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

We decided that the Plan does not have to pay for the ophthalmological medical examination and evaluation (92014) rendered by the out-of-network (OON) provider on September 17, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the ophthalmological medical examination and evaluation (92014) rendered by the out-of-network (OON) provider on September 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and related services received on June 9, 2021.
You asked the Plan to pay for the office visit and related services. You say that this provider never informed
you that they opted out of your insurance. The Plan denied your request. The Plan says the services received
are not a covered benefit.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items or services provided directly by a physician or practitioner who has opted out of the program except
in cases involving emergencies or urgently needed care.
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the office
visit and related services received on June 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmological services provided on September 7, 2021.
You asked the Plan to pay for ophthalmological services. The Plan denied your request. The Plan says you are
limited to 1 routine eye exam every year. This provider was issued payment for a routine eye exam
February 10, 2021.
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 these services when [Insert why/when the plan covers routine vision].
We looked at the file and the Plan's rules. The file shows that the Plan limit for a routine eye exam is 1 every
year and you have exhausted the benefit. Therefore, we decided that the Plan does not have to pay for
ophthalmological services provided on September 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for hemorrhoid removal performed from September 14, 2021, to September 30, 2021.
You asked the Plan to waive the copayments for the hemorrhoid removal. You say that you were informed that this was a global procedure and that you would only have one copayment for all three visits. 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 $40 copayment for each office visit with a specialist. You have been asked to pay a $40 copayment for each specialist office visit for the hemorrhoid removal.
The hemorrhoid removal falls 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 copayments for hemorrhoid removal performed from September 14, 2021, to September 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that inpatient rehabilitation services are medically
necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an IRF are
not met. The enrollee can safely receive the necessary services in an alternate setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
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 IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.
Our physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs
does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While
the documentation does support a need for physical and/or occupational therapy, there is no documented need
for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this
enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program
provided in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for Mycophenolate Mofetil.
You asked the Plan to pre-approve a tier exception. You say that you cannot afford the cost of this medication.
The Plan denied your request. The Plan says that tier exceptions are not available for drugs covered by Part B.
The Plan must follow Medicare rules. Medicare rules say that tier exceptions are only available for Part D
drugs.
The requested drug is covered under Part B. Based on this information, we decided that Medicare rules for
coverage of a tier exception have not been met. Therefore, we decided that the Plan does not have to pre-
approve a tier exception for Mycophenolate Mofetil.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a tetanus and diphtheria toxoids vaccine (90714) provided on
September 16, 2021.
You asked the Plan to pay for a tetanus and diphtheria toxoids vaccine. You say that your doctor said you
should get this if you are traveling. The Plan denied your request. The Plan says coverage of this vaccine is the
responsibility of your prescription drug plan.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a tetanus and
diphtheria toxoids vaccine. The Plan follows the same rules.
Records do not show that you have been injured or directly exposed to any illness related to a tetanus and
diphtheria toxoids vaccine. Therefore, we decided that the Plan does not have to pay for a tetanus and
diphtheria toxoids vaccine (90714) provided on September 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the replacement of broken teeth (D5640) provided on April 14, 2021, and July 21, 2021.
You asked the Plan to pay for the replacement of broken teeth. You say that you feel this service should be covered. The Plan denied your request. The Plan says this service is not covered.
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
replacement of broken teeth (D5640) provided on April 14, 2021, and July 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility supervision services rendered on May 24, 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 99379 is not separately payable.
The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is always bundled into payment for other services not specified. We looked at the file and Medicare rules. Billed procedure code 99379 (supervision of care of nursing facility patient, without patient present, 15-29 minutes) has a status indicator of B and no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for the nursing facility supervision services rendered on May 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for vision services provided on
September 8, 2021.
You asked the Plan to waive the copayment for vision services. The Plan denied your request. The Plan says
the correct cost share was applied to the claims.
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 $40
copayment for Vision Care, Medicare-covered eye exam.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
You have been asked to pay a $40 and $175 copayment for vision services. The vision services fall 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 services provided on
September 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and excision provided on March 22, 2021, and tissue exam provided on April 3, 2021, by an out-of-network provider.
You asked the Plan to pay for the office visit, excision, and tissue exam. The Plan denied your request. The Plan says out-of-network services were not authorized.
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. Therefore, we decided that the Plan does not have to pay for the office visit and excision provided on March 22, 2021, and tissue exam provided on April 3, 2021, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete maxillary denture (D5110) and complete
mandibular denture (D5120) provided on April 5, 2021.
You asked the Plan to pay for the complete maxillary denture and complete mandibular denture. You say that
you were told that all you would need to pay was $1,400 and insurance would cover the rest. The Plan denied
your request. The Plan says these services are not covered benefits 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
complete maxillary denture (D5110) and complete mandibular denture (D5120) provided on April 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 81206, 81301, and 81311
provided on February 1, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services are not payable as 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.
We find that CPT codes 81206, 81301, and 81311 are not supported in the medical record. Specifically, the
services rendered should be billed with one CPT code (81479) to bill the entire bundled multi-test panel. In
addition, the appropriate DEX-Z code identifier should be entered adjacent in the comment/narrative field for
the test. Based on this information, we decided that Medicare rules for coverage of the laboratory services have
not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 81206,
81301, and 81311 provided on February 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services coded 71045 provided on August 28, 2021.
You asked the Plan to pay for the x-ray services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately payable.
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 71045 is radiologic examination, chest; single view. We find that CPT code 71045 is not supported in the medical record. Specifically, the documentation shows that this is an exact duplicate claim. This code was billed twice on the same date of service. Additional documentation to support that this service was provided twice in one day was not provided. Based on this information, we decided that Medicare rules for coverage of the x-ray services have not been met.
Therefore, we decided that the Plan does not have to pay for the x-ray services coded 71045 provided on August 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids provided on July 9, 2021.
You asked the Plan to pay for the hearing aids. The Plan denied your request. The Plan says hearing aids must
be supplied by the Plan's hearing network vendor.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for
hearing aids only when supplied by the Plan's hearing network vendor.
We looked at the file and the Plan's rules. The file shows that the hearing aids were not supplied by the Plan's
hearing network vendor. Based on this information, we decided that the Plan's rules for coverage of the hearing
aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids provided on
July 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance angiography (MRA) of the head (70544) provided on September 13, 2021.
You asked the Plan to pay for the MRA services. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says this claim has not been billed with an appropriate modifier as required by Medicare coding regulations.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70544 is a column II code to column I code 70551. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the magnetic resonance angiography (MRA) of the head (70544) provided on September 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services (99153) provided on April 7,
2021.
You asked the Plan to pay for the moderate sedation services. You say that you would like this claim
reprocessed based on the medical documentation. The Plan denied your request. The Plan says this claim has
not been billed as required by Medicare coding regulations.
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 99153 is moderate sedation services provided by the
same physician or other qualified health care professional performing the diagnostic or therapeutic service that
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of
the patient's level of consciousness and physiological status.
We looked at the file and Medicare rules. CPT code 99153 in this case is a technical component only code. The
technical component will not be paid to the physician when performed in a facility setting. This means that
payment for this service is the responsibility of the facility to any vendor. Based on this information, we
decided that Medicare rules for coverage of the moderate sedation services have not been met. Therefore, we
decided that the Plan does not have to pay for the moderate sedation services (99153) provided on April 7,
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services rendered on July 3, 2021.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says procedure code 99053 is not separately payable.
The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is
always bundled into payment for other services not specified.
We looked at the file and Medicare rules. Billed procedure code 99053 (service[s] provided between 10:00 PM
and 8:00 AM at 24-hour facility, in addition to basic service) has a status indicator of B and no separate
Medicare payment. Therefore, we decided that the Plan does not have to pre-approve the medical services
rendered on July 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The
Plan denied your request. The Plan says that the enrollee did not have an adequate response to the diagnostic
MBBs.
The Plan must follow Medicare rules. Medicare rules say that RFA can be covered if the LCD criteria have
been met.
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 these services. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. On December 4,
2020, the patient had diagnostic MBBs and had 50% pain relief. The set of MBBs on January 15, 2021, results
are not documented. The patient subsequently had RFA on June 15, 2021 and did not have pain relief. The
prior RFA did not provide pain relief and therefore, should not be repeated. Our physician reviewer found that
your condition does not meet Medicare criteria for these services.
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve radiofrequency ablation (RFA).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99202) provided September 28,
2021.
You asked the Plan to pay for the chiropractic visit. You say that the service should be covered, and the copay
should be waived and/or changed. The Plan denied your request. The Plan says this service exceeds the benefit
frequency limitation.
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 Plan offers a chiropractic benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The health Plan contract says
that the Plan covers chiropractic evaluations once per calendar year. The records show that this service was
previously provided on date of service 9/21/2021.Therefore, we decided that the Plan does not have to pay for
the outpatient office visit (99202) provided September 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for fluoroscopic guidance (77003) provided on May 5, 2021.
You asked the Plan to pay for fluoroscopic guidance. You say that this was a separate service. The Plan denied
your request. The Plan says this was not billed with an appropriate primary code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 77003
is an add-on code and has not been billed with an appropriate primary procedure code. Based on the claim
submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to
pay for fluoroscopic guidance (77003) provided on May 5, 2021.