waive the copayment for the ambulance transportation. You say that you feel you should not be liable for these costs, as this transportation was only necessary after the hospital discharged you prematurely. The Plan denied your request. The Plan says this claim was processed correctly, and your copayment was assessed in accordance with your contract.
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 $195 copayment for each one-way Medicare-covered ambulance service.
You have been asked to pay a $195 copayment for the ambulance transportation. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency ambulance transportation services (A0427) provided on May 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for radiation therapy services you received from an out-of-network dermatologist on June 30, 2021.

You asked the Plan to waive the coinsurance for the radiation therapy services. You say that you were never advised that this was an out-of-network provider and you should have been referred to an in-network provider. The Plan denied your request. The Plan says you received radiation therapy (i.e., therapeutic radiological procedures) on this date of service. You were assessed the correct coinsurance for this service. Although this provider is out-of-network, these services were assessed the in-network 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 20% coinsurance for therapeutic radiology services.

You have been asked to pay 20% coinsurance for the radiation therapy services. The radiation therapy services fall within the therapeutic radiology 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 coinsurance for radiation therapy services you received from an out-of-network dermatologist on June 30, 2021.