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

We decided that the Plan does not have to waive the copayment for outpatient mental health care provided on May 6, 2021.

You asked the Plan to waive the copayment for outpatient mental health care. You say that you never had to pay copayments with a previous Plan. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 copayment for outpatient mental health care. 

You have been asked to pay a $25 copayment for outpatient mental health care. Outpatient mental health care falls within the outpatient mental health care benefit category.

This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for outpatient mental health care provided on May 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an occlusal adjustment (D9951) provided by a participating provider on September 2, 2021.

You asked the Plan to pay for an occlusal adjustment. You say that these services are related to a fall. The Plan denied your request. The Plan says the rendered dental work 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 an occlusal adjustment (D9951) provided by a participating provider on September 2, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the blood smear interpretation provided on June 25, 2021.

You asked the Plan to pay for the services provided. You say that the procedure was rendered in the appropriate place of service. The Plan denied your request. The Plan says the code may not be paid if furnished to hospital outpatients.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

We looked at the file and the rules. The claim lists a place of service as an outpatient hospital. We find that payment for CPT code 85060 may be made only if the physician interprets an abnormal smear for hospital inpatient. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the blood smear interpretation provided on June 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the electrocardiogram (ECG) recording (93225) provided on August 20, 2021.
You asked the Plan to waive the copayment for the ECG. You say that you were told you would not owe anything for this service, and you do not understand why the Plan will not pay. The Plan denied your request. The Plan says this service is covered, and the claim was processed in accordance with your contract. Diagnostic procedures and tests provided in an outpatient hospital setting require a $175 copayment. You are being asked to pay less than $175 because the Plan's allowed amount (discounted rate) is less than the required 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 $175 copayment for diagnostic procedures and tests provided in an outpatient hospital setting.
You have been asked to pay $100.54 for the ECG. An ECG falls within the diagnostic procedures and tests benefit category, and in this case the services were provided in an outpatient hospital setting. 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 electrocardiogram (ECG) recording (93225) provided on August 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services coded 99100 provided on November
16, 2020.

You asked the Plan to pay for the anesthesia services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.

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 99100 is anesthesia for patient of extreme age, younger
than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure).

We find that CPT code 99100 is not supported in the medical record. Specifically, this code has a status code of
"B". A status code of B means that payment for this code is always bundled into payment for other services not
specified. This means no separate payment can be made. Based on this information, we decided that Medicare
rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not
have to pay for the anesthesia services coded 99100 provided on November 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional intraoral periapical x-ray (D0230) and simple
extraction (D7140) provided on July 16, 2021, and August 25, 2021.

You asked the Plan to pay for the intraoral periapical x-ray and simple extraction. You say that you do not
understand why these services were denied for frequency limitations because you had not had any other dental
procedures rendered. The Plan denied your request. The Plan says your benefits for these services had been
satisfied and the frequency limitations had 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, intraoral x-rays are limited to one
procedure code per calendar year. The record shows that you received a first intraoral periapical x-ray (D0220)
on July 16, 2021 and your intraoral x-rays benefit had been exhausted. The Plan contract also says that
extractions are limited to two procedure codes per calendar year. The record shows that you received three
simple extractions (D7140 x3) on August 25, 2021, two of which were covered by the Plan, and your
extractions benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the
additional intraoral periapical x-ray (D0230) and simple extraction (D7140) provided on July 16, 2021, and
August 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a resin-based composite (D2391), and endodontic therapy
(D3320) provided by an out-of-network provider on August 11, 2021, to August 18, 2021.

You asked the Plan to pay for a resin-based composite and endodontic therapy. You say that you do not agree
with these charges. The Plan denied your request. The Plan says D3320 is not a covered service. D2391 was
provided by an out-of-network provider.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

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 a resin-based
composite (D2391), and endodontic therapy (D3320) provided by an out-of-network provider on August
11, 2021, to August 18, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the GeneSight Psychtropic testing (81479) provided on January 4, 2021.
You asked the Plan to pay for the GeneSight Psychotropic testing. You say that you would like reconsideration because this testing is covered by Medicare. The Plan denied your request. The Plan says this testing is non-covered per LCD guidelines. The Plan must follow Medicare rules. Medicare rules say that the present evidence does not clearly demonstrate that routine PGx testing for the purpose of medication selection offers a benefit over selection of medications based on contemporary evidence-based medication selection protocols. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the GeneSight Psychotropic testing have not been met. Specifically, this testing is explicitly listed as non-covered per Medicare's LCD and the Diagnostic Exchange. Therefore, we decided that the Plan does not have to pay for the GeneSight Psychtropic testing (81479) provided on January 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Pregabalin capsules.

You asked the Plan to pre-approve self-administered drug. You say that this medication is approved for treatment of the enrollee's condition. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Pregabalin capsules.

Benefits for self-administered drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for radiation therapy provided on August 9,
2021, and August 13, 2021.

You asked the Plan to waive the copayments for radiation therapy. You say that the physicians work together
and there should not be separate charges. The Plan denied your request. The Plan says the claims were
processed correctly, and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees
must pay a $45 copayment for radiation therapy.

The enrollee received radiation therapy on August 9, 2021, and August 13, 2021. Therefore, the enrollee is
responsible to pay a $45 copayment per each radiation therapy service. The total amount the enrollee owes is:
$45 (copayment) x 2 (radiation therapy services) = $90.

The enrollee has been asked to pay the total copayment amount of $90 for radiation therapy. Radiation therapy
falls within the physician/practitioner services, including doctor's office visits benefit category. This means that
the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a
contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan
does not have to waive the copayments for radiation therapy provided on August 9, 2021, and August 13, 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 you need physical therapy so you can walk. The Plan denied your request. The Plan says based on Medicare guidelines, your request for approval of an IRF admission does not meet the requirements for approval.
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 the complexity of your nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multidisciplinary
rehabilitation program. 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: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the nasal interface (A7034) and headgear (A7035) provided on November 30, 2020.
You asked the Plan to pay for the nasal interface and headgear. You say that you would like reconsideration because these supplies are separately payable. The Plan denied your request. The Plan says that these CPT codes have a status indicator of X meaning that they are statutorily excluded from coverage.
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 Plan's denial based on statutory exclusion is not valid in this case. The CPAP supplies are separately reimbursable. The Plan has not forwarded any evidence that the quantity of supplies billed is greater than those described in the Medicare policy as the usual maximum amounts. It is the burden of the Health Plan to substantiate their denial with evidence. In this case, the denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for the nasal interface (A7034) and headgear (A7035) provided on November 30, 2020.
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 pre-approve the changing of a specific primary care provider (PCP) to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the changing of a specific primary care provider (PCP). You say that you feel the service should be covered because the provider is an awesome provider. You also say that you would like to go to her because she is convenient, in town, has great bedside manner and has already taken care of your medical needs that the previous provider did not in the last three visits. The Plan denied your request. The Plan says you much choose a contract Plan primary care physician (PCP) or provide and oversee your care. This provider is not a contracted PCP.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the changing of a specific primary care provider (PCP) to be provided by an out-of-network (OON) provider
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the care could be received in another setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require, or to be able to tolerate, fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR). 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on March 30, 2021.

You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the place of
service must reflect where the specimen was obtained.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate code.

We looked at the file and the rules. The claim indicates a place of service as an independent laboratory. The
records provided do not indicate the specimen at issue was obtained at an independent laboratory. Based on this
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the
Plan does not have to pay for the drug testing services provided on March 30, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0481) provided on January 25, 2021.
You asked the Plan to pay for drug testing. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent
laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (G0481) provided on January 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the battery back-up (E1399).
You asked the Plan to pre-approve the battery back-up. You say that you will be making a trip and according to the instructions received from the airlines, it must be covered for at least 9 hours. You were already approved a battery but you are waiting for another. The Plan denied your request. The Plan says this is not a covered benefit under any normal circumstances.
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 the battery back-up (E1399).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided on August 31, 2021.

You asked the Plan to waive the copayment for a CT scan. You say that you feel that the services should not be
paid because of the crappy service you received due to the coronavirus. The Plan denied your request. The Plan
says the claims were processed correctly, and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $225
copayment for advanced imaging services.

You have been asked to pay a $225 copayment for a CT scan. A CT scan 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 CT scan provided on August 31, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (procedure code 38747) provided to the enrollee on July 16, 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 this code is ineligible to be paid separately.

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 38747 is a column II code to column I code 44120. 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 surgical services (procedure code 38747) provided to the enrollee on July 16, 2021.