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

We decided that the Plan does not have to pay for a cone beam computed tomography (CT) capture and interpretation (D0367) provided on July 7, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for a cone beam CT capture. You say that the provider's office advised you had to pay the bill and then file for reimbursement through your Plan. The Plan advised you to submit a copy of the paid receipt for reimbursement. The Plan denied your request. The Plan says there is no coverage for cone bean CT capture and interpretation with field of view of both jaws, with and without cranium services.
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 cone beam CT capture is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a cone beam computed tomography (CT) capture and interpretation (D0367) provided on July 7, 2021 by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from March 1, 2020 to March 6, 2020.
You asked the Plan to pay for SNF care. You say that the billed services are supported for payment. The Plan denied your request. The Plan says malnutrition does not qualify to be reported as an active diagnosis.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for SNF care. Our reviewer says that the services are not supported as billed. Our reviewer found the documentation is insufficient to support the
inclusion of a diagnosis of malnutrition as an active diagnosis in Section I of the assessment. We looked at this coder'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 pay for skilled nursing facility (SNF) care provided from March 1, 2020 to March 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused represented by dental code D0140 provided on June 8, 2021.
You asked the Plan to pay for dental code D0140. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says oral evaluations are covered once every 12 months. You received an oral evaluation previously on January 6, 2021. This means that the oral evaluation you received on June 8, 2021 exceeds your benefit limit for this 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. We looked at the file, the Plan's contract and Medicare rules. The Plan's contract says oral evaluations are covered once every 12 months. You received an oral evaluation previously on January 6, 2021.
This means that the oral evaluation you received on June 8, 2021 exceeds your benefit limit for this service. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem focused represented by dental code D0140 provided on June 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on March 20, 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 81206, 81210, 81235, 81275, 81276, 81292, 81295, 81298,
81301, 81317, 81401, 81194, 81309, and 81445. Codes 81206, 81210, 81235, 81275, 81276, 81292, 81295,
81298, 81301, 81317, 81401, 81194, and 81309 are column II codes with a modifier indicator of 1 when billed
with column I code 81445. Codes 81206, 81210, 81235, 81275, 81276, 81292, 81295, 81298, 81301, 81317,
81401, 81194, and 81309 were not billed with an appropriate modifier to allow for separate payment.
Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on March 20,
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for anticoagulant management services (93793) provided on May 25, 2021.
You asked the Plan to waive the copayment for anticoagulant management services. You say that the plan is charging you for a visit and you never saw the doctor. The Plan denied your request. The Plan says the copayment applied correctly based on the services rendered.
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 $40 copayment for Outpatient diagnostic tests and therapeutic services and supplies.
You have been asked to pay a $13.49 copayment which is less than $40 for anticoagulant management services. Anticoagulant management services fall 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 anticoagulant management services (93793) provided on May 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Cinacalcet coded as J0604-AX and unlisted dialysis
procedure coded as 90999-G4-V5 provided from April 2, 2021 to April 30, 2021.
You asked the Plan to pay for codes J0604-AX and 90999-G4-V5. 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, the CPT Code Manual definition of code J0604 is Cinacalcet, oral, 1 mg, (for esrd on dialysis).
The definition of code 90999 is Unlisted dialysis procedure, inpatient or outpatient.
We find that CPT codes J0604-AX and 90999-G4-V5 are not supported in the medical record. Specifically,
J0604 was billed with a modifier no longer payable by Medicare as of January 1, 2021. As a result, the
associated dialysis services associated with this drug administration will also be denied. Based on this
information, we decided that Medicare rules for coverage of codes J0604-AX and 90999-G4-V5 have not been
met. Therefore, we decided that the Plan does not have to pay for Cinacalcet coded as J0604-AX and unlisted
dialysis procedure coded as 90999-G4-V5 provided from April 2, 2021 to April 30, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on February 11, 2021.
You asked the Plan to pay for the genetic testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
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. Review of the file shows that the documentation does not support how the results of the genetic testing rendered would impact the enrollee's medical management or care. This means that the genetic testing 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 genetic testing provided on February 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a power wheelchair (K0823) provided from April 11, 2021, to August 11, 2021.
You asked the Plan to waive the coinsurance for a power wheelchair. You say that you have not been able to use the wheelchair since it's delivery. You also say that it just sits in the box in the corner of the room, as it has the wrong footrest and also due to an issue with your leg. You also say you thought it would be a one-time coinsurance. 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 20% coinsurance for Durable Medical Equipment.
You have been asked to pay a $508.15 in coinsurance, which is 20% of the allowed amount for a power wheelchair ($2,540.65 allowed amount x 20% coinsurance = $508.15). Power wheelchairs fall within the Durable Medical Equipment 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 a power wheelchair (K0823) provided from April 11, 2021, to August 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the filling (D2330) for tooth # 23 provided on April 20, 2021.
You asked the Plan to pay for the filling for tooth # 23. You say that you had old fillings that were deteriorating. You say that you had to have a repair done on your front tooth. You also say that these services should be covered. The Plan denied your request. The Plan says 2 fillings are covered per 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.
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental service have not been met. Specifically, the frequency limit has been exceeded. The record shows that the Plan paid for the fillings for teeth # 8 and 25 that you received on the date of service in this case. Therefore, we decided that the Plan does not have to pay for the filling (D2330) for tooth # 23 provided on April 20, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services (90832) provided April 15, 2021.
You asked the Plan to pay for the psychotherapy services. You say that you would like this claim reprocessed based on medical necessity. The Plan denied your request. The Plan says here is no documentation of a consultation with the attending physician.
The Plan must follow Medicare rules. Medicare rules say that CPs are required to document a consultation with the primary or attending physician or the attempt to make such a consultation.
We looked at the file and Medicare rules. There is no documentation in this record supporting consultation or attempt at consultation was performed. Based on this information, we decided that Medicare rules for coverage of the psychotherapy services have not been met. Therefore, we decided that the Plan does not have to pay for the psychotherapy services (90832) provided April 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an intravitreal injection of a pharmacological agent (67028) provided on June 25, 2021.
You asked the Plan to waive the copayment for an intravitreal injection of a pharmacological agent. You say that you were treated for macular degeneration at an office building on the campus. You also say that the building is not connected to the hospital and you were still charged a $252 copayment. 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 $250 copayment for outpatient hospital surgery services.
You have been asked to pay a $250 copayment for an intravitreal injection of a pharmacological agent. An intravitreal injection of a pharmacological agent falls within the Outpatient Hospital Services benefit category. A search of the Medicare database shows that the provider at issue is classified as a general acute care hospital. 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 intravitreal injection of a pharmacological agent (67028) provided on June 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that the item is necessary. The Plan denied your request. The Plan says the item is not primarily medical in nature.
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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the Arthrocentesis Aspirin Injection (20610) provided on June 24, 2021.
You asked the Plan to waive the copayment for the Arthrocentesis Aspirin Injection. You say that you should not be charged the copayment as you were in an office setting and not a hospital. The Plan denied your request. The Plan says the copayment applied correctly as the record shows you were receiving outpatient care in a hospital.
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 Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You have been asked to pay a $250 copayment for an Arthrocentesis Aspirin Injection. A search of the Medicare National Provider Identifier (NPI) database confirmed that the provider at issue is considered to be a General Acute Care Hospital. 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 Arthrocentesis Aspirin Injection (20610) provided on June 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377), harness for upgrade to expandable controller (E2313), and an electronic connection between wheelchair controller and two or more power seating system motors (E2311).
You asked the Plan to pre-approve an expandable controller, harness for upgrade to expandable controller, and an electronic connection between wheelchair controller and two or more power seating system motors. 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 follows Medicare rules. Medicare rules say that wheelchair accessories are covered when specific criteria are met. 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 an expandable controller, harness for upgrade to expandable controller, and an electronic connection between wheelchair controller and two or more power seating system motors. Our reviewer says that the items are not medically necessary. Our physician reviewer found the documentation does not reveal that you require other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.). You do not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. Your strength and function in the upper extremities supports that you can control any power options through their own individual switches. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an expandable controller, harness for upgrade to expandable controller, and an electronic connection between wheelchair controller and two or more power seating system motors have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377), harness for upgrade to expandable controller (E2313), and an electronic connection between wheelchair controller and two or more power seating system motors (E2311).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation (PVA).
You asked the Plan to pre-approve PVA. 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 follows Medicare rules. Medicare rules say that PVA (percutaneous vertebroplasty (PVP) or kyphoplasty (PKP)) is covered under specific circumstances. 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 PVA. Our reviewer says that the services are not medically necessary. Our physician reviewer found imaging studies do not show marrow edema and a fracture that is less than 12-week-old. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of PVA have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous vertebral augmentation (PVA).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the modification of a prefabricated abutment represented by dental code D6056 and a single crown restoration that is retained, supported and stabilized by an abutment on an implant represented by code D6058 provided on May 5, 2021.
You asked the Plan to pay for dental codes D6056 and D6058. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says dental codes D6056 and D6058 are not covered under the Plan's supplemental dental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, dental codes D6056 and D6058 are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the modification of a prefabricated abutment represented by dental code D6056 and a single crown restoration that is retained, supported and stabilized by an abutment on an implant represented by code D6058 provided on May 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care for pneumonia due to COVID-19 received from April 2, 2021, through April 12, 2021.
You asked the Plan to waive the copayment for inpatient hospital care. You say that the hospitalization should be fully covered because it was related to COVID-19. The Plan denied your request. The Plan says the cost-share was applied correctly. From May 11, 2020, until September 30, 2020, the Plan waived cost-shares for certain services in response to the COVID-19 pandemic. The service date at issue occurred after the temporary waiver concluded.
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 $295 copayment for the first 4 days of Medicare-covered hospital care and a $0 copayment for additional days. You have been asked to pay a total of $1,180 in copayments for inpatient hospital care ($295  4 days = $1,180). The Inpatient Hospital Care benefit category applies. 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 inpatient hospital care for pneumonia due to COVID-19 received from April 2, 2021, through April 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services you received on May 25, 2021.
You asked the Plan to waive the copayment for the lab services. You say that you believe these lab services should be considered part of your annual physical. The Plan denied your request. The Plan says 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 $10 copayment for lab services. You have been asked to pay a $10 copayment for the lab services. According to your Evidence of Coverage,
the annual physical exam includes the following services: bodily systems examinations, measurement and recording of vital signs, a complete prescription medication review, and a review of any recent hospitalizations. It does not include lab services. Lab services and other diagnostic tests are subject to separate cost sharing. 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 lab services you received on May 25, 2021.