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

We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on August 9, 2021.
You asked the Plan to pay for the panoramic x-ray (D0330). You say that the dentist and staff did not explain that you would have any out-of-pocket costs. You say that you are on a fixed income and cannot afford any bills. The Plan denied your request. The Plan says CPT code D0330 is only covered once every three plan years.
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 also have a maximum benefit of one panoramic x-ray every three plan years. The Plan paid for the panoramic x-ray provided on June 8, 2020, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on August 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the additional resin-based composites provided on July 5, 2021.  You asked the Plan to pay for the additional resin-based composites. You say that insurance only paid $196.65 and hope the Plan can give more benefits. The Plan denied your request. The Plan says the claim processed correctly toward your out-of-network 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, you also have a maximum benefit of two amalgam or resin-based composites per calendar year. The Plan paid for three resin-based composites provided on June 25, 2021 and one resin-based composite provided on July 5, 2021, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the additional resin-based composites provided on July 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the domiciliary or rest home visit (99335) provided on January 12, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the domiciliary or rest home visit. You say that the treatment received was medically necessary. The physician provided a statement of medical necessity and medical records to justify the reason for the enrollee's stay. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.  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 domiciliary or rest home visit (99335) provided on January 12, 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 outpatient office visit (99213) provided on June 23, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit. You say that you are appealing the claim with the medical records. Kindly review and process the claim towards payment. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 outpatient office visit (99213) provided on June 23, 2021 by an out-of-network (OON) provider
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for Genesight testing (81479) provided on June 15, 2021.  You asked the Plan to pay for Genesight testing. You say that this is a covered service. The Plan denied your request. The Plan says this is not supported.  The Plan must follow Medicare rules. Medicare rules say that in order for Pharmacogenomics Testing services to be covered, the patient's medical record must clearly reflect that the criteria listed in the rules section have been met.  We looked at the file and Medicare rules. The submitted medical records do not include records from the ordering provider demonstrating that the criteria for coverage have been met and that the testing at issue was medically necessary. Based on this information, we decided that Medicare rules for coverage of Genesight testing have not been met. Therefore, we decided that the Plan does not have to pay for Genesight testing (81479) provided on June 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) provided on August 26, 2021 by an out-of-network (OON) provider.  

You asked the Plan to pay for the periodic oral evaluation. You say that you would like to appeal this service. The Plan denied your request. The Plan says this service was rendered by an OON provider. The Plan also says that you must receive services at a participating 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 OON. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) provided on August 26, 2021 by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ultrasound services (76705) provided on August 1, 2021.  You asked the Plan to pay for code 76705. 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 as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.   In this case, we have confirmed that code 76705 is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the ultrasound services (76705) provided on August 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for Genesight testing (81479) provided on June 30, 2021.  

You asked the Plan to pay for Genesight testing. You say that this is a covered service. The Plan denied your request. The Plan says the requirements for coverage have not been met.  

The Plan must follow Medicare rules. Medicare rules say that in order for Pharmacogenomics Testing services to be covered, the patient's medical record must clearly reflect that the criteria listed in the rules section have been met.  

We looked at the file and Medicare rules. The submitted medical records do not include records from the ordering provider demonstrating that the criteria for coverage have been met and that the testing at issue was medically necessary. Based on this information, we decided that Medicare rules for coverage of Genesight testing have not been met. Therefore, we decided that the Plan does not have to pay for Genesight testing (81479) provided on June 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain rendered on July 27, 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 separately payable.  The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.  

The provider submitted a claim for procedure codes 70450 (CT head/brain) and 70496 (computed tomography angiography of the head). Code 70450 is a column II code with a modifier indicator of 1 when billed with column I code 70496. Code 70450 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain rendered on July 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that IRF care is medically reasonable and necessary. The Plan denied your request. The Plan says rules for IRF care have not been met.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that you were admitted for elective knee replacement surgery.

Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you do have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. In conclusion, there is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the transportation of portable x-ray equipment (R0700).  You asked the Plan to pay for the transportation of portable x-ray equipment. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the provider did not bill this claim as required by Medicare coding regulations.  The Plan must follow Medicare rules. The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Specifically, there were no medical records provided in this case. Without the medical records, we cannot review to see if the services were billed correctly. Therefore, we decided that the Plan does not have to pay for the transportation of portable x-ray equipment (R0700).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the cystoscopy procedure (52000) provided on June 12, 2020.

You asked the Plan to waive the copayment for the cystoscopy procedure. You say that you received a bill for this service several months after the fact and it was found that you owe additional money. You do not feel it was fair that the Plan took back payment and have concerns about owing the full cost of the service. The Plan denied your request. The Plan says initially this claim was processed incorrectly, but it has been reprocessed in accordance with your contract. Physician services require a $35 
copayment.

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 $35 copayment for physician services.

You have been asked to pay a $35 copayment for the cystoscopy procedure. The cystoscopy procedure falls within the physician 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 the cystoscopy procedure (52000) provided on June 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral x-ray (D0220) provided on September 7, 2021.

You asked the Plan to pay for the intraoral x-ray (D0220). You say that the benefits booklet states x-rays are covered every 3 years. You say that you thought the Plan would pay and you would be billed for the rest. The Plan denied your request. The Plan says the service is not a covered benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the intraoral x-ray (D0220) provided on September 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for the diagnostic tests and specialist visit provided on July 23, 2021.  

You asked the Plan to waive the copayments for the diagnostic tests and specialist visit. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received diagnostic tests and specialist services on the date of service at issue in this appeal. The Plan says that the correct copayments have applied per your contract with the Plan.  

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 $15 copayment for each Medicare-covered x-ray service, an $85 copayment for Medicare-covered radiological diagnostic services, and a $25 copayment for services obtained from a specialist.   

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received a limited bilateral noninvasive physiologic study (93922) provided on July 23, 2021. You have been asked to pay a $71.30 copayment for the limited bilateral noninvasive physiologic study (93922), which is less than the $85 copayment amount. The file also shows that you received an x-ray on your right (73630-RT) and your left (73630-LT) feet on July 23, 2021. You have been asked to pay a $15 copayment for each x-ray. The limited bilateral noninvasive physiologic study and x-rays fall within the Outpatient diagnostic tests benefit category.   

The file also shows that you received a specialist visit (99203) on July 23, 2021. You have been asked to pay a $25 copayment for the specialist visit. The specialist visit falls within the Physician/Practitioner services benefit category.   This means that you have been asked to pay the correct amounts 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 the diagnostic tests and specialist visit provided on July 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on August 30, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you would like the Plan to pay at least what they would have paid an in-network provider, and you will pay the difference. The Plan denied your request. The Plan says there is no coverage for when services are rendered by an OON provider. The Plan also says that you did not contact the Plan prior to this 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) and prophylaxis (D1110) provided on August 30, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate for the fillings (D2332) for teeth # 24, 25, 26, and 27 provided on July 7, 2021, by the out of network dentist.

You asked the Plan to pay the in network rate for the dental services. You say that you paid $196 at the time you received the fillings. You say that you received a bill for $900 a month later. You say that you were not aware that the provider was no longer in network. You also say that you should not be responsible for the out of network cost share. The Plan denied your request. The Plan says you pay 60% of what the provider charges for fillings that you receive out of network. The Plan also says that the claim was processed correctly.

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 fillings are listed as covered, there is a 60% coinsurance for restorative services you receive out of network. This is a contractual obligation you agreed to when you enrolled in the Plan's dental coverage. Therefore, we decided that the Plan does not have to pay the in network rate for the fillings (D2332) for teeth # 24, 25, 26, and 27 provided on July 7, 2021, by the out of network dentist.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound care provided on September 14, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the wound care. You say that the service was 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 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. 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 the wound care provided on September 14, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for medical nutrition therapy services provided by an in-network medical center on August 3, 2021.
You asked the Plan to pay for the medical nutrition therapy services. You say that these services should be approved because you are under weight. The Plan denied your request. The Plan says that these services are not covered.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. You were provided the medical nutrition therapy services by a contract provider. The file does not show that the Plan provided notice that the medical nutrition therapy services would not be covered. Medical Nutrition Therapy is potentially covered for patients with certain conditions and the Plan has failed to provide any medical records showing that you do not meet these criteria. Furthermore, the Plan has provided no evidence that the in-network medical center where you received these services advised you, prior to rendering the services, that they would not be covered. Under Medicare rules, this means the medical nutrition therapy services is considered approved by the Plan. Therefore, we decided that the Plan has to pay for medical nutrition therapy services provided by an in-network medical center on August 3, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-covered services (99203) provided on August 12, 2021.

You asked the Plan to pay for code 99203. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says code 99203 is not payable when billed by a chiropractor.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the non-covered services (99203) provided on August 12, 2021.