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

 We decided that the Plan does not have to pay for the additional intraoral periapical x-ray (D0230) provided on July 6, 2021.  You asked the Plan to pay for the additional intraoral periapical x-ray. You say that your statement with the dental office shows you have no balance. You also say that you owe nothing to your dental office. The Plan denied your request. The Plan says this service is not a covered expense under your dental 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 the additional intraoral periapical x-ray (D0230) provided on July 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the subsequent nursing facility care services coded 99309 provided on April 20, 2021.  You asked the Plan to pay for the subsequent nursing facility care services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately payable.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 99309 is a column II code to column I code 90792. 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 subsequent nursing facility care services coded 99309 provided on April 20, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 We decided that the Plan has to pre-approve a retainer crown (D6740), and a pontic (D62450) provided by a participating provider.  You asked the Plan to pre-approve a retainer crown and a pontic. You say that you think these services are medically necessary. The Plan denied your request. The Plan says that these services are not medically necessary.  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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has failed to provide the dental x-rays needed to determine a final decision. Therefore, we decided that the Plan has to pre-approve a retainer crown (D6740), and a pontic (D62450) provided by a participating provider.  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: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient hospital services rendered from June 23, 2021, to June 24, 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 claim was billed incorrectly.    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 services were billed with primary diagnosis code I63.412 (cerebral infarction due to embolism of left middle cerebral artery) and secondary diagnosis code I63.411 (cerebral infarction due to embolism of right middle cerebral artery). It is not appropriate to bill two diagnoses indicating laterality when a more appropriate bilateral diagnosis is available. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services rendered from June 23, 2021, to June 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for glucose monitoring supplies (K0553) provided on August 13, 2021.  You asked the Plan to pay for glucose monitoring supplies. You say that this was authorized. The Plan denied your request. The Plan says this exceeds the frequency limitation for this code.  The Plan must follow Medicare rules. Medicare rules say that no more than 1 unit of service (UOS) of code K0553 is billable per thirty (30) days.  We looked at the file and Medicare rules. The record shows that the enrollee received three units of K0553 in July 2021. The enrollee should not have received additional units of K0553 for three months. Based on this information, we decided that Medicare rules for coverage of glucose monitoring supplies have not been met. Therefore, we decided that the Plan does not have to pay for glucose monitoring supplies (K0553) provided on August 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a bedside commode for the enrollee.  You asked the Plan to pre-approve the commode. You say that this is medically necessary based on a diagnosis of pneumonia. The Plan denied your request. The Plan says there is no documentation that the covering criteria for a bedside commode have been met.  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 the commode. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that in this case, the documentation does not support that the enrollee is confined to a room or a level of the home without a toilet. Furthermore there is no indication that the enrollee cannot utilize the regular toilet facilities.  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 commode have not been met. Therefore, we decided that the Plan does not have to pre-approve a bedside commode for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the complete upper denture (D5110) provided on July 27, 2021, by an out-of-network provider.  You asked the Plan to pay for the denture. You say that you thought you had out-of-network benefits. The Plan denied your request. The Plan says out-of-network care is not covered by your dental benefit. The denture was received from an out-of-network provider.  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. If you receive supplemental dental services out-of-network, you are responsible for 100% of the cost.   Though the Plan offers a dental benefit in excess of Medicare coverage, items or services received from out-of-network providers are not covered under this benefit. Therefore, we decided that the Plan does not have to pay for the complete upper denture (D5110) provided on July 27, 2021, by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the self-administered drug provided on September 23, 2021.  You asked the Plan to pay for the self-administered drug. You say that you were not aware that there would be an out-of-pocket charge. You also say that you could have brought your own inhaler. The Plan denied your request. The Plan says self-administered drugs are not covered services under your plan.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drug provided on September 23, 2021.   Benefits for the self-administered drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided on March 9, 2020.  You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you had Medicaid at the time and should not owe anything. 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 March 9, 2020. The record shows that you did not have Medicaid at the time services were received. Therefore, you are responsible to pay your share of the cost-sharing charges. The total allowed amount is $136.06 and 20% of that is $27.21.   You have been asked to pay the total coinsurance of $27.21 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 on March 9, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for outpatient mental health care provided from March 19, 2021, to April 23, 2021.  You asked the Plan to waive the copayments for outpatient mental health care. You say that you disagree with the charges because you have a document stating that there is a $0 copayment for telehealth 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 $40 copayment for individual or group visits and for telehealth visits for outpatient mental health care.   You received outpatient mental health care from March 19, 2021, to April 23, 2021, for a total of 5 visits. The record shows that the services you received do not qualify for the coronavirus waiver. Therefore, you are responsible to pay a $40 copayment per each visit. The total amount you owe is: $40 (copayment) x 4 (outpatient mental health care visits) = $200.  You have been asked to pay the total copayment amount of $200 for outpatient mental health care. Outpatient mental health care falls within the outpatient mental health care 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 outpatient mental health care provided from March 19, 2021, to April 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) provided August 10, 2021.  You asked the Plan to pay for the core buildup. You say that the core buildup should be covered together with crowns and you cannot afford the cost of the core buildup. The Plan denied your request. The Plan says this service is not covered under your benefits.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) provided August 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the range of motion measurements and report services coded 95851 provided on April 19, 2021.  You asked the Plan to pay for the range of motion measurements and report services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately payable.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 95851 is a column II code to column I code 99213. 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 range of motion measurements and report services coded 95851 provided on April 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the retrobulbar injection services coded 67500 provided on May 12, 2021.  You asked the Plan to pay for the retrobulbar injection services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately payable.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 67500 is a column II code to column I code 00140. 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 retrobulbar injection services coded 67500 provided on May 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on September 16, 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 cardiac screening, 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 September 16, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the short-latency somatosensory evoked potential study (95938) provided on May 5, 2021.  You asked the Plan to pay for the short-latency somatosensory evoked potential study. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the provider's specialty is not eligible to perform the services rendered.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We find that CPT code 95938 is not supported in the record. Specifically, the record does not clearly evidence that this provider has training and expertise to perform and interpret these tests. Based on this information, we decided that Medicare rules for coverage of the short-latency somatosensory evoked potential study have not been met. Therefore, we decided that the Plan does not have to pay for the short-latency somatosensory evoked potential study (95938) provided on May 5, 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 September 3, 2021.  You asked the Plan to pay for the problem focused limited oral evaluation. You say that you had not received any dental care for 18 months due to the pandemic, which the Plan also did not pay any of your insurance for. You also say that you think it is unfair that your two visits were used for the appointments on July 6, 2021, and August 16, 2021. The Plan denied your request. The Plan says this service exceeds the benefit level.  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, you are limited to two oral examinations per calendar year. The record shows that you received oral exams on July 6, 2021, and August 16, 2021, and your oral examinations benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on September 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the office visit (99213) rendered by the
out-of-network (OON) provider on August 25, 2021.
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to issue reimbursement for the office visit (99213) rendered by the out-of-network (OON) provider on August 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for IV infusion therapy services provided on March 23, 2020  You asked the Plan to waive the copayment for the IV infusion therapy services. You say that the services should be covered as you had Medicaid during the date of services. The Plan denied your request. The Plan says the cost-sharing 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 Medicare Part B prescription drugs.       . You have been asked to pay a 20% coinsurance for IV infusion therapy services (the total allowed amount is $207.75 x 20% = $41.55). IV infusion therapy services 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 copayment for IV infusion therapy services provided on March 23, 2020
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided from April 29, 2021, to October 21, 2021.  You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you were not aware of the charges and cannot afford them. 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 $0 copayment for allergy serum and generic nebulized medications and 20% coinsurance for chemotherapy drugs and all other Medicare Part B drugs.  You received Medicare Part B drugs from April 29, 2021, to October 21, 2021. Therefore, you are responsible to pay your share of the cost-sharing charges. Please see the chart below.   Date of Service  Service Allowed Amount Amount You Owe 4/29/2021 Medicare Part B Drugs $2,075.77 $415.15 6/3/2021 Medicare Part B Drugs $2,075.77 $415.15 7/9/2021 Medicare Part B Drugs $2,149.69 $429.94 8/23/2021 Medicare Part B Drugs $2,149.69 $429.94 9/23/2021 Medicare Part B Drugs $2,149.69 $429.94 10/21/2021 Medicare Part B Drugs $2,158.46 $187.43  The total amount you owe is: $2,307.55.   You have been asked to pay the total coinsurance amount of $2,307.55 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 April 29, 2021, to October 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a CT scan of the lumbar spine (72131).  You asked the Plan to pre-approve a CT scan of the lumbar spine. You say that the requested service is a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the requested service have not been met.  The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a CT scan of the lumbar spine. Our reviewer says that the requested service is not medically reasonable and necessary in this case. Our physician reviewer found that the record indicates a normal neurologic examination. The record does not indicate that plain radiographs have been performed or that the enrollee has had a failed trial of conservative therapy.     We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CT scan of the lumbar spine have not been met. Therefore, we decided that the Plan does not have to pre-approve a CT scan of the lumbar spine (72131).