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

We decided that the Plan does not have to waive the cost-shares for a computed tomography (CT) scan of the abdomen, a CT scan of the thorax, inpatient hospital care and an emergency room visit provided on December 30, 2019, to January 15, 2021.

You asked the Plan to waive the cost-shares for a CT scan of the abdomen, a CT scan of the thorax, inpatient hospital care and an emergency room visit. You say that you would like the copayments reduced for four claims as you are not financially able to honor all the bills from 2019 through 2021. The Plan denied your request. The Plan says the cost-shares you are being charged are correct.

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 $200 copayment for each outpatient diagnostic tests and therapeutic services and supplies. Your contract with the Plan also clearly says that you must pay a $95 copayment each day, for days 1 to 5 for inpatient hospital care. Your contract with the Plan also clearly says that you must pay a $75 copayment for emergency room visits.

You have been asked to pay a $200 copayment for a CT scan of the abdomen, a $200 copayment for a CT scan of the thorax, a $95 per day copayment for inpatient hospital care and a $75 copayment for an emergency room visit.

The records show that you had a CT scan of the abdomen on December 30, 2019. The EOC confirms that $200 is the required copayment for this service.

The records also show that you had a CT scan of the thorax on December 3, 2020. The EOC confirms that $200 is the required copayment for this service.

The records also show that you were inpatient for five (5) days from January 2, 2021 to January 7, 2021. The EOC confirms that $95 per day is the required copayment for this service ($95 x 5 days = $475).

The records also show that you had an emergency room visit on January 15, 2021. The EOC confirms that $75 is the required copayment for this service.

Your total cost-share amount is $950 ($200 + $200 + $475 + $75 = $950). 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 cost-shares for a CT scan of the abdomen, a CT scan of the thorax, inpatient hospital care and an emergency room visit provided on December 30, 2019, to January 15, 2021.

Your complaint about reducing the copayment obligation is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation and inhalation of nitrous oxide/analgesia provided on May 27, 2021.

You asked the Plan to pay for the limited oral evaluation and inhalation of nitrous oxide/analgesia. You say that you were told it would take the Plan 7 to 10 days to get approval for the services. You say that you were in a lot of pain and couldn't wait that long, so you scheduled the appointment with the oral surgeon. The Plan denied your request. The Plan says the services are not covered benefits.

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 limited oral evaluation and inhalation of nitrous oxide/analgesia provided on May 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for special services provided between 10:00pm and 8:00am at a 24-hour facility, in addition to basic service (99503) provided March 2, 2021.
You asked the Plan to pay for the special services. You say that the attached medical record supports the claim as originally submitted. The Plan denied your request. The Plan says this procedure code is considered a procedure code that is always bundled into payment for another service so separate payment cannot be made.
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 the special services has a bundled relationship with code 99285 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for special services provided between 10:00pm and 8:00am at a 24-hour facility, in addition to basic service (99503) provided March 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ultra-lightweight manual wheelchair.
You asked the Plan to pre-approve ultra-lightweight manual wheelchair. You say that you need a lighter wheelchair because you cannot push yourself and your spouse cannot lift a heavier wheelchair. The Plan denied your request. The Plan says the denial of authorization for this item is correct, because you were authorized for another lightweight wheelchair and there is no indication in the records that you require feature which cannot be accommodated by another wheelchair.
The Plan follows Medicare rules. Medicare rules state that an ultra-lightweight manual wheelchair may be covered if certain criteria are 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 ultra-lightweight manual wheelchair. Our reviewer says that you do not meet the Medicare criteria for this wheelchair. Our physician reviewer found the records submitted do not document that you are a full-time manual wheelchair user or require individualized fitting and adjustments for one or more features such as - but not limited to - axle configuration, wheel camber, or seat and back angles and which cannot be accommodated by another K0001-K0004 manual wheelchair. The records do not document that a specialty evaluation was performed by a licensed/certified medical professional that documents the medical necessity for the wheelchair and its special feature or that the wheelchair is provided by a rehabilitative technology supplier (RTS) that employs a RESNA-certified assistive technology professional (ATP) who specialized in wheelchair and who has direct, in-person involvement in the wheelchair selection for you. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ultra-lightweight manual wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve an ultra-lightweight manual wheelchair
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral -- periapical first radiographic image (D0220) and Intraoral -- periapical each additional radiographic image (D0230) provided June 1, 2021.
You asked the Plan to pay for the intraoral x-rays. You say that you were told you had unlimited coverage. The Plan denied your request. The Plan says these services are not covered under your benefits.
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 intraoral -- periapical first radiographic image (D0220) and Intraoral -- periapical each additional radiographic image (D0230) provided June 1, 2021.
Your complaint about potentially receiving confusing or contradictory information from Plan representatives is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home mechanical ventilator after March 27, 2022.
You asked the Plan to pre-approve a home mechanical ventilator after March 27, 2022. You say that the documentation supports the need for the requested device. The Plan denied your request. The Plan says the records do not show that the enrollee meets the criteria for coverage of the requested device after March 27, 2022.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 a home mechanical ventilator after March 27, 2022. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has chronic obstructive pulmonary disease (COPD) and was recently hospitalized with an exacerbation, and an Arterial Blood Gas (ABG) showed carbon dioxide (CO2) retention. The enrollee was
treated with bilevel positive airway pressure (BiPAP) in the hospital, and a ventilator was prescribed at discharge. There is no evidence that BiPAP has been tried at home. The average volume-assured pressure support (AVAPS) setting can be provided via BiPAP, and Medicare does not cover a ventilator when used as BiPAP. The Plan has approved the ventilator until March 26, 2022, to allow time for the enrollee to transition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a home mechanical ventilator after March 27, 2022, have not been met. Therefore, we decided that the Plan does not have to pre-approve a home mechanical ventilator after March 27, 2022.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for the bitewing x-rays. We decided that the Plan does not have to pay for the oral evaluation and complete series x-ray.
You asked the Plan to pay for the dental services. You say that you went to the closest provider. You say that you had an exam but did not move forward with the services as they were too expensive. You also say that the office would not accept scans from a previous provider. The Plan denied your request. The Plan says that coverage for a comprehensive oral evaluation is limited to once every 3 plan years. The Plan says that 1 complete series x-ray is covered every 3 plan years. The Plan says that the frequency limits have been exceeded. The Plan also says that bitewing x-rays are not covered in the same year as a complete series x-ray.
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 the dental services when the services are medically necessary and reasonable.
We decided that the Plan has to pay for the bitewing x-rays.
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Specifically, the bitewing x-rays were performed in 2021 and the complete series x-ray was performed in 2020. The Evidence of Coverage does not clearly state what constitutes a year. Therefore, we decided that the Plan has to pay for the bitewing x-rays.
We also decided that the Plan does not have to pay for the oral evaluation and complete series x-ray.
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Specifically, the frequency limits have been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation and complete series x-ray that you received on November 25, 2020. Therefore, we decided that the Plan does not have to pay for the oral evaluation and complete series x-ray.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography services coded 70450 and 70460 provided on February 28, 2021.
You asked the Plan to pay for the computed tomography 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, we have confirmed that code 70450 for the computed tomography services have a bundled relationship with code 70460 and code 70460 for the computed tomography services have a bundled relationship with code 70450 and cannot be paid as billed. This code cannot be paid as a separate line item. 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 computed tomography services coded 70450 and 70460 provided on February 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a health club membership (S9970) for the 2020 benefit allowance.
You asked the Plan to reimburse you for a health club membership. You say that you did not realize there was a deadline because of the pandemic. The Plan denied your request. The Plan says your reimbursement request for the 2020 benefit year was received after the March 31st deadline.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan contract says that the Plan reimburses you up to $150 each calendar year towards your cost for membership in a qualified health club or fitness facility. Reimbursement requests must be received by the Plan no later than March 31st of the following year.
The Plan's rules for coverage of gym benefits have not been met. The records show that you submitted a
reimbursement request to the Plan on May 5, 2021. The EOC confirms that reimbursement requests must be
sent to the Plan by March 31st of the following year. Therefore, we decided that the Plan does not have to
reimburse you for a health club membership (S9970) for the 2020 benefit allowance.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the myocardial perfusion imaging with regadenoson injection you received on June 16, 2021.
You asked the Plan to waive the cost sharing for the myocardial perfusion imaging with regadenoson injection. You say that you were authorized for this procedure and no copayment was listed on the authorization letter. The Plan denied your request. The Plan says you were charged this cost sharing 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 $300 copayment for diagnostic imaging, including myocardial perfusion imaging and 20% coinsurance for Medicare Part B drugs.
You have been asked to pay a $300 copayment for the myocardial perfusion imaging and 20% coinsurance for the regadenoson injection. 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. There is no requirement that these cost sharing amounts be listed in an authorization letter because they are already disclosed in your Evidence of Coverage. Therefore, we decided that the Plan does not have to waive the cost sharing for the myocardial perfusion imaging with regadenoson injection you received on June 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a posterior interspinous decompression spacer procedure.
You asked the Plan to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869) and insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second level (List separately in addition to code for primary procedure) (22870) and interspinous process distraction device (implantable) (C1821). You say that the enrollee has suffered from her condition for greater than three years and it has greatly impacted her quality of life. The Plan denied your request. The Plan says Medical studies haven't proven that the device is helpful for treatment of the enrollee's health problem.
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 a posterior interspinous decompression spacer procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found interspinous process devices remain experimental. More research is needed to show safety and efficacy of the devices We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869) and insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second level (List separately in addition to code for primary procedure) (22870) and interspinous process distraction device (implantable) (C1821) have not been met. Therefore, we decided that the Plan does not have to pre-approve posterior interspinous decompression spacer procedure.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the laminectomy, facetectomy, and foraminotomy (63047) rendered by the out-of-network (OON) provider on March 11, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider and were not urgent/emergent in nature.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue.
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the laminectomy, facetectomy, and foraminotomy (63047) rendered by the out-of-network (OON) provider on March 11, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotropic assay identified with code 81479 and
analysis identified with code 81291 provided on May 17, 2021.
You asked the Plan to pay for the psychotropic assay and analysis. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered
benefit.
The Plan must follow Medicare rules. Medicare rules say that providers are required to code to specificity
however, if CPT 81479 (unlisted molecular pathology procedure) is used the documentation must clearly
identify the unique molecular pathology procedure performed. In addition, MTHFR gene analysis is not
considered to be clinically efficacious; therefore, testing is not medically necessary.
We looked at the file and Medicare rules. Review of the file shows that the documentation does not clearly
identify the reasoning for the psychotropic assay was completed and what affect it would have on the enrollee's
medical treatment. In addition, the testing identified with code 81291 is non-covered. Based on this
information, we decided that Medicare rules for coverage of the psychotropic assay and analysis have not been
met. Therefore, we decided that the Plan does not have to pay for the psychotropic assay identified with code
81479 and analysis identified with code 81291 provided on May 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the custom fabricated abutments (D6057) and abutment
supported retainers (D6069) provided on May 21, 2021.
You asked the Plan to pay for the dental services. You say that these services were necessary. The Plan denied
your request. The Plan says these services are not covered by your dental benefit.
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
custom fabricated abutments (D6057) and abutment supported retainers (D6069) provided on May 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the adjunctive pre-diagnostic test (D0431) and drugs or medicaments (D9630) provided on June 8, 2021.
You asked the Plan to pay for the adjunctive pre-diagnostic test (D0431) and drugs or medicaments (D9630). You say that you were told they accepted your insurance and the appointment would only cost $57. You say that you weren't told you would be getting a bill for uncovered services and you can't afford to pay. The Plan denied your request. The Plan says the adjunctive pre-diagnostic test (D0431) and drugs or medicaments (D9630) are not covered benefits. The Plan also says that the remaining services were paid.
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 adjunctive pre-diagnostic test (D0431) and drugs or medicaments (D9630) provided on June 8, 2021.