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

We decided that the Plan does not have to pay for the laboratory services coded 87798, 87486, 87581, 87631 and U0003 provided on August 6, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not 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. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. Code 87798 at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. We find that CPT codes 87798, 87486, 87581, 87631 and U0003 are not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. Therefore, codes 87486, 87581, 87631 and U0003 cannot be verified. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 87798, 87486, 87581, 87631 and U0003 provided on August 6, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for diagnostic testing provided on
November 6, 2020.
You asked the Plan to waive the copayment for diagnostic testing. You say that you did not ask your provider for this test, so you do not believe you should have to pay for the test. The Plan denied your request. The Plan says the claim processed correctly assessing a $10 copayment for a diagnostic visual screening test during your annual wellness visit.
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 copayment for Outpatient diagnostic tests and therapeutic services and supplies. You have been asked to pay a $10 copayment for diagnostic testing. Diagnostic testing falls within the outpatient diagnostic tests and therapeutic services and 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 copayment for diagnostic testing provided on November 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient rehabilitation facility (IRF) care.
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or
provider must corroborate the documentation in the enrollee's medical records and confirm that Medicare
coverage criteria have been met.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of IRF care have not been met. Specifically, medical records were not provided. Without this
documentation, medical necessity is not able to be established. Therefore, we decided that the Plan does not
have to pre-approve inpatient rehabilitation facility (IRF) care.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on April 11, 2021.
You asked the Plan to waive the copayment for ambulance services. You say that you required the ambulance services due to a bad reaction to the coronavirus vaccine. 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 $250 copayment for ambulance services. You have been asked to pay a $250 copayment for ambulance services. Ambulance 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 provided on April 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a tooth extraction (D7210) provided on June 10, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for a tooth extraction. You say that you would like to be reimbursed for one tooth 
extraction. You also say that you were aware that the provider was not in network. The Plan denied your 
request. The Plan says there is no benefit for dental services performed by an OON dentist. 
 
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 a tooth 
extraction when the services are rendered with a participating provider.  
 
We looked at the file and Medicare rules. The Plan confirms that you had an active treatment plan with a 
network provider and was authorized to receive one tooth extraction with the network provider. The EOC 
confirms you must use network providers to obtain covered services. Based on this information, we decided 
that the Plan's rules for coverage of a tooth extraction have not been met. Therefore, we decided that the Plan 
does not have to pay for a tooth extraction (D7210) provided on June 10, 2021, by an out-of-network (OON) 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a 2D oral/facial photographic image (D0350) provided on 
June 22, 2021. 
 
You asked the Plan to pay for a 2D oral/facial photographic image. You say that the service should be covered 
because you cannot afford the payment. The Plan denied your request. The Plan says this service is not covered 
under 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, 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 a 2D 
oral/facial photographic image (D0350) provided on June 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee. 
 
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your 
request. The Plan says the criteria is not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results and have had an in-person visit with their treating physician to assesses 
adherence to their CGM regimen and diabetes treatment plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of the monitor 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose 
monitor for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections.
You asked the Plan to pre-approve facet joint injections. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that facet joint injections are only covered for certain
indications.
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 facet joint injections. Our reviewer says
that the documentation does not support that the requested services are medically reasonable or necessary. Our
physician reviewer found the enrollee has chronic low back pain. The enrollee takes cyclobenzaprine,
Cymbalta, Gabapentin and Norco. The enrollee has tried chiropractic, aquatherapy, and bilateral epidural
steroid injections. The enrollee is status post right radiofrequency ablation at L2-L3 with 80% pain relief and
left radiofrequency ablation L3-L4 with 80% pain relief. The enrollee underwent Bilateral L3, L4, L5 medial
branch blocks but the degree of pain relief and duration is not specified. The degree and duration of pain relief
must be clearly documented. At this point, there is a lack of documentation of the effectiveness of the
injections, therefore, the request is considered not medically reasonable or 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 facet joint injections have not been met. Therefore, we decided that the Plan
does not have to pre-approve facet joint injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit, x-ray, and shoulder orthosis received on 
March 15, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit, x-ray, and shoulder orthosis. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a 
covered benefit when provided by an OON provider. 
 
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 office visit, x-ray, and shoulder orthosis 
received on March 15, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical pathology tissue exam, cytopathology,
immunohistochemistry. and special staining provided on March 17, 2021.
You asked the Plan to pay for the physician pathology services. You say that this should be paid as it was
medically necessary. The Plan denied your request. The Plan says the services can only be paid when billed
with modifier -26.
The Plan must follow Medicare rules. Medicare rules say that the TC of physician pathology services is not
paid for services provided to hospital patients.
The pathology services were provided to a registered outpatient. As such, the TC cannot be paid to the
physician. This means that modifier -26 is needed to pay just the professional component. Therefore, we
decided that the Plan does not have to pay for the surgical pathology tissue exam, cytopathology,
immunohistochemistry. and special staining provided on March 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a retainer crown - porcelain fused to base metal (D6751 x3) and a pontic - porcelain fused to base metal (D6241).
You asked the Plan to pre-approve dental services. You say that this should be covered under your Plan. The Plan denied your request. The Plan says if a code is not listed, then it is not 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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a retainer crown - porcelain fused to base metal (D6751 x3) and a pontic - porcelain fused to base metal (D6241).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for eyeglasses provided on May 7, 2021.
You asked the Plan to reimburse you for eyeglasses. The Plan denied your request. The Plan says the Plan has paid the maximum eyewear benefit of $250 for disposable contact lenses provided on May 4, 2021.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan pay these services up to $250 every year. 
We looked at the file and the Plan's rules. The file shows that the Plan has paid the maximum eyewear benefit of $250 for disposable contact lenses provided on May 4, 2021. The Plan coverage of the eyewear benefit is every year. Therefore, we decided that the Plan does not have to reimburse you for eyeglasses provided on May 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.
You asked the Plan to pre-approve the requested LDCT scan. You say that the requested procedure is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung cancer screening for enrollees who meet all the criteria listed in the Medicare rules section.
We reviewed the file and the Medicare rules. We find that there is no evidence provided that the enrollee has a tobacco smoking history of at least 30 pack-years. Therefore, we decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on May 24, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. 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 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 provided on May 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an inpatient hospital stay provided from 
April 27, 2021, to April 30, 2021. 
 
You asked the Plan to waive the deductible for an inpatient hospital stay. You say that you have never been 
charged before and cannot afford the charges. 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. Your 
contract with the Plan says that there is a $300 deductible which applies to inpatient hospital care.  
 
The medical records show that you had an inpatient hospital stay from April 27, 2021, to April 30, 2021. The 
record shows that you had paid $0 toward the $300 deductible prior to receiving the services. Therefore, you 
are responsible to pay the $300 deductible.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category inpatient 
hospital care. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $300 
deductible which applies to inpatient hospital care. This cost sharing is a contractual obligation that had not 
been met at the time an inpatient hospital stay was received on April 27, 2021 to April 30, 2021. Therefore, we 
decided that the Plan does not have to waive the deductible for an inpatient hospital stay provided from April 
27, 2021, to April 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a periapical first radiographic image (D0220) and a periapical additional radiographic image (D0230) provided on June 3, 2021.
You asked the Plan to pay for a periapical first radiographic image and a periapical additional radiographic image. You say that you advised the provider's office that you only had coverage for two bitewing x-rays. The Plan denied your request. The Plan says the services at issue exceeds the bitewing 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 a periapical first radiographic image (D0220) and a periapical additional radiographic image (D0230) provided on June 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair with accessories.
You asked the Plan to pre-approve a shower chair with accessories. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says a shower chair with accessories is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair with accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a durable medical equipment (DME) evaluation to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve a DME evaluation to be provided by an OON provider. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The Plan says there are in-network providers available to the enrollee that can provide the services at issue.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a durable medical equipment (DME) evaluation to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the urgent care visit you had with a nurse 
practitioner on June 11, 2021. 
 
You asked the Plan to reduce the copayment for the urgent care visit. You say that this nurse practitioner is not 
a specialist, so your copayment should only be $10. The Plan denied your request. The Plan says because this 
was an urgent care visit, you were charged this copayment 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 $25 
copayment for office visits with any provider who is not your primary care provider for urgently needed 
services.  
 
You have been asked to pay a $25 copayment for the urgent care visit. We looked at the medical records from 
this visit.  The records clearly state that this was an urgent care visit for a stye in your left eye. The nurse 
practitioner from whom you received these services is not your primary care providerThis 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 reduce the copayment for the urgent care visit you had with a nurse practitioner on June 11, 2021.