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

We decided that the Plan does not have to waive the copayment for the routine electrocardiogram (ECG) with at least 12 leads, including the tracing, interpretation, and report (93000) provided May 24, 2021.
You asked the Plan to waive the copayment for the diagnostic service. You say that you are being billed $10 for an ECG that you don't think you should be responsible for due to you already doing one and the hospital not recording your results. The Plan denied your request. The Plan says the claim was processed with the correct copayment applied per the Evidence of Coverage.
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 $10 copayment for diagnostic lab services and diagnostic procedures and tests (per day, per facility).
You have been asked to pay $10 copayment for the diagnostic service. The diagnostic service 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 the routine electrocardiogram (ECG) with at least 12 leads, including the tracing, interpretation, and report (93000) provided May 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) receiver (K0554) and supplies (K0553).
You asked the Plan to pre-approve a CGM receiver and supplies. You say that the item is medically necessary. The Plan denied your request. The Plan says the notes do not indicate that you adjust your insulin based on blood sugar determinations.
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 the enrollee does not require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM receiver and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) receiver (K0554) and supplies (K0553).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the chiropractic visits to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the chiropractic visits. You say that the services are medically necessary. The Plan denied your request. The Plan says the provider is out-of-network
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the chiropractic visits to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for fillings (D2391 x3, D2394, D2331) provided on January 7, 2021.
You asked the Plan to pay for fillings. You say that the services should be covered. The Plan denied your request. The Plan says the services are a covered benefit, but you have exceeded the frequency limit of 2 per calendar year.
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. 
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of fillings have not been met. Specifically, the record shows that you had exceeded the frequency limit for fillings. Therefore, we decided that the Plan does not have to pay for fillings (D2391 x3, D2394, D2331) provided on January 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation (D9310) provided on May 24, 2021.
You asked the Plan to pay for the dental service. You say that after you got to your appointment, you were advised that you needed medical clearance from your primary care physician in order to proceed. You also say that you feel you should not have to pay for a visit where you did not have any services done. The Plan denied your request. The Plan says consultation is not listed as a covered service. The Plan also says the
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 consultation is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the consultation (D9310) provided on May 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the out of network cost share for oral exam (D0120) and prophylaxis (D1110) provided on May 11, 2021, by the out of network dentist.
You asked the Plan to waive the out of network cost share for the dental services. You say that the Summary of Benefits does not say that the plan will only cover the in network allowed amount for the out of network dental services. You say that the coverage summary says that the plan will cover preventive services in network and out of network up to $1,000. You also say that you feel you cannot rely on the written summary of benefits from the plan. The Plan denied your request. The Plan says the cost share was applied correctly. The Plan says that out of network dentists are paid according to the maximum allowable fee schedule. The Plan also says you are responsible for all of the fees of this amount from the billed 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, out of network dentists may bill you for any amount greater than what the plan pays
Procedure Code
Billed Amount
Allowed Amount
Plan Paid
Difference
Your Responsibility
D0120
$65
$24
$24
$41
$41
D1110
$115
$53
$53
$62
$62
TOTAL:
$103
$103
This is a contractual obligation you agreed to when you enrolled in the Plan's dental coverage. Therefore, we decided that the Plan does not have to waive the out of network cost share for oral exam (D0120) and prophylaxis (D1110) provided on May 11, 2021, by the out of network dentist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Purewick System. 
 
You asked the Plan to pre-approve Purewick System. You say that this request is medically necessary. The 
Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. In this case, the medical records do not demonstrate you have a permanent urinary incontinence 
problem. The record shows that the Plan made several attempts to obtain the necessary documentation without 
success. Therefore, we decided that the Plan does not have to pre-approve the Purewick System.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the laser and soft tissue treatment provided on September 22, 2020.
You asked the Plan to pay for the services provided. You say that you are requesting reimbursement. The Plan denied your request. The Plan says the services are not a covered benefit.
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. Services other than manual manipulation, when provided by a chiropractor, are not covered. Therefore, we decided that the Plan does not have to pay for the laser and soft tissue treatment provided on September 22, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the x-ray provided on February 24, 2021 and the MRI provided on May 11, 2021.
You asked the Plan to reduce the copayment for the x-ray and MRI. You say that these were coded as being outpatient rather than a stand-alone facility. You say that the cost difference is too significant, and you feel you overpaid for these procedures. The Plan denied your request. The Plan says the copayments 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 $95 copayment for basic radiological services at an in-network outpatient hospital and a $250 for advanced imaging services at an in-network outpatient hospital.
You have been asked to pay a $95 copayment for the x-ray and a $250 for the MRI. The total amount you owe is $345 ($95 + $250 = $345). The x-ray and MRI fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show the x-ray and MRI were billed by the hospital. 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 reduce the copayment for the x-ray provided on February 24, 2021 and the MRI provided on May 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on February 26, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the OON services. You say that the services were medically necessary due to the enrollee's condition and history. The Plan denied your request. The Plan says there was no authorization for non-emergent services.

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 file shows the enrollee was seen for ongoing management of her condition. 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 office visit provided on February 26, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre 14-Day Reader.

You asked the Plan to pre-approve the Freestyle Libre 14-Day Reader. You say that your fingers are sore from poking them. You also say that you think if you can better control what you are doing wrong, you can stop poking yourself and just check on your arm. The Plan denied your request. The Plan says it was determined you are not using insulin, and the criteria for coverage of a Freestyle Libre 14-Day Reader 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 the enrollee does not use insulin with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the Freestyle Libre 14-Day Reader have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 14-Day Reader.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapy services and home management training provided from February 16, 2021, through February 23, 2021.
You asked the Plan to pay for therapy services and home management training. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the medical records do not support the units billed.
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 97140 is manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes. The definition of code 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. The definition of code 97535 is self-care/home management training (eg, activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact, each 15 minutes.
We asked our coder 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 therapy services and home management training. Our reviewer says that the criteria for coverage has not been met. Our reviewer says that CPT 97110, CPT 97140 and CPT 97535 are codes reported by time the services were performed. Our reviewer found that the documentation for all therapies and dates of service do not have the total time services were performed. Therefore, the units cannot be confirmed and would not be covered. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of therapy services and home management training have not been met. Therefore, we decided that the Plan does not have to pay for therapy services and home management training provided from February 16, 2021, through February 23, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pathology exam of tissue provided on May 3, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the pathology exam of tissue. You say that your claim was charged as out-of-network while your wife's claim for the same service, at the same location was processed as in-network. The Plan denied your request. The Plan says no prior authorization was obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the services at issue were urgent or emergent. Therefore, we decided that the Plan does not have to pay for the pathology exam of tissue provided on May 3, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be rendered by the out-of-network (OON) provider.

You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested service.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the service at issue in this appeal. We found no exception that would require the Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve an office visit to be rendered by the out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two removals of torus mandibularis (D7473 x2).

You asked the Plan to pre-approve the removals of torus mandibularis. You say that you need this surgery provided in order to get dentures. You also say that you are unable to eat because you are in pain. The Plan denied your request. The Plan says this service is not covered under your benefit package.

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 two removals of torus mandibularis (D7473 x2).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient hospital stay for a reverse total shoulder arthroplasty.
You asked the Plan to pay for the hospital stay. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay.
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 the hospital stay. Our reviewer says that the
documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the requested reverse total shoulder arthroplasty is documented to have been supported. However, detailed documentation is not evident regarding a significant past and/or current medical history that would place this enrollee at increased risk for peri-surgical complications requiring an inpatient stay. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the request for inpatient hospital stay of a reverse total shoulder arthroplasty is not medically reasonable or necessary. 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 hospital stay have not been met. Therefore, we decided that the Plan does not have to pay for an inpatient hospital stay for a reverse total shoulder arthroplasty.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on June 22, 2020. 
 
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 claim was billed incorrectly. 
 
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 drug testing 
rendered on June 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the partial upper denture with resin base (D5211) and the partial lower denture with resin base (D5212) provided on January 14, 2021.

You asked the Plan to pay for the dental services. You say that you were advised by a plan representative last year that dentures were covered at 30 to 35%. You say that after you were given this information you made an appointment. The Plan denied your request. The Plan says dentures are not listed as covered services.

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 partial dentures are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the partial upper denture with resin base (D5211) and the partial lower denture with resin base (D5212) provided on January 14, 2021.