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

 We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) and complete series of intraoral x-rays (D0210) provided on April 6, 2021 by a Medicare opt out provider.  You asked the Plan to pay for the comprehensive periodontal evaluation and complete series of intraoral x-rays. You say that your office was advised to opt out of Medicare because you had absolutely no interaction with Medicare at all since the practice started in 2007. The Plan denied your request. The Plan says the treating provider has opted out of Original Medicare participation. The Plan also says that no payment can be made for services rendered by an opt out 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.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered when they are received by a provider who has opted out of Medicare. Therefore, we decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) and complete series of intraoral x-rays (D0210) provided on April 6, 2021 by a Medicare opt out provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for pain management services (procedure code 62320) provided to the enrollee on September 13, 2021.

You asked the Plan to pay for the services. You say that the services were billed correctly and should be paid for. The Plan denied your request. The Plan says the records are insufficient to support payment for the services.

The Plan must follow Medicare rules. Medicare rules say that in order for code 62320 to be covered, certain documentation requirements must be met. The documentation must include the legible signature of the physician or non-physician practitioner responsible for providing the care to the patient. In addition, the procedure report should clearly document the indications and the medical necessity for the blocks along with the pre and post percent pain relief achieved immediately post-injection. 

The medical records in this case do not meet Medicare's documentation requirements. Specifically, there is no notation of the percent of pain relief achieved either before or after the injection. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of procedure code 62320 have not been met. 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 pain management services (procedure code 62320) provided to the enrollee on September 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office visit services provided on October 13, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the office visit services. You say that the services were medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.

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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the services at issue were urgent or emergent.

Therefore, we decided that the Plan does not have to pay for office visit services provided on October 13, 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 the limited oral evaluation (D0140) provided on October 11, 2021.

You asked the Plan to pay for the dental service. You say that a large chunk of your tooth fell off while you were eating. You say that it was determined you needed a root canal. You also say that it was determined a root canal could not be performed and you needed the tooth to be extracted instead. The Plan denied your request. The Plan says 1 limited oral evaluation is covered per plan year. The Plan also says that the frequency limit has been exceeded.

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 and limited oral evaluation is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a limited oral evaluation that you received on June 15, 2021. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on October 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), first intraoral periapical x-ray (D0220), bitewing x-rays (D0274), and prophylaxis (D1110) provided on November 18, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the periodic oral evaluation, first intraoral periapical x-ray, bitewing x-rays, and prophylaxis. You say that if the Plan does not cover these services you will return to Original Medicare and Medicaid. The Plan denied your request. The Plan says services performed by an OON provider are not covered because your plan does not have OON benefits. The Plan also says that you did not contact the Plan prior to the date of service to verify benefits and provider eligibility.


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 responsible for 100% of the cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120), first intraoral periapical x-ray (D0220), bitewing x-rays (D0274), and prophylaxis (D1110) provided on November 18, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for ostomy supplies provided on October 5, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the ostomy supplies. You say that you have been using this company's products for 30 years and have never been denied. You say the supplies are medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
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 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 ostomy supplies provided on October 5, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on March 22, 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 the denied services should have been reported with CPT 81479.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. 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 Comprehensive Genomic Profile (CGP) testing provided to the enrollee on March 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture, initial 15 minutes (97813 x22) acupuncture, each additional 15 minutes (97814 x18) provided July 5, 2021, to October 8, 2021.
You asked the Plan to pay for the acupuncture services. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says the enrollee does not meet the criteria.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the enrollee does not have a diagnosis of chronic low back pain. The limited documents provided show the enrollee was seen for evaluation and management of peripheral neuropathy. The records show the Plan requested additional information from the provider without success. Therefore, we decided that the Plan does not have to pay for the acupuncture, initial 15 minutes (97813 x22) acupuncture, each additional 15 minutes (97814 x18) provided July 5, 2021, to October 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an x-ray of the knee (73564) provided on July 14, 2021.

You asked the Plan to waive the copayment for the x-ray of the knee. You say that the services should be covered as you have never had a copayment before. 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 $150 copayment for Outpatient hospital services.

You have been asked to pay a $75.48 copayment for an x-ray of the knee, which is less than the $150 copayment stated in the Plan's contract. The record indicates that these services were performed in an outpatient hospital.. X-rays 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 an x-ray of the knee (73564) provided on July 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME provided on July 29, 2021.
You asked the Plan to waive the coinsurance for DME. You say that you were misled and switched to a Plan where you owe higher 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for DME and related supplies. You received DME on July 29, 2021. The total allowed amount is $41.20 and 20% of that is $8.24. You have been asked to pay the total coinsurance amount of $8.24 for DME. DME falls within the 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 DME provided on July 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided on September 30, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the home health services. You say that the services were medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the services at issue were urgent or emergent. Therefore, we decided that the Plan does not have to pay for home health services provided on September 30, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (procedure code 9900) provided to the enrollee on August 24, 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 payment for this code is always bundled into payment for other codes.  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 99000 is "Handling and/or conveyance of specimen for transfer from the office to a laboratory."  We find that CPT code 99000 is not supported in the medical record. Specifically, this code has a status indicator of "B." This means that this code cannot be paid for separately, and is always bundled into payment for other services not specified. 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 the services (procedure code 9900) provided to the enrollee on August 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for skin debridement services provided from August 9, 2021, to September 20, 2021.  You asked the Plan to waive the copayments for the skin debridement. You say that your specialist copayment should only be $20 per visit. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 copayment for outpatient hospital surgical services.   The file shows that you had a total of 5 outpatient visits for the skin debridement services. Please note that any procedure involving tissue removal is considered surgical. Therefore, you have been asked to pay $500 for the skin debridement ($100 copayment x 5 visits = $500). The skin debridement falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for skin debridement services provided from August 9, 2021, to September 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection rendered on October 4, 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. Medicare rules say that in order for code 62320 to be covered, certain documentation requirements must be met. 

The medical records in this case do not meet Medicare's documentation requirements. Specifically, the record is not signed and there is no notation of the percent of pain relief achieved either before or after the injection. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of procedure code 62320 have not been met. Therefore, we decided that the Plan does not have to pay for the injection rendered on October 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (62320) provided on August 9, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the records do not support the billed service.
The Plan must follow Medicare rules. Medicare rules say that in order for code 62320 to be covered, certain documentation requirements must be met. The documentation must include the legible signature of the physician or non-physician practitioner responsible for providing the care to the patient. In addition, the procedure report should clearly document the indications and the medical necessity for the blocks along with the pre and post percent pain relief achieved immediately post-injection.
The medical records in this case do not meet Medicare's documentation requirements. Specifically, the record is not signed and there is no notation of the percent of pain relief achieved either before or after the injection. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of procedure code 62320 have not been met. Therefore, we decided that the Plan does not have to pay for the services (62320) provided on August 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for pain management services (procedure code 62320) provided to the enrollee on September 27, 2021.  You asked the Plan to pay for the services. You say that the services were billed correctly and should be paid for. The Plan denied your request. The Plan says the records are insufficient to support payment for the services.  The Plan must follow Medicare rules. Medicare rules say that in order for code 62320 to be covered, certain documentation requirements must be met. The documentation must include the legible signature of the physician or non-physician practitioner responsible for providing the care to the patient.  In addition, the procedure report should clearly document the indications and the medical necessity for the blocks along with the pre and post percent pain relief achieved immediately post-injection.  The medical records in this case do not meet Medicare's documentation requirements.  Specifically, the record is not signed and there is no notation of the percent of pain relief achieved either before or after the injection. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of procedure code 62320 have not been met. 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 pain management services (procedure code 62320) provided to the enrollee on September 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit (99213) and podiatry services (11721) rendered from June 29, 2018, to August 27, 2018.
You asked the Plan to waive the copayment for an office visit and podiatry services. You say that you just received this bill and you do not know why you are getting a bill for this much. You also say you never had to pay the doctor and you do not understand why you owe and why the payment goes all the way back to 2018. The Plan denied your request. The Plan says you were charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 copayment for services obtained from a primary care provider or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals in a primary care provider's office. The Plan contracts also says that there is a $45 copayment for each Medicare-covered visit in an office or home setting for Podiatry Services. You have been asked to pay a $10 copayment for an office visit. You have also been asked to pay $41.67, which is less than the $45 copayment for podiatry services. 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 an office visit (99213) and podiatry services (11721) rendered from June 29, 2018, to August 27, 2018.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for FoundationOne testing (81455) provided on September 20, 2021.
You asked the Plan to pay for FoundationOne testing. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that genetic testing procedures submitted under the code 81455 are unlikely to impact therapeutic decision-making in the clinical management of the patient and will be denied automatically as not medically necessary. We looked at the file and Medicare rules. The testing at issue is not considered medically necessary. Based on this information, we decided that Medicare rules for coverage of FoundationOne testing have not been met. Therefore, we decided that the Plan does not have to pay for FoundationOne testing (81455) provided on September 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on February 22, 2021.
You asked the Plan to pay for the dental service. You say that the services should be covered until you are able to opt back in to the Medicare program. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan also says payment cannot be made to 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, dental services performed by a dentist that has opted out of Medicare are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on February 22, 2021.