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

 We decided that the Plan does not have to pay for the additional extraction, panoramic x-ray and comprehensive oral evaluation provided on July 7, 2021.  You asked the Plan to pay for the additional extraction, panoramic x-ray and comprehensive oral evaluation. You say that your previous office was no longer open, and you were referred to this doctor. You say that you were not told the exam, x-ray or extractions weren't covered and you are requesting the decision be reversed. The Plan denied your request. The Plan says reimbursement was previously issued for two extractions, a comprehensive oral evaluation.  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, you also have a maximum benefit of one comprehensive oral evaluation every three years, one panoramic x-ray every five years and two extractions per calendar year. The Plan paid for the comprehensive oral evaluation and panoramic x-ray provided on April 25, 2019 and for two extractions provided on July 7, 2021, which exhausted your benefits. Therefore, we decided that the Plan does not have to pay for the additional extraction, panoramic x-ray and comprehensive oral evaluation provided on July 7, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the diagnostic colonoscopy with polyp removal you had at an outpatient hospital facility on April 12, 2021.

You asked the Plan to waive the cost sharing for the diagnostic colonoscopy. You say that you are entitled to have this service covered at 100%. The Plan denied your request. The Plan says you were assessed the deductible and copayment correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract says that there is no cost sharing for colorectal cancer screening. However, when a screening colonoscopy because a diagnostic procedure (e.g., results in a biopsy or removal of a lesion or growth), then outpatient surgery cost sharing and deductible apply. There is a $750 deductible that applies to outpatient surgery. Once the deductible is met, enrollees must pay a $125 copayment for outpatient surgery.

We looked at the medical records in this case. The records show that you had polyps removed during this colonoscopy. According to your contract, this means that the colonoscopy is considered a diagnostic procedure for which the deductible and copayment apply. You have been asked to pay the $750 deductible and a $125 copayment for the diagnostic colonoscopy. The diagnostic colonoscopy falls within the outpatient surgery benefit category. This means that you have been asked to pay the correct amounts 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 cost sharing for the diagnostic colonoscopy with polyp removal you had at an outpatient hospital facility on April 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve lumbar fusion (a procedure to join spinal bones in your back), including any associated procedures, implants or supplemental bone products, unspecified instrumentation (devices such as plates, screws and rods used to help support the spine's healing process after surgery, and hospital inpatient admission (CPT code(s): 22612, 27280, 22614, 22842).  You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the services are not necessary.  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 services. Our physician reviewer found the criteria not met. There is no documentation of spinal instability. No radiographs showing abnormal spinal motion.  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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar fusion (a procedure to join spinal bones in your back), including any associated procedures, implants or supplemental bone products, unspecified instrumentation (devices such as plates, screws and rods used to help support the spine's healing process after surgery, and hospital inpatient admission (CPT code(s): 22612, 27280, 22614, 22842).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (88305, 88312, 88313) rendered by
the out-of-network (OON) provider on August 31, 2020.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. 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 the laboratory services (88305, 88312, 88313) rendered by the out-of-network
(OON) provider on August 31, 2020.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the diagnostic tests (51798, 51728) provided on April 30, 2021.  You asked the Plan to waive the copayment for the diagnostic tests. You say that these services were part of a necessary follow-up visit relating to a previous surgery, and you feel they should be covered in full. The Plan denied your request. The Plan says they have agreed to lower the copayment to the $35 copayment for specialist physician services; however, you are still responsible for your share of the cost for care 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 $35 copayment for physician specialist services.   You have been asked to pay a $35 copayment for the diagnostic tests which were provided during an office visit with a specialist. 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 tests (51798, 51728) provided on April 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the critical care services provided from January 9, 2021, to January 12, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services cannot be verified.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  In this case, the CPT Code Manual definition of code 99291 is "Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes".  We find that CPT code 99291 is not supported in the medical record. Specifically, the records do not show that 30-74 minutes of critical care services were provided on the date of service in question. 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 the critical care services provided from January 9, 2021, to January 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the limited oral evaluation (D0140), personal protective equipment (D1999 x 2), and the periapical x-ray (D0220) provided from May 24, 2021, to July 15, 2021.  You asked the Plan to pay for the dental services. You say that you had an old filling break off. You say that you preferred to have a crown done to save the tooth. You also say that the services should be covered. The Plan denied your request. The Plan says limited oral evaluation is not listed as a covered service. The Plan says that personal protective equipment are not listed as covered services. The Plan says that 1 periapical x-ray is covered per calendar 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, the limited oral evaluation and personal protective equipment are not among those covered under this benefit. Additionally, the frequency limit for periapical x-ray has been exceeded. The record shows that the Plan paid for the periapical x-ray that you received on May 24, 2021. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), personal protective equipment (D1999 x 2), and the periapical x-ray (D0220) provided from May 24, 2021, to July 15, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the self-administered drugs provided from June 28, 2021, through June 29, 2021.  You asked the Plan to pay for the self-administered drugs. You say that a cost of the medications was not given to you until 10:50 and you assumed all drugs given were necessary for his treatment. You say that a small amount of medications was dispensed and all or a reasonable cost of the drugs should be paid for. The Plan denied your request. The Plan says self-administered drugs in an outpatient hospital setting are not covered by Medicare Part B.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided from June 28, 2021, through June 29, 2021.   Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the breast ultrasound you had on June 16, 2021.  You asked the Plan to waive the copayment for the breast ultrasound. You say that you had to have a mammogram a second time and it was done with ultrasound. You said that you cannot afford this copayment. The Plan denied your request. The Plan says you were charged this copayment correctly.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for x-rays and ultrasounds.   You have been asked to pay a $50 copayment for the breast ultrasound. This copayment applies regardless of the reason for the service. 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 breast ultrasound you had on June 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the cost sharing for the visit you had with a pain management specialist on March 25, 2021, the epidural injection procedure with sedation you had at an outpatient hospital facility on April 22, 2021, the office visits you had with an orthopedic surgeon on June 11, 2021, and June 21, 2021, the x-ray services you had on August 18, 2021, the back brace you received on August 17, 2021, and the inpatient hospital services you received from August 18, 2021, to August 22, 2021.  You asked the Plan to waive the cost sharing for the specialist visits, the outpatient surgery procedure, the x-ray, the back brace, and the inpatient hospital services. You did not provide an argument with your appeal request. The Plan denied your request. The Plan says you were charged these cost sharing amounts 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 $25 copayment per visit for specialist visits, a $325 copayment for outpatient hospital services, a $25 copayment for x-rays, 20% coinsurance for prosthetics and supplies, and a $320 copayment per day for days 1-5 for inpatient hospital services.   You have been asked to pay a $25 copayment per visit for each of the specialist visits, a $325 copayment for the outpatient surgery procedure, a $25 copayment for the x-ray, and 20% coinsurance for the back brace.  In addition, records show that you were in the hospital for 4 days.  You were charged a $320 copayment per day, for a total of $1280. This means that you have been asked to pay the correct amounts 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 cost sharing for the visit you had with a pain management specialist on March 25, 2021, the epidural injection procedure with sedation you had at an outpatient hospital facility on April 22, 2021, the office visits you had with an orthopedic surgeon on June 11, 2021, and June 21, 2021, the x-ray services you had on August 18, 2021, the back brace you received on August 17, 2021, and the inpatient hospital services you received from August 18, 2021, to August 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the surgical services rendered on April 12, 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 procedure code 20680 is 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.  In this case, the CPT Code Manual definition of code 20680 is removal of implant; deep (eg, buried wire, pin, screw, metal band, nail, rod or plate).  We find that CPT code 20680 is not supported in the medical record. Specifically, there is no documentation of removal of a deep implant. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services rendered on April 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the placement of intra-socket biological dressing (D7922) and therapeutic parenteral drug (D9610) provided on June 22, 2021.  You asked the Plan to pay for the placement of intra-socket biological dressing and therapeutic parenteral drug. You say that you contacted the Plan multiple times trying to find an in-network oral surgeon but could not find one that could pull your tooth. You also say that you were told by the Plan that in these situations the Plan would consider the out-of-network claim toward your in-network benefits. The Plan denied your request. The Plan says these services are not covered expenses under your dental plan.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the placement of intra-socket biological dressing (D7922) and therapeutic parenteral drug (D9610) provided on June 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an office visit with a specialist (99213) rendered on June 28, 2021. We have also decided that the Plan does not have to waive the deductible for the destruction (cryosurgery) of premalignant lesions (17000) rendered on June 28, 2021.  You asked the Plan to waive the copayment for an office visit with a specialist. You also asked the Plan to waive the deductible for the destruction (cryosurgery) of premalignant lesions. You say that it appears you are being charged twice for the same procedure. You also say you feel you should have been told of these charges ahead of time. You also say that this was not a surgical excision, it was cryotherapy. The Plan denied your request. The Plan says you were 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 $35 copayment for each in-person specialist visit. Your contract with the Plan also says that there is a $750 deductible for all items and services except those specifically excluded by the Plan contract.  You have been asked to pay a $35 copayment for an office visit with a specialist. You have also been asked to pay $210.39 for the destruction (cryosurgery) of premalignant lesions. This was broken down among two claims, one for the professional services of the physician ($52.32) and the other for the facility services related to the procedure ($158.07). 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 office visit with a specialist (99213) rendered on June 28, 2021. We also decided that the Plan does not have to waive the deductible for physician services and the destruction (cryosurgery) of premalignant lesions.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital services rendered on June 18, 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 payment is included in the global surgical package.

The Plan must follow Medicare rules. The rules say that A/B MACs (B) pay for an evaluation and management service on the day of or on the day before a procedure with a 90-day global surgical period if the physician uses CPT modifier "-57" to indicate that the service resulted in the decision to perform the procedure. 

We looked at the file and Medicare rules. Billed procedure code 99223 (initial hospital visit) was billed during the global surgery period for minor procedure 92960 (elective cardioversion) and was billed with the -57 modifier. Payment for code 99223 is included in the global surgical package. Therefore, we decided that the Plan does not have to pay for the initial hospital services rendered on June 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for the computed tomography (CT) scan of the cervical spine you had on June 16, 2021, and the neurosurgery office visit you had on July 6, 2021.  You asked the Plan to waive the copayments for the CT scan and the neurosurgery visit. You say that you should not have to pay these copayments because you never said anything about your neck.  You said that you went to this doctor because of muscle and pinched nerves. The Plan denied your request. The Plan says you were charged these copayments 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 $100 copayment for CT scans and a $35 copayment for specialist services.   You have been asked to pay a $100 copayment for the CT scan and a $35 copayment for the neurosurgery visit. These copayments apply regardless of your satisfaction with the services received. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the computed tomography (CT) scan of the cervical spine you had on June 16, 2021, and the neurosurgery office visit you had on July 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve transthoracic echocardiography (TTE) for the enrollee.  You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says repeat imaging is not supported without results of prior imaging that show a clear reason for it.  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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the TTE in 3/2021 was technically satisfactory and interpreted by a cardiologist. His cardiologist noted the enrollee's clinical improvement in a 5/2021 clinic visit. Neither the 3/2021 TTE findings, nor his 5/2021 history and physical findings, would point to a change in status that would support the medical necessity of a repeat study. Clinical guidelines support a repeat TTE every three years after prosthetic valve replacement or when there is a change in clinical status or new signs and symptoms and suggestion of prosthetic valve dysfunction, thrombosis or infection. In summary, there is no supportive evidence for the medical necessity of a repeat study.  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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve transthoracic echocardiography (TTE) for the enrollee.