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

We decided that the Plan does not have to pay for the preventative procedure (D1999), core buildup (D2950), crown (D2740), endodontic therapy (D3320), and peroapical radiographic images (x-ray ) (D0220 and D0230)

You asked the Plan to pay for the routine dental care. You say that the services were medically necessary. The Plan denied your request. The Plan says there's no coverage for Unspecified Procedures by Report and Core Build Ups. Additionally, Periapical X-rays allows one procedure per calendar year at 100% when services are performed by an in-network provider and one Endodontic Therapy per calendar year. Records indicate the Plan has already issued reimbursement for Periapical X-rays and Endodontic Therapy.

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 preventative procedure (D1999), core buildup (D2950), crown (D2740), endodontic therapy (D3320), and peroapical radiographic images (x-ray ) (D0220 and D0230)
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient hospital services received on
July 2, 2021.
You asked the Plan to waive the copayment for the services. You say that the copayment should be waived.
The Plan denied your request. The Plan says the copayment was applied appropriately.
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 $400
copayment for outpatient hospital services.
You have been asked to pay a $400 copayment for the services. The services fall within the outpatient hospital
services 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 outpatient hospital services
received on July 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine dental services, provided on July 13, 2021, to
July 27, 2021.
You asked the Plan to pay for the routine dental services. You say that the services were medically necessary.
The Plan denied your request. The Plan says you obtained these services through a provider that has opted out
of Medicare.
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
routine dental services, provided on July 13, 2021, to July 27, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for electromyography and intraoperative testing provided to the enrollee on July 29, 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 a corrected claim needs to be submitted.

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 pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found at the present time, the evidence to date on the overall utility of intraoperative neuromonitoring (IONM) during thyroid surgery is limited and conflicting. There remains a lack of literature demonstrating clear clinical benefits from the procedure and the use of IONM remains controversial in thyroid procedures. Given the limitations in the published evidence to date and the overall consensus across publications that more studies are needed in order to reach a consensus on the use of IONM in this procedure the services would not have been 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 the services have not been met. Therefore, we decided that the Plan does not have to pay for electromyography and intraoperative testing provided to the enrollee on July 29, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transport rendered on July 7, 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 must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis
code.
We looked at the file and Medicare rules. The file shows that the claim was billed with an invalid diagnosis
code. 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 pay for the ambulance transport rendered on July 7,
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the limited oral evaluation (D0140), provided on October 25, 2021.  You asked the Plan to pay for the limited oral evaluation. You say that the service was medically necessary. The Plan denied your request. The Plan says this is not a covered service under the member's preventive 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 limited oral evaluation (D0140), provided on October 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the monthly supply allowance for a continuous glucose monitor (CGM) provided on July 23, 2021.  You asked the Plan to pay for the CGM supply allowance. You say that the documentation supports that the criteria are met. The Plan denied your request. The Plan says documentation submitted did not sufficiently support the billed supply code.  The Plan must follow Medicare rules. Medicare rules say that CGMs may be covered for enrollees with diabetes when certain criteria are met. Among these are that the treating physician must have an in-person visit within 6 months of ordering the CGM where it is determined that criteria are met. Every six months after the order, the physician must have an in-person visit in which it is confirmed that the enrollee is compliant with CGM testing.  In this case, none of the progress notes submitted made any mention of the intent to order a CGM. The only progress note that indicates the frequency of testing in October 2020 shows that the enrollee was testing only 3 times per day, not the required 4. The other progress notes from after the order do not confirm that the enrollee was using the CGM and, in fact, supported that the enrollee was using a OneTouch standard glucose meter. For all of these reasons, we find that the records do not support that the criteria for the CGM have been met. Therefore, we decided that the Plan does not have to pay for the monthly supply allowance for a continuous glucose monitor (CGM) provided on July 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided from December 31, 2020, to
January 4, 2021.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed
services cannot be verified.
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 99291 is critical care, evaluation and management of the
critically ill or critically injured patient; first 30-74 minutes. The definition of code 99239 is hospital discharge
day management; more than 30 minutes. We find that CPT codes 99291 and 99239 are not supported in the
medical record. Specifically, the records do not indicate the amount of time the provider spent with the
enrollee. Based on this information, we decided that Medicare rules for coverage of the services provided have
not been met. Therefore, we decided that the Plan does not have to pay for the physician services provided
from December 31, 2020, to January 4, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services rendered on June 9, 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 must follow Medicare rules. The rules say that a clinical psychologist must have a referral and consult
from the beneficiary's primary care physician (PCP).
We looked at the file and Medicare rules. There is no documentation of a referral and consult from the
enrollee's PCP. 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 pay for the psychotherapy services rendered
on June 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown repair necessitated by restorative material failure
(D2980) provided on August 10, 2021.
You asked the Plan to pay for the dental service. You say that the services were not performed for cosmetic
reasons. You say that you needed a root canal and for the crown to be replaced. You also say that the repair
was necessary after the root canal. The Plan denied your request. The Plan says crown repair necessitated by
restorative material failure 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 crown repair necessitated by
restorative material failure is not among those covered under this benefit. Additionally, 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.
Therefore, we decided that the Plan does not have to pay for the crown repair necessitated by restorative
material failure (D2980) provided on August 10, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing services provided on March 8, 2021.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says there is a lack
of medical documentation.
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.
We looked at the file and the rules. In this case, there are insufficient medical records to show that the referring
physician listed on the claim is treating the enrollee for a specific medical problem. The test at issue in this
appeal was requested for screening purposes. Medicare does not cover this test for screening purposes.
Therefore, we decided that the Plan does not have to pay for the genetic testing services provided on March 8,
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient services provided on July 6, 2021, through
July 9, 2021.
You asked the Plan to pay for the outpatient services. You say that you would like reconsideration for payment
of the outpatient services. The Plan denied your request. The Plan says a new outpatient claim will need to be
submitted.
The Plan must follow Medicare rules. Medicare rules say that in the event that there is no Part A coverage for
the inpatient stay, the hospital may bill Part B for the services provided to the beneficiary prior to the point of
inpatient admission.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the outpatient services have not been met. Specifically, it is not possible to carve the outpatient
services from the inpatient claim that has been submitted. An outpatient claim must be submitted for Part B
services. Therefore, we decided that the Plan does not have to pay for the outpatient services provided on July
6, 2021, through July 9, 2021.
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 April 28, 2021, and August 16, 2021.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you were not aware
that these services would be denied. You also say that having to pay this bill that you did not expect is putting
you in a financial bind. The Plan denied your request. The Plan says these services exceed the maximum
allowed per period.
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 April 7, 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 April 28, 2021, and August 16, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services received on July 8,
2021.
You asked the Plan to waive the copayment for the services. You say that you were told that you didn't have to
pay this copayment due to already paying the emergency room copayment. The Plan denied your request. The
Plan says the decision to apply the copayment was appropriate.
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 $250
copayment for ambulance services.
You have been asked to pay a $250 copayment for the services. The services fall within the ambulance services
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 ambulance services received on
July 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for hereditary cardiovascular screening testing provided on July
1, 2020.
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan
denied your request. The Plan says the denial of payment for these services is correct.
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, genetic testing, was requested for screening purposes. Medicare does not cover
this test for screening purposes. Therefore, we decided that the Plan does not have to pay for hereditary
cardiovascular screening testing provided on July 1, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to waive the copayment for laboratory services provided on August 24, 2021.

You asked the Plan to waive the copayment for the laboratory services. You say that the copayment for the labs should be included during the doctor visit since there is a copayment for that. The Plan denied your request. The Plan says that there was no copayment for the office visit so there was no issue of copayment stacking.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The rules say that the Plan must disclose to the enrollee in clear terms all cost-sharing information. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not submit a complete copy of the Evidence of Coverage (EOC) for 2021. You say that the enrollee copayment amount for this service is $10. Without a complete EOC, the Plan has not shown that its decision to apply this cost-sharing is correct or justified. Therefore, we decided that the Plan has to waive the copayment for laboratory services provided on August 24, 2021.

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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a bronchoscopy provided on September 8,
2021.
You asked the Plan to waive the copayment for a bronchoscopy. You say that you should be charged less for
the copayment because the EOC is misleading on different procedures. The Plan denied your request. The Plan
says the proper copayment was applied for the service that was billed.
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 $320
copayment for Medicare-covered surgery or other services provided to you at an ambulatory surgical center,
including but not limited to hospital or other facility charges and physician or surgical charges.
You have been asked to pay a $320 copayment for a bronchoscopy. A bronchoscopy falls within 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 a bronchoscopy provided on September 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional coronary artery branch of percutaneous
transluminal angioplasty provided on March 29, 2021, billed with code 92921-LD-51.
You asked the Plan to pay for the angioplasty services as billed. You say that the records support the necessity
of this surgery as well as the billing. The Plan denied your request. The Plan says it is noted that the other line
items on this claim were paid and that only 92921 remains at appeal. This is not separately paid by Medicare.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
CPT code 92921 has a status indicator of "B" in the Physician Fee Schedule. This means that payment for this
is always bundled into payment for other services. Based on this information, we decided that Medicare r.ules
for coverage of the angioplasty services as billed have not been met. Therefore, we decided that the Plan does
not have to pay for the additional coronary artery branch of percutaneous transluminal angioplasty provided on
March 29, 2021, billed with code 92921-LD-51.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for portable X-Ray equipment transportation provided on July
19, 2021.
You asked the Plan to pay for portable X-Ray equipment transportation. You say that you are appealing with
supporting records. The Plan denied your request. The Plan says the denial of payment for this service is
correct, because the transportation code was reported but no setup codes were reported which does not follow
industry standards.
The Plan must follow Medicare rules. Medicare rules say that no transportation charge is payable unless the
portable X-Ray equipment used was actually transported to the location where the X-Ray was taken.
We looked at the file and Medicare rules. No set-up or radiology codes were billed on this claim, and the
record does not confirm that the X-Ray equipment used was actually transported to the location where the X-
Ray was taken. Based on this information, we decided that Medicare rules for coverage of portable X-Ray
equipment transportation have not been met. Therefore, we decided that the Plan does not have to pay for
portable X-Ray equipment transportation provided on July 19, 2021.