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

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on October 15, 2021.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that the complication with your blood pressure caused the procedure to be cancelled, otherwise they would have been able to do the extraction. You also say that you would like this service to be covered. The Plan denied your request. The Plan says this service exceeds the frequency limitation in your benefit 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, problem focused limited oral evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem focused limited oral evaluation (D0140) on October 14, 2021 and your problem focused limited oral evaluation (D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on October 15, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on April 25, 2021.  You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you would like to appeal this service because you do not agree with the charge. The Plan denied your request. The Plan says this service is not covered by Medicare.  The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.   The ambulance company did not provide transport services on April 25, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on April 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) and panoramic x-ray (D0330) provided on November 9, 2021.

You asked the Plan to pay for the first intraoral periapical x-ray and panoramic x-ray. You say that you would like to appeal these services. The Plan denied your request. The Plan says these services are 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. The only type of x-rays covered under your plan are horizontal bitewing x-rays. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) and panoramic x-ray (D0330) provided on November 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for dialysis treatment services provided from August 1, 2021, to August 31, 2021.
You asked the Plan to waive the copayments for the dialysis treatment. You say that you met your maximum out of pocket expenses and would like the claims paid in full. 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 20% coinsurance for each outpatient dialysis treatment.
Date(s) of Service Allowed Amount 20% Coinsurance
August 1, 2021 - August 16, 2021 (16 days) $129.00 $25.80 (x 16 days = $412.80)
August 17, 2021 $129.00 $11.20 (maximum met)
Total: $424.00
The file shows that you met your maximum out of pocket amount on August 17, 2021. Therefore, you have
been asked to pay $424, which is 20% of the allowed amount for the dialysis treatments. The dialysis
treatments fall within the Services to Treat Kidney Disease 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 dialysis treatment services provided from August 1, 2021, to August 31, 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 you need an IRF admission covered. The Plan denied your request. The Plan says you do not meet the Medicare criteria for admission to an IRF.
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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are
stable. There are no complex nursing or rehabilitation needs. 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 you 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: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for occupational and physical therapy provided on November 1, 2021, to November 3, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for occupational and physical therapy. You say that you were unaware that the patient had a Medicare Replacement Plan and you billed Medicare and Medicare denied the claim. You also say that is why prior authorization was not obtained. The Plan denied your request. The Plan says there was no prior authorization obtained for non-emergent and non-participating services. The Plan also says that the services were provided by a non-participating skilled nursing facility and the services could have been provided by a participating skilled nursing facility.  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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for occupational and physical therapy provided on November 1, 2021, to November 3, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lymphovenous bypass.
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 the services are not medically necessary.
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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a history of malignant neoplasm of upper-outer quadrant of the left breast. The record does not indicate that the enrollee has lymphedema. The records do not establish that the requested procedure is necessary compared to other standard of care treatments. The lymphovenous bypass is not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve lymphovenous bypass.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) of the abdomen (74183) rendered on August 8, 2021. We have also decided that the Plan does not have to waive the coinsurance for a gadobutrol injection (A9585) also rendered on August 8, 2021.

You asked the Plan to waive the copayment for a magnetic resonance imaging. You also asked the Plan to waive the coinsurance for a gadobutrol injection. You say that you cannot afford this at all. The Plan denied your request. The Plan says you were 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 enrollees must pay a $300 copayment for Medicare-covered diagnostic radiology services. The Plan contract also says that enrollees must pay 20% of the cost for Medicare Part B prescription drugs.

You have been asked to pay a $300 copayment for a magnetic resonance imaging. A magnetic resonance imaging falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. You have also been asked to pay $5.60 in coinsurance, which is 20% of the allowed amount for a gadobutrol injection ($28 allowed amount x 20% coinsurance = $5.60). Gadobutrol injections fall under the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) of the abdomen (74183) rendered on August 8, 2021. We have also decided the Plan does not have to waive the coinsurance for a gadobutrol injection (A9585) also rendered on August 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for debridement provided on September 10, 2021.
You asked the Plan to waive the copayment for debridement. You say that you were not informed of the surgery charges prior to receiving the services. 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 $360 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities. You received debridement at an outpatient hospital facility on September 10, 2021. Debridement is considered an outpatient surgical procedure. Therefore, you are responsible to pay the allowed amount of $343.31, which is less than the $360 copayment. You have been asked to pay $343.31 for debridement. Debridement falls within the outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers 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 debridement provided on September 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the take home drugs (D9630) provided on October 4, 2021.
You asked the Plan to pay for the take home drugs. You say that these services should be covered under your
dental plan. The Plan denied your request. The Plan says take home drug is not listed as a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the take home drug is not among those
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the take home drugs
(D9630) provided on October 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a specialist visit provided on July 12, 2021.  You asked the Plan to waive the copayment for a specialist visit. You say that you were told that you would not owe a copayment for follow-up visits. 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 $45 copayment for specialist services.   You had a specialist visit on July 12, 2021. Follow-up visits are subject to cost-sharing charges. Therefore, you are responsible to pay the $45 copayment.   You have been asked to pay a $45 copayment for a specialist visit. A specialist visit 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 copayment for a specialist visit provided on July 12, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for hemodialysis (90999) provided from August 2, 2021, to August 30, 2021.  You asked the Plan to waive the coinsurance for the hemodialysis services. You say that the services should be covered. The Plan denied your request. The Plan says the coinsurance applied correctly based on the services provided.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Services to treat kidney disease.    You have been asked to pay a 20% coinsurance for hemodialysis services (total allowed is $4,964.25 x 20% = $992.85). Hemodialysis services fall within the Services to treat kidney disease 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 hemodialysis (90999) provided from August 2, 2021, to August 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on August 4, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on August 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided from July 15, 2021, to September 16, 2021.
You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you were not informed that the injections would be considered outpatient surgical procedures. 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 20% coinsurance for Medicare Part B prescription drugs.
You received Medicare Part B drugs on July 15, 2021. The total allowed amount is $353.51 and 20% of that is $70.70. You received Medicare Part B drugs on September 16, 2021. The total allowed amount is $51.61 and 20% of that is $10.32. The total amount you owe is: $81.02. You have been asked to pay the total coinsurance amount of $81.02 for Medicare Part B drugs. Medicare Part B drugs fall within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided from July 15, 2021, to September 16, 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 you need IRF care. The Plan denied your request. The Plan says you do not meet the Medicare criteria for admission to an IRF.
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 your nursing, medical and rehabilitation needs does not require
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. 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 you 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for electrocardiogram services (procedure code 93010) provided to the enrollee on January 20, 2021.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says there is no documentation supporting an additional study, which was billed and remains denied.

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 93010 is "Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only." 

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 the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found the documentation does not support the rationale for the duplicate study. As a result, at this time the duplicate study would not be considered supported in the medical records or in the enrollee's clinical management.

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for electrocardiogram services (procedure code 93010) provided to the enrollee on January 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the dental cleaning (D1110) provided on October 13, 2021.  You asked the Plan to pay for the cleaning. You say that you only go to the dentist every 6 months, so this should not be denied. The Plan denied your request. The Plan says you previously had cleanings provided and covered on January 13, 2021, and July 14, 2021. Your dental benefit covers a maximum of 2 cleanings per year; therefore, the cleaning provided on October 13, 2021, exceeds what is covered by your 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. The Plan can cover up to two standard adult dental cleanings (D1110) per plan year.  Though the Plan offers a dental benefit in excess of Medicare coverage, the cleaning is requested in a frequency that exceeds what is covered by your dental benefit. Documentation shows that the Plan has already paid for two previous standard dental cleanings in 2021. Therefore, we decided that the Plan does not have to pay for the dental cleaning (D1110) provided on October 13, 2021.