Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on September 9, 2021.

You asked the Plan to waive the copayment for the office visit. You say that the services should be covered. 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 $40 copayment for Physician/Practitioner services, including doctor's office visits.

You have been asked to pay a $40 copayment for the office visit. 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 provided on September 9, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a complete bilateral duplex scan of 
extracranial arteries (93880) provided on November 4, 2021. 
 
You asked the Plan to waive the copayment for an ultrasound of the arteries. You say that you have not had a 
copayment for this service in the past and disagree with the charges. The Plan denied your request. The Plan 
says the cost-sharing was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $25 
copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 
 You have been asked to pay a $25 copayment for an ultrasound of the arteries. The service at issue falls within 
the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost-sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for a complete bilateral duplex scan of extracranial arteries (93880) 
provided on November 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a ROMtech PortableConnect Adaptive Rehab device.
You asked the Plan to pre-approve 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. The rules say that for equipment to be covered, it must primarily serve a
medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pre-approve a ROMtech PortableConnect Adaptive Rehab device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional supplies (99072) provided on July 27, 2021. 
 
You asked the Plan to pay for additional supplies. You say that this was not available in-network. The Plan 
denied your request. The Plan says this is not separately payable. 
 The Plan must follow Medicare rules. Medicare rules say that a Medicare Physician Fee Schedule Database 
(MPFSDB) Status Indicator of B indicates that payment for covered services is always bundled into payment 
for other services not specified. 
 
We looked at the file and Medicare rules. Code 99072 has a status indicator of B and is not separately payable. 
Based on this information, we decided that Medicare rules for coverage of additional supplies have not been 
met. Therefore, we decided that the Plan does not have to pay for additional supplies (99072) provided on July 
27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a pontic, porcelain/ceramic crown (D6245x3), a retainer crown (D6740x6), 2D oral/facial photographic image obtained intra-orally or extra-orally (D0350x2), a diagnostic cast (D0470x2) and a crown (D2740) and other miscellaneous dental items/services provided on June 16, 2021, to November 16, 2021, by an out-of-network (OON) provider.
You asked the Plan to reimburse you for dental services. You say that your daughter has special needs, and this dental provider specializes in treatment for individuals with special needs. You also say you would like to be reimbursed for these services. The Plan denied your request. The Plan says the enrollee must receive care from a network provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to reimburse you 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 reimburse you for these items/services. Therefore, we decided that the Plan does not have to reimburse you for a pontic, porcelain/ceramic crown (D6245x3), a retainer crown (D6740x6), 2D oral/facial photographic image obtained intra-orally or extra-orally (D0350x2), a diagnostic cast (D0470x2) and a crown (D2740) and other miscellaneous dental items/services provided on June 16, 2021, to November 16, 2021, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for an ultrasound provided on September 29, 2021. 
 
You asked the Plan to pay for the ultrasound. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says that the costs share that was applied was correct. 
 
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. Specifically, the case file sent by the Plan is incomplete. The Plan has not 
forwarded a complete claim or an explanation of benefits to verify what services were billed and what the 
member's responsibility it. It is the burden of the Health Plan to substantiate their denial with evidence. In this 
case, the Plan's denial has not been substantiated so we must find in your favor. Therefore, we decided that the 
Plan has to pay for an ultrasound provided on September 29, 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 Continuous intraoperative neurophysiology monitoring
(95941) provided January 12, 2021.
You asked the Plan to pay for the neuromonitoring service. You say that you are requesting an exception in this
case and processing of the claim at the in-network benefit level. The Plan denied your request. The Plan says
this service is not a covered code for Medicare.
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 95941is continuous intraoperative neurophysiology
monitoring, from outside the operating room (remote or nearby) or for monitoring of more than one case while
in the operating room, per hour.
We find that CPT code 95941is not supported in the medical record. Specifically, Per CMS, the Billing
Medicare for Remote Intraoperative Neurophysiology Monitoring (HCPCS Code G0453) (Updated September
2020) (cms.gov), states, CMS created HCPCS code G0453 in response to concerns about the then new CPT
code 95941 which allows a physician to monitor multiple Medicare beneficiaries (patients) simultaneously. In
the CY 2013 final rule, we wrote that HCPCS code G0453can be billed only for undivided attention by a
monitoring physician to a single beneficiary, and not for simultaneous attention by the monitoring physician to
more than one patient. Based on this information, we decided that Medicare rules for coverage of the
neuromonitoring service have not been met. Therefore, we decided that the Plan does not have to pay for
Continuous intraoperative neurophysiology monitoring (95941) provided January 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for insertion of intrauterine device (IUD) (58300)
Levonorgestrel-releasing intrauterine contraceptive system (J7298) provided June 3, 2021.
You asked the Plan to pay for the outpatient procedure. You say that you believe that your IUD is medically
necessary, and the Plan should reconsider their decision to deny. Having an IUD for prevention helps your
overall health, especially your back. The Plan denied your request. The Plan says this service is not covered
under any normal circumstances.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the outpatient procedure have not been met. Therefore, we decided that the Plan does not have to
pay for insertion of intrauterine device (IUD) (58300) Levonorgestrel-releasing intrauterine contraceptive
system (J7298) provided June 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture, initial 15 minutes (97813) and acupuncture, each additional 15 minutes (97814) provided October 29, 2021.

You asked the Plan to pay for the acupuncture services. You say that you have provided the enrollee with acupuncture treatment since February 5, 2018, and he has been reporting profound improvements in his pain levels. Therefore, there is medical necessity for his acupuncture treatments.

The Plan denied your request. The Plan says the services were rendered by a non-covered provider type. A licensed acupuncturist, not a physician.

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, acupuncture services must be provided by a legally qualified physician practicing within the scope of their license. The services were rendered by a licensed acupuncturist not a physician. This provider is also not supervised by a physician, PA or NP/CNS. Therefore, we decided that the Plan does not have to pay for the acupuncture, initial 15 minutes (97813) and acupuncture, each additional 15 minutes (97814) provided October 29, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided to the enrollee on March 22, 2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the claim records show another provider with the same Tax ID and the same specialty 
rendered procedure code 27265 on date of service March 19, 2021. Surgery procedure 27265 has a global value 
of 090 on the CMS National Physician Fee Schedule (NPFS) Relative Value (RVU) file. This is a major 
procedure that has a global surgery period of 90 days. Procedure 31500 billed on date of service March 22, 
2021, is included within the global surgery package of procedure 27265 billed on date of service March 19, 
2021. Therefore, the provider did not bill as required by Medicare coding regulations.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, this claim cannot be paid as billed due 
to services submitted for payment by a secondary provider for the same date of service.  Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for medical services provided to the enrollee on March 22, 2021.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to reduce the copayment for the breathing capacity test from $45 to $40.  
 
You asked the Plan to waive the copayment for the breathing capacity test. You say that the services should be 
covered. The Plan says that the cost-sharing applied correctly based on the services provided. 
 
We decided that the Plan has to reduce the copayment for the breathing capacity test.  
 
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 the breathing capacity test. Therefore, we decided that the Plan has to reduce the copayment for 
the breathing capacity test from $45 to $40 as stated in their contract. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the office or other outpatient visit for 
the evaluation and management of an established patient (99214) and determination of refractive state (92015) 
provided June 21, 2021. 
 
You asked the Plan to provide additional payment for the office visit and eye refraction. You say that you were 
unaware that the Plan had a third-party routine vision vendor. The Plan denied your request. The Plan says the 
office visit has been processed correctly and the eye refraction is not covered. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers the office visit with a $30 copayment. The Plan covers eye refractions when they are 
provided as part of a routine eye exam by a provider in the Plans third-party vision vendors network. 
 
We looked at the file and the Plan's rules. In this case you have been asked to pay a $30 copayment for the 
medical vision office visit. This office visit falls within the Medicare-covered vision services benefit category. 
This means you have been asked to pay the correct amount based on your contract with the Plan. Medicare 
does not pay for procedures performed in the course of any eye exam to determine the refractive state of the 
eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or 
treatment of illness or injury. The eye refraction was not performed as part of a routine eye exam nor was it 
performed by one of the Plans vision vendors network providers. Based on this information, we decided that 
the Plan's rules for coverage of the eye refraction have not been met. Therefore, we decided that the Plan does 
not have to provide additional payment for the office or other outpatient visit for the evaluation and 
management of an established patient (99214) and determination of refractive state (92015) provided June 21, 
2021.  
 
Your complaint about feeling misled about you vision benefits is not a valid appeal for medical coverage. This 
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 2D oral imaging (D0350), panoramic imaging (D0330), and 
complete radiographic images (D0210) provided by a participating provider on October 14, 2021. 
 
You asked the Plan to pay for 2D oral imaging, panoramic imaging, and complete radiographic images. You 
say that you are on a fixed income. You say that you would like the Plan to pay for this. The Plan denied your 
request. The Plan says the dental services that are being appealed are not covered 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 2D oral imaging (D0350), panoramic imaging (D0330), and complete radiographic images (D0210) provided by a participating provider on October 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an urgent care visit provided on October 31, 2020.

You asked the Plan to waive the copayment for the urgent care visit. You say that the services should be covered as you have already paid the $30 copayment. 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 $40 copayment for each out-of-network visit of Urgently Needed Services.

You have been asked to pay an additional $10 copayment for the out-of-network urgent care visit. The record indicates that the clinic you went to is not in network with the plan, and there is a $40 copayment for out-of-network 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 urgent care visit provided on October 31, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory work provided on October 9, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the laboratory work. 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 service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for laboratory work provided on October 9, 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 prefabricated post and core in addition to crown (D2954) 
endodontic therapy, premolar tooth (excluding final restoration) (D3320), unspecified preventive procedure, by 
report (D1999), and incision and drainage of abscess - intraoral soft tissue (D7510) provided July 6, 2021. 
 
You asked the Plan to pay for the post and core, root canal, unspecified preventative procedure, and incision 
and drainage of abscess. You say that you were given misinformation about whether the provider was part of 
the Plan's network. The Plan denied your request. The Plan says the claims from this date of service have been 
reprocessed as in-network, however these services are 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 Plans 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 
prefabricated post and core in addition to crown (D2954) endodontic therapy, premolar tooth (excluding final 
restoration) (D3320), unspecified preventive procedure, by report (D1999), and incision and drainage of 
abscess - intraoral soft tissue (D7510) provided July 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for x-rays provided on May 17, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the x-rays. You say that the enrollee is unable to choose which radiologist reads their x-rays. 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 x-rays provided on May 17, 2021, by an out-of-network (OON) provider.