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

We decided that the Plan does not have to pay for the computed tomography (CT) coded 70450 provided on September 17, 2021.

You asked the Plan to pay for the CT. 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 is a column II code to column I code 70496. 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 computed tomography (CT) coded 70450 provided on September 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extractions (D7210) provided on September 3, 2021.

You asked the Plan to pay for the surgical extractions. You say that you would like reconsideration because you confirmed with your dental provider that the extractions would be covered. The Plan denied your request. The Plan says these extractions are not a covered 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. Specifically, the Plan contract states that non-surgical extractions are covered. The record indicates that you received surgical extractions. Therefore, we decided that the Plan does not have to pay for the surgical extractions (D7210) provided on September 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (70544) provided September 2, 2021.

You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the code billed shares a bundled relationship with another code 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, 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 radiology services (70544) provided September 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management services (99238) provided on August 24, 2021.
You asked the Plan to pay for the hospital discharge day management services. You say that you would like reconsideration because the records support that this service was rendered by your provider on the billed date of service. The Plan denied your request. The Plan says CPT code 99238 was reported the day prior to this submitted date of service by same provider.
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 99238 is hospital discharge day management; 30 minutes or less. We find that CPT code 99238 is not supported in the record. Specifically, the record submitted supports that CPT code 99238 was processed and paid for the day prior to this billed date of service. CPT code 99238 may only be paid once per member per hospital admission. Based on this information, we decided that Medicare rules for coverage of the hospital discharge day management services have not been met. Therefore, we decided that the Plan does not have to pay for the hospital discharge day management services (99238) provided on August 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for genetic testing (81479) provided August 31, 2021.  You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan denied your request. The Plan says billing requirements have not been met.  The Plan must follow Medicare rules. Medicare rules say that to report a pharmacogenomics testing service, providers must report 1 unit of the appropriate procedure code and an appropriate Z-code identifier.  We looked at the file and Medicare rules. The order for this service was not signed and the claim was not submitted with an appropriate Z-code identifier. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (81479) provided August 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services (D0274, D0150, D1110, and D0330) provided by an out-of-network provider on August 5, 2021.
You asked the Plan to pay for dental services. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says the correct amount is being charged based on the rendering dentist being out-of-network.
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 dental services when the services are provided out-of-network. We looked at the file and Medicare rules. Benefits received out-of-network are subject to any in-network benefit maximums, limitations, and/or exclusions. You may be billed by the out-of-network provider for any amount greater than the payment made by the Plan to the provider. Based on this information, we decided that
the Plan's rules for coverage of dental services have not been met. Therefore, we decided that the Plan does not have to pay for dental services (D0274, D0150, D1110, and D0330) provided by an out-of-network provider on August 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for progressive lens enhancement (V2744) and photochromatic
lens tint (V2781) for the eyeglasses purchased on October 1, 2021.
You asked the Plan to pay for the lens enhancements. You say that lens enhancements should be covered by
your benefit. The Plan denied your request. The Plan says lens enhancements are not covered by your eyewear
benefit; however, you did receive a discounted rate for these additions through the provider.
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 does not cover lens enhancements.
We looked at the file and the Plan's rules. Enhancements such as photochromatic lenses or progressive lenses
are not covered by your vision benefit. Therefore, we decided that the Plan does not have to pay for progressive
lens enhancement (V2744) and photochromatic lens tint (V2781) for the eyeglasses purchased on October 1,
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a continuous positive airway pressure
(CPAP) machine provided from June 9, 2021, to September 9, 2021.
You asked the Plan to waive the coinsurance for the CPAP machine. You say that you should not be charged
coinsurance for the CPAP machine. The Plan denied your request. The Plan says the proper coinsurance was
applied.
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 10%
coinsurance for covered items and related supplies. There is a monthly charge of $83 for the CPAP machine
with a coinsurance of $8.30 ($83 x 10% coinsurance). From June 9, 2021, to September 9, 2021, the total
coinsurance charge was $33.20 ($8.30 x 4 months).
You have been asked to pay a 10% coinsurance for the CPAP machine. The CPAP machine falls within
Durable medical equipment (DME) and related 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 coinsurance for a continuous positive airway pressure (CPAP) machine provided from June 9, 2021, to
September 9, 2021.
Your complaint about the providers quality of service 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: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the abdominal ultrasound (76700) provided on October 7, 2021.  You asked the Plan to pay for the abdominal ultrasound. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says an appropriate modifier as required by Medicare rules has not been 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, we have confirmed that code 76700 is a column II code to column I code 93976. 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 abdominal ultrasound (76700) provided on October 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the astigmatism correcting function of intraocular lens (A-C IOL) (V2787) provided October 6, 2021.
You asked the Plan to pay for the A-C IOL. You say that you don't understand why you are being charged this additional amount. The Plan denied your request. The Plan says this service is not covered.
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a conventional IOL. While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatism-correcting feature of an IOL. Therefore, we decided that the Plan does not have to pay for the astigmatism correcting function of intraocular lens (A-C IOL) (V2787) provided October 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services provided on June 21, 2021, through June 25, 2021.
You asked the Plan to pay for the inpatient hospital services. You say that you would like reconsideration because this service was billed with the appropriate diagnosis codes. The Plan denied your request. The Plan says a corrected claim with an updated primary diagnosis code is needed.
The Plan must follow Medicare rules. Medicare rules say that Mitral valve TEER claim lines in a clinical trial billed without ICD-10 diagnosis code I34.0 or I34.1 and secondary ICD-10 diagnosis code Z00.6 shall be denied. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the inpatient hospital services have not been met. Specifically, the record indicates that the member
underwent a mitrial valve TEER procedure. The claim was not submitted with the appropriate diagnosis codes for this service. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services provided on June 21, 2021, through June 25, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the SelectMDx testing provided on August 12, 2021.
You asked the Plan to pay for the SelectMDx testing. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.
The documentation does not include the results of a prior prostate biopsy. There was no documented significant
interval increase in prostate specific antigen level. This means that the SelectMDx testing at issue in this appeal
was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.
Therefore, we decided that the Plan does not have to pay for the SelectMDx testing provided on August 12,
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for custom fabricated abutments (D6057 x 4), dental connector bar (D6920), implant supported retainer crowns (D6075 x 5), pontics (D6245 x 6), prophylaxis (D1110), and periodic oral evaluation (D0120), cone beam CT (D0367 x 2), implants (D6010 x 5), alveoloplasty with extractions (D7310 x 2), deep sedation (D9222), and additional deep sedation (D9223), bone replacement grafts (D4264 x 5), removal of residual tooth roots (D7250), panoramic x-ray (D0330) provided from January 4, 2021, to June 22, 2021.
You asked the Plan to pay for the dental services. You say that the services you received should be covered under your medical plan. The Plan denied your request. The Plan says the dental services that were received were routine dental services. The Plan also says that routine dental services are not covered under Medicare.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Additionally, the record shows that the annual allowance of $1,500 for covered dental services has been exhausted with the payment of a pontic. Therefore, we decided that the Plan does not have to pay for custom fabricated abutments (D6057 x 4), dental connector bar (D6920), implant supported retainer crowns (D6075 x 5), pontics (D6245 x 6), prophylaxis (D1110), and periodic oral evaluation (D0120), cone beam CT (D0367 x 2), implants (D6010 x 5), alveoloplasty with extractions (D7310 x 2), deep sedation (D9222), and additional deep sedation (D9223), bone replacement grafts (D4264 x 5), removal of residual tooth roots (D7250), panoramic x-ray (D0330) provided from January 4, 2021, to June 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray (71046), the transportation of portable x-ray
equipment and personnel to home or nursing home, per trip to facility or location (R0070), and the set-up of
portable x-ray equipment (Q0092) rendered by the out-of-network (OON) provider on October 6, 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, 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 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 chest x-ray (71046), the transportation of portable x-ray equipment and
personnel to home or nursing home, per trip to facility or location (R0070), and the set-up of portable x-ray
equipment (Q0092) rendered by the out-of-network (OON) provider on October 6, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on June 28, 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 the services are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.
The test at issue in this appeal, a hereditary cancer panel, was requested solely for screening purposes.
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not
have to pay for the laboratory services rendered on June 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for the ophthalmological medical examination and evaluation (92014), the visual field examination (92083), the fundus photography with interpretation and report (92250), and the eye refraction (92015) provided on August 17, 2021.  You asked the Plan to waive the deductible. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the deductible has been applied correctly to 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 combined in-network and out-of-network medical deductible of $110. This is the amount you have to pay out-of-pocket before the Plan will pay their share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost for most of your covered services. Once you have paid your deductible, the Plan will begin to pay their share of the costs for covered medical services and you will pay your share (your copayment or coinsurance amount) for the rest of the plan year.   You have been asked to pay $51.66 for the ophthalmology services provided as you had not previously met the yearly deductible. The claim for date of service January 21, 2021 was originally processed applying a $51.66 deductible. However, this claim was reprocessed by the Plan to pay the deductible to the provider of service. Hence, the deductible had not been fully met. 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 deductible for the ophthalmological medical examination and evaluation (92014), the visual field examination (92083), the fundus photography with interpretation and report (92250), and the eye refraction (92015) provided on  August 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (72040) provided September 29, 2021.

You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the billed code shares a bundled relationship with another code 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, we have confirmed that code 72040 has a bundled relationship with code 72082. 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 radiology services (72040) provided September 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the anesthesia services coded 99140 provided on January 13, 2021.  You asked the Plan to pay for the anesthesia 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 99140 is anesthesia complicated by emergency conditions (specify) (List separately in addition to code for primary anesthesia procedure).    We find that CPT code 99140 is not supported in the medical record. Specifically, this code has a status indicator of "B". This means payment for this service is always bundled into payment for other services not specified and no separate payment can be made. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services coded 99140 provided on January 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on August 31, 2021 by an out-of-network (OON) provider.
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 services were 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 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 the laboratory services provided on August 31, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for radiology services (70544) provided August 9, 2021.  You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the code billed shares a bundled relationship with another code billed and is 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 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 radiology services (70544) provided August 9, 2021.