Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BRCA genetic testing.
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 medically necessary.
The Plan must follow Medicare rules. Medicare rules say that BRCA testing 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 pre-approve these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has a personal history of
malignant neoplasm of breast and a family history of malignant neoplasm of the breast, prostate, and ovary.
The submitted records are insufficient to support that the criteria for coverage for BRCA testing are met. The
testing is not reasonable or medically necessary for the enrollee at this time.
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 pre-approve BRCA genetic testing.
Local Coverage Determination (LCD) L35000 referenced by the Plan is not valid for the state of California
where the testing would be performed and was not used in the Maximus determination.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ophthalmological medical examination and evaluation (92004), the fundus photography with interpretation and report (92250), and the visual field examination (92083) rendered by an out-of-network (OON) provider on February 9, 2021.  You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.  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.   You are not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the ophthalmological medical examination and evaluation (92004), the fundus photography with interpretation and report (92250), and the visual field examination (92083) rendered by an out-of-network (OON) provider on February 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services (0202U) provided September 15, 2021.  You asked the Plan to pay for the lab services. You say that this testing was medically necessary. The Plan denied your request. The Plan says the test performed is not covered.  The Plan must follow Medicare rules. Medicare rules say that Multiplex PCR respiratory viral panels of 6 or more pathogens are non-covered.  We looked at the file and Medicare rules. The test was for more than 6 pathogens. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (0202U) provided September 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Coronavirus testing rendered on August 16, 2021.
You asked the Plan to pay for these services. You say that the test was required to re-enter the United States from Aruba. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that Medicare covers specific preventive services only. The Plan contract says that tests will not be covered for members who need a COVID-19 test to travel. We looked at the file and the Plan's rules rules. The file shows that you received Coronavirus/COVID-19 testing for travel purposes. This preventive service is not covered by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the Coronavirus testing rendered on August 16, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (82785, 86003) rendered by the out-
of-network (OON) provider on August 23, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of
network provider, without prior authorization.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue.
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the
Plan does not have to pay for the laboratory services (82785, 86003) rendered by the out-of-network (OON)
provider on August 23, 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 March
23, 2021.
You asked the Plan to waive the copayment for the specialist office visit. You say that you have received
multiple bills from multiple claims. 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. The specialist office visit falls
within the Physician/Practitioner Services, Including Doctor's Office 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 March 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the transitional care management services provided on July 22, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the transitional care management services. You say that the service 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 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 the transitional care management services provided on July 22, 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) provided on August 26, 2021.  You asked the Plan to pay for the dental service. You say that your dental rider should have covered this service. The Plan denied your request. The Plan says 1 limited oral evaluation is covered per plan year. The Plan also says that the frequency limit has been exceeded.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage and limited oral evaluation is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a limited oral evaluation that you received on April 21, 2021. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on August 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the malignant lesion excision (11623) and complex repair (13121) provided on August 4, 2020.  You asked the Plan to pay for the malignant lesion excision (11623) and complex repair (13121). You say that the documentation should be reviewed and reprocessed. The Plan denied your request. The Plan says the records do not support the services billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  In this case, the CPT Code Manual definition of code 11623 is excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 2.1 to 3.0 cm. The CPT Code Manual definition of code 13121 is repair, complex, scalp, arms, and/or legs; 2.6 cm to 7.5 cm.  We asked our coder 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 the malignant lesion excision (11623) and complex repair (13121). Our reviewer says that the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found that the procedure report documents excision of lesion on left forehead, with a complex repair. The codes reported are inappropriate for services performed on the forehead and there are more appropriate codes to report for these services.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the malignant lesion excision (11623) and complex repair (13121) have not been met. Therefore, we decided that the Plan does not have to pay for the malignant lesion excision (11623) and complex repair (13121) provided on August 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit and electrical stimulation services provided on December 11, 2020.  You asked the Plan to pay for the office visit and electrical stimulation services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says these services are not covered when performed by a chiropractor.  The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.   The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the office visit and electrical stimulation services provided on December 11, 2020.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the surgery services provided on April 26, 2021.  You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed codes cannot be verified.  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 22612 is arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transverse technique, when performed). The CPT Code Manual definition of code 63048 is laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [e.g., spinal or lateral recess stenosis]), single vertebral segment; each additional segment, cervical, thoracic, or lumbar.  We asked our coder 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 the services provided. Our reviewer found that for CPT code 22612, the operative report does not include enough documentation to confirm this procedure has been performed. Operative report states a discectomy and endplates were rasped; this does not include enough description to confirm correct coding. For CPT code 63048, the operative report does not include details of this procedure and therefore cannot be verified if correct code was reported.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the surgery services provided on April 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME and related supplies provided on September 2, 2021.

You asked the Plan to waive the coinsurance for DME and related supplies. You say that you disagree with the increase in charges. 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 20% coinsurance for DME and related supplies.

You received DME and related supplies on September 2, 2021. The total allowed amount is $1,346.40 and 20% of that is $269.28.

You have been asked to pay the total coinsurance amount of $269.28 for DME and related supplies. DME and related supplies fall within the DME and related 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 coinsurance for DME and related supplies provided on September 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve custom fabricated abutment - includes placement (D6057) and abutment supported porcelain/ceramic crown (D6058).

You asked the Plan to pre-approve the custom fabricated abutment and abutment supported crown. You say that you would like these services covered. The Plan denied your request. The Plan says 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 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 pre-approve custom fabricated abutment - includes placement (D6057) and abutment supported porcelain/ceramic crown (D6058).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided on August 25, 2021.

You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you disagree with the increase in charges for this date of service. 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 20% coinsurance for Medicare Part B prescription drugs. 

You have been asked to pay $233.85, which is less than 20% coinsurance for Medicare Part B drugs. Medicare Part B drugs fall within the Medicare Part B prescription 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 Medicare Part B drugs provided on August 25, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (71045) provided October 6, 2021.
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the code billed shares a bundled relationship with another code billed and is 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 71045 is a column II code to column I code 36556. 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 radiology services (71045) provided October 6, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (36415, 80061, 82043, 82570, 83036)
provided on October 7, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for laboratory services. You say that this is supported in the records. The Plan
denied your request. The Plan says this was not authorized.
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 laboratory services (36415, 80061, 82043, 82570,
83036) provided on October 7, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a walker (E1399, S9999) purchased on August 13, 2021, from an out-of-network (OON) provider.
You asked the Plan to pay for a walker. You say that you need this reimbursed. The Plan denied your request. The Plan says this was not authorized.
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 a walker (E1399, S9999) purchased on August 13, 2021, from an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the consultation (D9310) provided on August 3, 2021.  You asked the Plan to pay for the dental service. You say that you were not informed by the provider that this service would not be covered. You say that you ended up with an unexpected bill. You also say that you are on a limited income. The Plan denied your request. The Plan says consultation is not listed as a covered service.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the consultation is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the consultation (D9310) provided on August 3, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on May 31 2020.
You asked the Plan to waive the copayment for emergency care. You say that you left before being treated and
disagree with the charges. 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 $60
copayment for emergency care.
The medical records show that you received emergency care on May 31, 2020. Therefore, you are responsible
to pay the $60 copayment.
You have been asked to pay a $60 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
May 31 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for an office visit provided on September 8, 2021.
You asked the Plan to waive the copayment for the office visit. You say that you did not speak to a specialist
and you should not be responsible for the copayment. The Plan denied your request. The Plan says that 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 does not say in clear and accurate terms
how much you should expect to pay for a non-specialty visit when the provider is not your primary care
physician (PCP).
We looked at your contract with the Plan. We did not see where the contract says enrollees must pay a $40
copayment for each office visit with a non-specialty provider who is not your PCP. The Plan contract does not
clearly say how much enrollees must pay for these types of providers. This means that the Plan did not follow
Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the
copayment for an office visit provided on September 8, 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.