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

We decided that the Plan does not have to pay for the CxBladder testing provided on April 2, 2021.

You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered service.

The Plan must follow Medicare rules. Medicare rules say that CPT codes 0012M and 0013M for CxBladder are non-covered. 

We looked at the file and Medicare rules. In this case, CPT code 0013M was billed for CxBladder testing. Per LCD L35396, this is a non-covered code. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the CxBladder testing provided on April 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on January 2, 2021, by an OON
provider.
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 physician services provided on January 2, 2021,
by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI provided on April 20, 2021.
You asked the Plan to waive the copayment for an MRI. You say that you disagree with the charges because you should not be charged for this kind of service. 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 $175 copayment for MRI's. You have been asked to pay the allowed amount of $147.99, which is less than the $175 copayment for an MRI. An MRI falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an MRI provided on April 20, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care (G0283) provided June 4, 2021 to June 8, 2021.

You asked the Plan to pay for the chiropractic services. You say that you suffer from severe migraine headaches. No doctor has been able to reduce the number of migraines you get but the electrical stimulation. The Plan denied your request. The Plan says this service is not covered when rendered by a chiropractor.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care (G0283) provided June 4, 2021 to June 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the lumbar-sacral orthosis (L0648), provided on July 12, 2021.

You asked the Plan to waive the coinsurance for the lumbar-sacral orthosis. You say that the item should be covered The Plan denied your request. The Plan says the cost share was applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for prosthetic devices and related supplies. 

You have been asked to pay a 20% coinsurance for the lumbar-sacral orthosis. the lumbar-sacral orthosis falls within the prosthetic devices and related supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the lumbar-sacral orthosis (L0648), provided on July 12, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the infusions (96415, 96413, 96375), provided on June 7, 2021.

You asked the Plan to waive the coinsurance for the infusions. You say that service should be covered. The Plan denied your request. The Plan says the cost share was applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for chemotherapy/radiation drugs, biologicals and other drugs for Medicare Part B prescription drugs. 

You have been asked to pay a 20% coinsurance for chemotherapy/radiation drugs, biologicals and other drugs for the infusions. the infusions falls within the Medicare Part B prescription drugs 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 the infusions (96415, 96413, 96375), provided on June 7, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve prefabricated abutments (D6056) for tooth #'s 22 and 27.

You asked the Plan to pre-approve the prefabricated abutments. You say that you have two implants in the mandibular area and the denture you have does not work because it got out of place and does not allow you to eat. You also say that you cannot wait four years to receive these services. The Plan denied your request. The Plan says that you have exceeded the limits set in the subscriber agreement.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has not provided any evidence that states that prefabricated abutments (D6056) are only covered once every five years. We requested a full list of covered dental codes with limitations from the Plan, but it was not provided to us. Without this documentation, we cannot determine if the Plan's decision to deny these services for exceeding the frequency limitation is correct. Therefore, the Plan has not shown that its decision to deny payment for these services is correct or justified by the health plan contract. Therefore, we decided that the Plan has to pre-approve prefabricated abutments (D6056) for tooth #'s 22 and 27.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a thermal facet joint radiofrequency ablation (RFA) procedure.
You asked the Plan to pre-approve the thermal facet joint RFA procedure. You say that you have episodes of falling due to the pain. You say that there has been no relief using medications. You say that you are unable to walk due to the pain in the sciatic nerve. The Plan denied your request. The Plan says the records show there has been an extended time of more than two years since the enrollee's last radiofrequency ablation service. The Plan says that there is a question as to the source of the recurrent pain and a diagnostic procedure must therefore be repeated.
The Plan follows Medicare rules. Medicare rules say that if there is an extended period of time, two years or more, since the last RFA and/or there is a question as to the source of the recurrent pain then diagnostic procedures must be repeated. 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 thermal facet joint RFA procedure. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee received a radiofrequency ablation (RFA) procedure on July 3, 2019, which provided 100% pain relief. The enrollee presented to her provider on October 19, 2021 with low back pain. She was evaluated for a re-check after a right sided Transforaminal Epidural Steroid Injection (TFESI) for which she reported 0% improvement. The enrollee's low back pain was rated as a 10/10. She described the current pain as burning, shooting, stabbing
and tingling. She complained of leg numbness and muscle spasms. The pain limited her normal activities of daily living. The enrollee continued to have symptoms despite over 6 weeks of conservative care within the last 6 months including a home exercise program, over-the-counter medications, NSAIDs, Tylenol, opiates, and physical therapy. It has been more than two years since the enrollee's last RFA and diagnostic procedures have not been repeated. Therefore, the requested RFA is not considered medically reasonable and necessary in this case. 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 thermal facet joint RFA procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a thermal facet joint radiofrequency ablation (RFA) procedure.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for drug testing (G0483) provided on May 18, 2021.

You asked the Plan to pay for drug testing. You say that this is supported in the records. The Plan denied your request. The Plan says that the records do not document 22 or more drug classes were tested.

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 G0483 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed. 

We find that CPT code G0483 is supported in the medical record. Specifically, records show that more than 22 drug classes were tested. Based on this information, we decided that Medicare rules for coverage of drug testing have been met. Therefore, we decided that the Plan has to pay for drug testing (G0483) provided on May 18, 2021.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on June 11, 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 were not billed correctly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. 

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on June 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the dental consultation (D9130), provided on May 20, 2021.

You asked the Plan to pre-approve the dental consultation. You say that the services should be covered. The Plan denied your request. The Plan says this is 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. 

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 pre-approve the dental consultation (D9130), provided on May 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), provided on July 14, 2021.

You asked the Plan to pay for the limited oral evaluation. You say that the service should be covered. The Plan denied your request. The Plan says you have exceeded your Plan's maximum frequency allowance for this service.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

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. Specifically, the records show you already received two exams this plan year. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), provided on July 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic procedure (D3999), provided on May 19, 2021.

You asked the Plan to pay for the endodontic procedure. You say that the service was medically necessary. The Plan denied your request. The Plan says this is not a covered service.

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 endodontic procedure (D3999), provided on May 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on June 7, 2021.
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you were unaware of the dentist canceling her contract with the Plan. You say that you didn't realize you should have called to see if you were still covered since your last visit was covered. The Plan denied your request. The Plan says there is no coverage for services rendered by an out-of-network 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, out-of-network dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on June 7, 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 November 25, 2020.
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 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 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 November 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copays for the specialist services provided on May 5,
2020, to May 26, 2020.
You asked the Plan to waive the copays for the services provided. You say that the services were coded wrong
with extra charges. The Plan denied your request. The Plan says the copay applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $39
copay for specialist services.
The file shows that an outpatient clinic visit with a cardiovascular specialist was provided. You have been
asked to pay a $39 copay for each date of service at issue. The services fall within the physician 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 copays for the specialist services provided on
May 5, 2020, to May 26, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for cataract surgery you had at an ambulatory surgery center on November 9, 2020.
You asked the Plan to waive the copayment for the outpatient surgery. You say that you do not agree with this bill. 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 $110 copayment for ambulatory surgery center services. You have been asked to pay a $110 copayment for the outpatient surgery. The outpatient surgery falls within the ambulatory surgery center 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 cataract surgery you had at an ambulatory surgery center on November 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series x-ray (D0210) provided on May 19, 2021.
You asked the Plan to pay for the dental service. You say that you are being billed for unnecessary x-rays. You say that you were assured that the services were covered under your plan. You also say that you told them that you did not want any services that were not covered by your insurance. The Plan denied your request. The Plan says 1 complete series x-ray or 1 panoramic x-ray are 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 and complete series x-ray is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a panoramic x-ray that you received on May 14, 2019. Therefore, we decided that the Plan does not have to pay for the complete series x-ray (D0210) provided on May 19, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the laparoscopy (57425) provided on March 16, 2021 by a registered nurse (RN).
You asked the Plan to pay for the laparoscopy. You say that since both the primary surgeon and the facility are in network and the laparoscopy (57425) is payable to the assistant surgeon, you believe this claim should be processed at the in-network rate. The Plan denied your request. The Plan says payment is not allowed for this claim because registered nurse first assistants are not recognized as physicians per Medicare guidelines.
The Plan must follow Medicare rules. Medicare rules say that registered nurses are not eligible to enroll in Medicare.
We looked at the file and Medicare rules. This service was billed by an RN, and RNs are not eligible to enroll in Medicare or receive payment. Based on this information, we decided that Medicare rules for coverage of the laparoscopy have not been met. Therefore, we decided that the Plan does not have to pay for the laparoscopy (57425) provided on March 16, 2021 by a registered nurse (RN).