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

 We decided that the Plan does not have to pay for the additional removal of torus mandibularis and simple extractions or pay in full for the one removal of torus mandibularis provided on June 21, 2021.    You asked the Plan to pay for the removals of torus mandibularis and simple extractions. The Plan denied your request. The Plan says due to you not being appropriately informed that the treating provider had opted out of Medicare, the Plan paid the annual $1,000 allowance toward these services. The Plan also says that the remaining balance is $1,005 and you are responsible for this amount.  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 Plan offers a $1,000 combined allowance for supplemental preventive and comprehensive dental services every year. The contract says that you are responsible for any amount over and above the allowance amount. The record shows that the Plan made an exception for these services due to a misunderstanding, and you met the annual maximum benefit while processing this claim for the June 21, 2021 date of service and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the additional removal of torus mandibularis and simple extractions or pay in full for the one removal of torus mandibularis provided on June 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve microarray genetic testing for the enrollee.  You asked the Plan to pre-approve the testing. You say that this is medically necessary, as the enrollee is already receiving treatment for multiple conditions. The Plan denied your request. The Plan says the medical record must contain documentation that the testing is expected to influence treatment of the condition toward which the testing is directed.  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 testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review has determined that the enrollee does not meet the criteria for this testing.  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 testing have not been met. Therefore, we decided that the Plan does not have to pre-approve microarray genetic testing for the enrollee.
Appeal type: Imaging
Decision: Favorable

 We decided that the Plan has to pre-approve Magnetic Resonance Imaging (MRI) of the shoulder (73221).  You asked the Plan to pre-approve the MRI. You say that the MRI is medically necessary. The Plan denied your request. The Plan says that coverage criteria has not been met.  The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 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 MRI. Our reviewer says that the MRI is medically necessary. Our physician reviewer found the patient has a positive Hawkins test and rotator cuff pathology is highly likely. She has tried home exercises and is currently taking Gabapentin. Due to the enrollee's abnormal physical exam, she meets the criteria for MRI of the left shoulder.  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 MRI have been met. Therefore, we decided that the Plan has to pre-approve Magnetic Resonance Imaging (MRI) of the shoulder (73221).   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: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hot or cold packs therapy provided on August 12, 2021.  You asked the Plan to pay for the hot or cold packs therapy. You say that authorization is not needed, and the claim should be reprocessed. The Plan denied your request. The Plan says CPT code 97110 was approved and paid. The Plan also says that CPT code 97010 remains denied as bundled services are not eligible for separate reimbursement.  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 97010 is application of a modality to 1 or more areas; hot or cold packs.    We find that CPT code 97010 is not supported in the medical record. Specifically, CPT code 97010 has a status indicator of B. This means that CPT code 97010 is considered bundled and not separately payable. Based on this information, we decided that Medicare rules for coverage of the hot or cold packs therapy have not been met. Therefore, we decided that the Plan does not have to pay for the hot or cold packs therapy provided on August 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay more for the eyeglasses provided on August 23, 2021.  

You asked the Plan to pay more for the eyeglasses. You say that you went to a plan provider, but the eyeglasses were denied. The Plan denied your request. The Plan says the $200 eyeglasses benefit was applied which leaves a remaining balance of $601.  

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers $200 every calendar year for eyeglasses, frames, lenses or contact lenses.  

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Specifically, the Plan paid $200 toward the eyeglasses. Therefore, we decided that the Plan does not have to pay more for the eyeglasses provided on August 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the pharmacogenetic testing provided on May 27, 2021.  

You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the testing remains unproven as a screening tool.  

The Plan must follow Medicare rules. Medicare rules say that the information submitted must corroborate the documentation in the beneficiary's medical documentation. 

We looked at the file and Medicare rules. In this case, there were insufficient medical records to show that the enrollee has a condition where clinical evaluation has determined the need for a medication that has a known gene-drug interaction for which the test results would directly impact the drug management of their condition.  Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the pharmacogenetic testing provided on May 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the pharmacogenomic testing provided on October 28, 2020.  

You asked the Plan to pay for the testing services. You say that the facts align with the coverage criteria. The Plan denied your request. The Plan says the testing has not been shown to be useful.  

The Plan must follow Medicare rules. Medicare rules say that pharmacogenetic testing is only covered under certain medical indications.    

The file shows that GeneSight Psychotropic testing was provided. We looked at the file and Medicare rules. The records show that the testing was ordered to make decisions about the enrollee's medications. Medications should be provided based on the presence of a diagnosis and should be adjusted based on a response to the medication. It is not necessary to do genetic testing to provide or adjust medications. Furthermore, genetic markers may or may not correlate with actual clinical findings. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the pharmacogenomic testing provided on October 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the reline of a complete maxillary denture (D5750) provided on September 29, 2021.  You asked the Plan to waive the coinsurance for the reline of a complete maxillary denture. You say that you are on a fixed income and cannot afford this bill. The Plan denied your request. The Plan says this claim processed correctly assessing the appropriate cost share.  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 are responsible for a 50% coinsurance for supplemental comprehensive dental services. Therefore, we decided that the Plan does not have to waive the coinsurance for the reline of a complete maxillary denture (D5750) provided on September 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a specialist telehealth visit provided on July 7, 2021.  

You asked the Plan to waive the copayment for the specialist telehealth visit. You say that you were billed twice for a 10 minute phone appointment. 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 $25 copayment for each specialist visit, including telehealth visits.   

You have been asked to pay a $25 copayment for the specialist telehealth visit. Specialist telehealth visits fall within the Physician/Practitioner Services Including Doctor's Office Visits 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 specialist telehealth visit provided on July 7, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for emergency care provided on September 1, 2021.  

You asked the Plan to waive the copayment for emergency care. You say that you disagree with the charges. 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 $120 copayment for emergency care.   

You have been asked to pay a $120 copayment for emergency care. Emergency care falls within the emergency care 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 emergency care provided on September 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab services provided on August 24, 2021, by an out-of-network (OON) provider.  

You asked the Plan to pay for the OON services. You say that the specimen was sent by the doctor to process. The Plan denied your request. The Plan says the services were not urgent, emergent, or approved in advance.  

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.   

The provider in this case is not a network provider with the Plan. The services were not ordered by 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 lab services provided on August 24, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a mandibular and maxillary partial denture (D5214 and D5213) provided by a participating provider.  You asked the Plan to pre-approve a mandibular and maxillary partial denture. You say that you lost your dentures and need new ones. The Plan denied your request. The Plan says this benefit has already been exhausted.  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 a mandibular and maxillary partial denture once every five years.  We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a mandibular and maxillary partial denture have not been met.  Therefore, we decided that the Plan does not have to pre-approve a mandibular and maxillary partial denture (D5214 and D5213) provided by a participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for vision care provided on September 27, 2021.  You asked the Plan to waive the copayment for vision care. You say that you received routine eye care and should not owe a copayment. 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 $20 copayment for eye exams to diagnose and treat diseases of the eye and a $0 copayment for routine eye exams for vision care.   The medical records show that you received vision care that went beyond a routine exam on September 27, 2021. Therefore, you are responsible to pay the $20 copayment.   You have been asked to pay a $20 copayment for vision care. Vision care falls within the vision care 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 vision care provided on September 27, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 2 additional non-ambulance transportation (A0100).  

You asked the Plan to pre-approve 2 additional trips. You say that you do not have the means to get to your appointment in the city. The Plan denied your request. The Plan says additional routine trips that exceed the benefit limit are not covered.  

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 16 one-way trips trips per year.   

We looked at your request, the records in the case file, and the rules. Based on this information, you have coverage for 16 on-way trips for routine transportation. The record shows that you have used 10 one-way trips and have 6 remaining one-way trips. Any additional trips in excess of 16 one-way trips are not covered. Therefore, we decided that the Plan does not have to pre-approve 2 additional non-ambulance transportation (A0100).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for an aqueous shunt to extraocular reservoir provided on April 26, 2021.  You asked the Plan to waive the coinsurance for an aqueous shunt to extraocular reservoir. You say that you were told that the provider was in-network. 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 50% coinsurance for out-of-network outpatient hospital services.   You received an aqueous shunt to extraocular reservoir provided at an out-of-network hospital facility on April 26, 2021. Therefore, you are responsible to pay your share of the out-of-network cost-sharing charges. The total allowed amount is $3,811.49 and 50% of that is $1,905.74.   You have been asked to pay the total coinsurance amount of $1,905.74 for an aqueous shunt to extraocular reservoir. An aqueous shunt to extraocular reservoir 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 coinsurance for an aqueous shunt to extraocular reservoir provided on April 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for additional supplies, materials, and clinical staff time  You asked the Plan to pay for these medical services. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says no separate payment is made for this claim per Medicare rules.  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 99072 is additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease.  We find that CPT code 99072 is not supported in the medical record. Specifically, this claim has a status code indicator of "B" in the Physician Fee Schedule. This indication means that payment for these services are always bundled into payment for other services not specified. Based on this information, we decided that Medicare rules for coverage of these medical services have not been met. Therefore, we decided that the Plan does not have to pay for additional supplies, materials, and clinical staff time
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for ambulance services provided on April 4, 2021.  

You asked the Plan to waive the copayment for ambulance services. You say that the charges are too high because you did not receive any treatment in the ambulance and only traveled a short distance. 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 $275 copayment for ambulance services.   

You have been asked to pay a $275 copayment for ambulance services. Ambulance services fall 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 services provided on April 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that LTACH services are medically necessary for the enrollee's recovery. The Plan denied your request. The Plan says the criteria for admission to an LTACH are not met. The enrollee is receiving the medically necessary care in the current hospital; transfer to an LTACH would not provide a clinical advantage.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided indicating medical necessity for LTACH services. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan.   The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.  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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.