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

 We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) provided September 9, 2021.  You asked the Plan to pay for the panoramic x-ray. You say that you cannot afford the cost of the service. The Plan denied your request. The Plan says you have exceeded the frequency limit the panoramic x-ray.  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. The Plan covers the panoramic x-ray once every three plan years.  We looked at the file and Medicare rules. The Plan provided documentation showing that a panoramic x-ray was previously covered on April 26, 2019. Based on this information, we decided that the Plan's frequency limit for coverage of the panoramic x-ray has been exceeded. Therefore, we decided that the Plan does not have to pay for the panoramic radiographic image (D0330) provided September 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory work provided on July 29, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the laboratory work. You say that the claim was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.    The requested provider in this case is not a network provider with the Plan. The Plan 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 record shows CPT code 36415 was billed which means the provider had the opportunity to confirm insurance coverage and authorization. Therefore, we decided that the Plan does not have to pay for the laboratory work provided on July 29, 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 limited oral evaluation (D0140), intraoral-periapical images (D0220 and D0230), cone beam computed tomography (D0364), pulp vitality test (D0460), preventive procedure (D1999), endodontic therapy (D3330 and D3999) and  adjunctive procedure (D9999) provided on July 21, 2021.  You asked the Plan to pay for the dental services. You say that you would like reconsideration because it was not clearly communicated that you would not be reimbursed if the provider did not accept Medicare. The Plan denied your request. The Plan says you received this service from a provider who does not receive Medicare funds.  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 limited oral evaluation (D0140), intraoral-periapical images (D0220 and D0230), cone beam computed tomography (D0364), pulp vitality test (D0460), preventive procedure (D1999), endodontic therapy (D3330 and D3999) and  adjunctive procedure (D9999) provided on July 21, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for ambulance services you received on March 19, 2021, and May 4, 2021.  You asked the Plan to waive the copayments for the ambulance services. You say that no one told you that the return trip home would not be covered. The Plan denied your request. The Plan says these services were not denied, rather, you were charged a copayment for each transport.  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 $300 copayment per trip for ambulance services.   You have been asked to pay a $300 copayment per trip for the ambulance 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 ambulance services you received on March 19, 2021, and May 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the neuromonitoring services coded as 99072, 95700, 95718 and 95713 provided on October 26, 2020 by an out-of-network (OON) provider.  You asked the Plan to pay for the neuromonitoring services. You say that please review and reconsider approval for these medically necessary services for payment. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the neuromonitoring services coded as 99072, 95700, 95718 and 95713 provided on October 26, 2020 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory work provided on July 24, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the laboratory work. You say that the claim was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.    The requested provider in this case is not a network provider with the Plan. The Plan 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 record shows CPT code 36415 was billed which means the provider had the opportunity to confirm insurance coverage and authorization. Therefore, we decided that the Plan does not have to pay for the laboratory work provided on July 24, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing coded 80305 provided on June 30, 2021.  You asked the Plan to pay for the drug testing. 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 80305 is drug test(s), presumptive, any number of drug classes, any number of devices or procedures; capable of being read by direct optical observation only (eg, utilizing immunoassay [eg, dipsticks, cups, cards, or cartridges]), includes sample validation when performed, per date of service.   We find that CPT code 80305 is not supported in the medical record. Specifically, the Clinical Laboratory Improvement Amendment Number (CLIA) on the claim is not valid. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded 80305 provided on June 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a specialist office visit provided on August 30, 2021.  You asked the Plan to waive the copayment for the specialist office visit. You say that you were switched to a nurse practitioner without prior notice. 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 $30 copayment for each specialist office visit.     You have been asked to pay a $30 copayment for the specialist office visit. Specialist office visits fall within the Doctor Visits 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 specialist office visit provided on August 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the endocrinology telehealth visit you had on July 12, 2021.  You asked the Plan to waive the copayment for the telehealth visit. You say that the doctor lied to you so you shouldn't have to pay the copayment. 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 $25 copayment for telehealth visits with a specialist.     You have been asked to pay a $25 copayment for the telehealth visit. This copayment applies regardless of your satisfaction with the services received. 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 endocrinology telehealth visit you had on July 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve power wheelchair, group 2 standard, captains chair, patient weight capacity up to and including 300 pounds (CPT code K0823), u-1 sealed lead acid battery (E2365), adjustable height, detachable armrest (E0973), heel loop/holder, any type, with or without ankle strap (E0951), and swingaway, detachable footrests (K0052), for the enrollee.  You asked the Plan to pre-approve the DME. You say that the enrollee has fallen about four (4) times in the last year transferring. You state you remodeled the bathroom, but the enrollee cannot get into the bathroom without the chair. The Plan denied your request. The Plan says the Medicare rules have not been met.  The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.   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 the DME. Our physician reviewer found this enrollee has a personal mobility deficit that impairs participation in Mobility Related Activity of Daily Living (MRADLs). The enrollee's mobility deficit cannot be helped by a walker, cane, manual wheelchair due to falls, weakness, and shoulder pain. The documentation notes the enrollee has some short- term memory deficits. There is no detailed cognitive evaluation with memory, recall and attention by the treating physician indicating the patient can safely use the requested power mobility device (PMD). Furthermore, the documentation notes the bathroom is 23 inches. There is no evidence that the requested wheelchair will fit into the bathroom. The documentation states the bathroom was remodeled but there is no objective evidence of detailed measurements of a new bathroom or indication that new wheelchair will significantly improve MRADL participation.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the durable medical equipment (DME) have not been met. Therefore, we decided that the Plan does not have to pre-approve power wheelchair, group 2 standard, captains chair, patient weight capacity up to and including 300 pounds (CPT code K0823), u-1 sealed lead acid battery (E2365), adjustable height, detachable armrest (E0973), heel loop/holder, any type, with or without ankle strap (E0951), and swingaway, detachable footrests (K0052), for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the IV tubing (S1015) and infection control supplies (S8301) provided on June 25, 2021.  You asked the Plan to pay for the medical equipment. You say that you would like these claims reprocessed based on the medical documentation. The Plan denied your request. The Plan says these codes are not valid for Medicare purposes.  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 S1015 is IV tubing extension set. The CPT Code Manual definition of code S8301 is infection control supplies, not otherwise specified.  We find that CPT codes S1015 and S8301 are not eligible for payment according to Medicare rules. Specifically, these codes both have a status indicator of "I" under the Physician Fee Schedule which indicates these codes are both not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services. Based on this information, we decided that Medicare rules for coverage of the medical equipment have not been met. Therefore, we decided that the Plan does not have to pay for the IV tubing (S1015) and infection control supplies (S8301) provided on June 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the rapid release gel-caps purchased on September 26, 2021.  You asked the Plan to pay for the rapid release gel-caps. You say that you want to know how there is insufficient funds for $12. The Plan denied your request. The Plan says your benefit of $550 was met on March 2, 2021.  You have $550 for eligible items through the Pick Your Perks program. The Plan paid $550 for the purchase on February 8, 2021 and February 22, 2021, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the rapid release gel-caps purchased on September 26, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on June 3, 2021.  You asked the Plan to pay for the physical therapy services. You say that plans are required to pay non-contracted providers at the preferred provider rate when services are not available from preferred providers in the service area. You say that the in-network benefits should be honored, and the claim processed for payment. The Plan denied your request. The Plan says the code is not appropriate for the service billed.  The Plan must follow Medicare rules. Medicare rules say that the services of a physical therapy assistant (PTA) shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the physical therapy services have not been met. Specifically, the billing provider is a nurse practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on June 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the cost sharing for the photodynamic therapy and aminolevulinic acid received at an out-of-network dermatologist's office on July 8, 2021.  You asked the Plan to waive the cost sharing for the photodynamic therapy and aminolevulinic acid. You say that you were billed for a cancer treatment that you were told was covered by Medicare. You said that you were told that the Plan refused to pay for the aminolevulinic acid.  You stated that this is a necessary part of the treatment. The Plan denied your request. The Plan says these services were not denied.  Rather, the Plan says that you were charged the appropriate cost sharing amounts for these items and services.  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 $65 copayment for out-of-network physician services and 20% coinsurance for Medicare Part B drugs.   You have been asked to pay a $65 copayment for the photodynamic therapy and 20% coinsurance for the aminolevulinic acid. The photodynamic therapy falls within the out-of-network physician services benefit category. The aminolevulinic acid is a Medicare Part B drug. 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 cost sharing for the photodynamic therapy and aminolevulinic acid received at an out-of-network dermatologist's office on July 8, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ultarsound services coded 76705 provided on August 5, 2021.  You asked the Plan to pay for the ultarsound 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 separately payable.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76705 for [CASE/DECISION_TREE/ITEMSERV]] is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the ultarsound services coded 76705 provided on August 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient hospital services rendered from January 17, 2021 to January 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 the submitted records do not support the billing of primary diagnosis code A41.51 and secondary diagnoses R65.20 and G92.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.    In this case, you billed the inpatient services provided with primary diagnosis A41.51 (sepsis due to e. coli) and secondary diagnoses R65.20 (severe sepsis without septic shock) and G92 (toxic encephalopathy). 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 submitted records do not support the billing of primary diagnosis code A41.51 and secondary diagnoses R65.20 and G92. Our physician reviewer found the diagnostic information in the emergency department (ED) shows that the enrollee had no acute distress on physical examination and was not ill appearing with normal pulmonary effort. She had a Glasgow coma score (GCS) of 14. The documentation indicates she underwent a septic work-upand labs revealed a stable complete blood count (CBC) and complete metabolic panel. Subsequent documentation consistently recorded no acute distress and was incomplete to support evidence of hemodynamic instability, hypoxemia, abnormal serum platelet, creatinine, or total bilirubin levels.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services rendered from January 17, 2021 to January 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for crowns (D2750) provided by a participating provider May 13, 2021.  You asked the Plan to pay for crowns. You say that you fell and broke your two front teeth. You say that these crowns were medically necessary. The Plan denied your request. The Plan says the benefit limit has already been exhausted.  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 crowns have already been exhausted. Therefore, we decided that the Plan does not have to pay for crowns (D2750) provided by a participating provider on May 13, 2021.