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

We decided that the Plan does not have to pay for an office visit and ophthalmic imaging provided on August
25, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit and ophthalmic imaging. You say that due to your medical history
you prefer to see the highly recommended out-of-network provider. 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 office visit and ophthalmic imaging provided on August 25,
2021, by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for emergency care provided on July 7, 2021.  You asked the Plan to waive the copayment for emergency care. You say that you disagree with the charges because you did not receive emergency services. 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 $90 copayment for emergency care.   You have been asked to pay a $90 copayment for emergency care. Emergency care falls within the emergency 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 emergency care provided on July 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral x-ray provided on September 21, 2021.
You asked the Plan to pay for the intraoral x-ray. You say that you found a new dentist who needed to process
his own exam and x-ray. You say that this was an urgent matter and should be paid. The Plan denied your
request. The Plan says the maximum benefit has been reached.
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 dental x-rays per year. The Plan paid for two x-rays provided on March 22, 2021, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the intraoral x-ray provided on September 21, 2021
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 70450 billed for date of service July 24, 2021.  You asked the Plan to pay for procedure code 70450. You say that the patient had multiple services on this date, so this code should be paid. The Plan denied your request. The Plan says this code is bundled into payment for code 70496.  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 procedure code 70450 is a column II code to column I code 70496. 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 procedure code 70450 billed for date of service July 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dentures (D5110), dentures (D5120), and dental
procedure (D9999), provided on March 10, 2021.
You asked the Plan to pay for the dentures and procedure. You say that the services should be covered. The
Plan denied your request. The Plan says you obtained these services from a provider who has opted out of
Medicare.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, 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
dentures (D5110), dentures (D5120), and dental procedure (D9999), provided on March 10, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for chiropractic services you received from January 9, 2021, to April 7, 2021.  You asked the Plan to waive the copayments for the chiropractic services. You say that you want to make sure you are being billed the correct amount. The Plan denied your request. The Plan says you were charged these copayments 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 $20 copayment per visit for chiropractic services.   You have been asked to pay a $20 copayment per visit for the chiropractic 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 copayments for chiropractic services you received from January 9, 2021, to April 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the intraoral periapical radiographic image (x-ray) (D0220), provided on August 13, 2021.  You asked the Plan to pay for the intraoral periapical radiographic image. You say that the services were medically necessary. The Plan denied your request. The Plan says you exceeded the allowed frequency for this 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 periapical radiographic image (x-ray) (D0220), provided on August 13, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Eylea injections you received from December 18, 2020, to June 4, 2021.
You asked the Plan to waive the coinsurance for the Eylea injections. You say that no one ever told you that these injections would cost this much. You said that you were not expecting this bill. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for Medicare Part B drugs. You have been asked to pay 20% coinsurance for the Eylea injections. the Eylea injections fall within the Medicare Part B drugs 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 the Eylea injections you received from December 18, 2020, to June 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to reimburse you for the massage therapy services provided from February 3, 2021, to March 23, 2021.  You asked the Plan to reimburse you for the massage therapy services. You say that the services you received fall under the naturopathic services. You also say that these services would be necessary for injuries and surgery. The Plan denied your request. The Plan says massage therapy is not a covered benefit under the Wellness Wallet.  Medicare generally does not cover massage therapy. However, the Plan offers a supplemental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a supplemental benefit in excess of Medicare coverage, the massage therapy services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the massage therapy services provided from February 3, 2021, to March 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services rendered on May 23, 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 procedure code 99291 is not supported.
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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes.
We find that CPT code 99291 is not supported in the medical record. Specifically, there is no documentation of 30-74 minutes of critical care time. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services rendered on May 23, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on March 1, 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 procedure codes 27134 and 27030 are not supported.
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 27134 is revision of total hip arthroplasty; both components, with or without autograft or allograft. The definition of code 27030 is arthrotomy, hip, with drainage (eg, infection). We find that CPT codes 27134 and 27030 are not supported in the medical record. Specifically, there is no documentation of revision of total hip arthroplasty to support code 27134. There is no documentation of a hip arthrotomy with drainage to suport code 27030. Based on this information, we decided that Medicare rules for
coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services rendered on March 1, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for pneumatic compression devices (E0675, E0673) provided on June 15, 2021.
You asked the Plan to pay for pneumatic compression devices. You say that the items at issue were a medical necessity for you. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, these items are not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pay for pneumatic compression devices (E0675, E0673) provided on June 15, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tempus Gene Panel rendered on February 12, 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 testing was not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that next generation sequencing (NGS) is 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 pay for these services. Our reviewer says that the testing was not medically necessary. Our physician reviewer found the enrollee has a listed diagnosis of neoplasm of unspecified behavior of other genitourinary organ. The Surgical Pathology report demonstrated metastatic carcinoma. The case file does not contain clinical records for review. The documentation is insufficient to support that the enrollee has ecurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer, has not been previously tested with the same test using NGS for the same cancer genetic content, and has decided to seek further cancer treatment. The documentation is insufficient to show that Tempus Gene Panel testing was medically reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the Tempus Gene Panel rendered on February 12, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90837) provided on May 19 and June 9, 2021.
You asked the Plan to pay for psychotherapy services. You say that the provider of the services at issue is a Medicare doctor. The Plan denied your request. The Plan says rules for payment have not been met because the provider is not part of the Medicare program.
The Plan must follow Medicare rules. Medicare rules say that the clinical social worker will attempt to consult with the enrollee's attending or primary care physician. Review of the file and Medicare records indicates that the provider of the services at issue is enrolled in the
Medicare program as a clinical social worker. However, Medicare rules for coverage of psychotherapy services have not been met. Specifically, the provided records do not document an attempt to consult with, nor a referral from, the enrollee's attending or primary care physician. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90837) provided on May 19 and June 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection rendered on December 16, 2020.
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 procedure code 64493 is 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 64493 (facet injection) and 01935 (anesthesia). Code 64493 is a column II code with a modifier indicator of 1 when billed with column I code 01935. Code 64493 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 injection rendered on December 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on April 23, 2020.
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 were not billed correctly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on April 23, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the acupuncture services provided on February 23, 2021 to April 30, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the acupuncture services. You say that the enrollee has been receiving acupuncture services for his back pain due to bad posture caused by his Parkinson's disease. The acupuncture services have been helping him. 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 acupuncture services provided on February 23, 2021 to April 30, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for inpatient rehabilitation hospital services provided from August 9, 2021, to August 18, 2021.  You asked the Plan to waive the copayment for the inpatient rehabilitation hospital services. You say that you were under the impression that this stay would be covered under a continuous inpatient stay starting on July 31, 2021.  You said that you were told by the facility that the rehab facility was a part of the hospital, so you disagree with having to pay two copayments. The Plan denied your request. The Plan says this copayment was charged 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $345 copayment per day per stay for days 1-5, and $0 for additional days for inpatient hospital care.   Records show that the enrollee was in an acute inpatient hospital from July 31, 2021, to August 9, 2021. He was charged a 5-day copayment of $345 per day for this stay.  He was then discharged from the acute inpatient hospital and admitted to an inpatient rehabilitation hospital that is a separate and distinct facility from the first hospital.  Because it is a different facility type and a new admission, the copayment charges can start again.  The enrollee was in the inpatient rehabilitation hospital for 9 days.  He was charged a $345 copayment for each of the first 5 days, for a total of $1725. 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 copayment for inpatient rehabilitation hospital services provided from August 9, 2021, to August 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the duplex scan (93976) provided on September 16, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the diagnostic service. You say that you were not aware that procedure code 93976 was being performed. It is not fair that you would have to pay for something that was done without your knowledge and consent. 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 duplex scan (93976) provided on September 16, 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 dental services provided on July 8, 2021.  You asked the Plan to pay for the dental services. You say that you had no choice in providers since this oral surgery had to be performed by a specialist to prevent major nerve damage and potential paralysis. You say that the Plan is only required to pay the reimbursement of $1,000. The Plan denied your request. The Plan says services provided by Medicare opt out providers will not be reimbursed.   Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, dental services provided by a dentist that has opted out of Medicare are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental services provided on July 8, 2021.