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

 We decided that the Plan does not have to pay for the office or other outpatient visit for the evaluation and management of an established patient (99213), deep sedation/general anesthesia - each subsequent 15-minute increment (D9223), removal of torus mandibularis (D7473), and extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) provided June 30, 2021.  You asked the Plan to pay for the office visit, anesthesia, removal of torus mandibularis, and tooth extraction. You say that these services were medically necessary, are covered by Medicare and should be covered. The Plan denied your request. The Plan says this provider has opted out of Medicare, and therefore the services are not covered.  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 states that you can use any licensed dental provider who has not opted out of Medicare.  We looked at the file and Medicare rules. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Based on this information, we decided that the Plan's rules for coverage of the office visit, anesthesia, removal of torus mandibularis, and tooth extraction have not been met. Therefore, we decided that the Plan does not have to pay for the office or other outpatient visit for the evaluation and management of an established patient (99213), deep sedation/general anesthesia - each subsequent 15-minute increment (D9223), removal of torus mandibularis (D7473), and extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) provided June 30, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ultrasound of a pregnant uterus (76816) and fetal biophysical profile (76819) provided on June 29, 2021 by an out-of-network (OON) provider.  

You asked the Plan to pay for the ultrasound of a pregnant uterus and fetal biophysical profile. The Plan denied your request. The Plan says these services were rendered by a non-network provider, and the enrollee was referred by another non-network provider for these services. The Plan also says that no necessity for an OON provider has been documented.  

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. Therefore, we decided that the Plan does not have to pay for the ultrasound of a pregnant uterus (76816) and fetal biophysical profile (76819) provided on June 29, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a consultation and endodontic therapy to be rendered by an endodontist.  

You asked the Plan to pre-approve the consultation and endodontic therapy. The Plan denied your request. The Plan says your contract only provides coverage for dental services when they are performed by a participating general dentist. The Plan also says that dental services performed by an endodontist are not covered.  

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 covered when they are received by anyone other than a participating general dentist. Therefore, we decided that the Plan does not have to pre-approve a consultation and endodontic therapy to be rendered by an endodontist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for oxygen equipment provided from April 18, 2021, to July 18, 2021.
You asked the Plan to waive the coinsurance for the oxygen equipment. You say that there should not be any charges due to your coronavirus diagnosis. The Plan denied your request. The Plan says the correct coinsurance was applied.
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% coinsurance for medical equipment, including oxygen equipment.
Equipment
Allowed Amount
20% Coinsurance
Oxygen Concentrator - April 18, 2021
$81.01
$16.20
Portable Gaseous Oxygen - April 18, 2021
$40.50
$8.10
Oxygen Concentrator - May 18, 2021
$81.01
$16.20
Portable Gaseous Oxygen - May 18, 2021
$40.50
$8.10
Oxygen Concentrator - June 18, 2021
$81.01
$16.20
Portable Gaseous Oxygen - June 18, 2021
$40.50
$8.10
Oxygen Concentrator - July 18, 2021
$81.01
$16.20
Portable Gaseous Oxygen - July 18, 2021
$40.50
$8.10
Total:
$97.20
You have been asked to pay $97.20, which is 20% of the allowed amount for oxygen equipment. Please note that the Plan's cost share waivers for coronavirus ended as of April 1, 2021. The oxygen equipment falls within the Durable Medical Equipment (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 oxygen equipment provided from April 18, 2021, to July 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve two alveoloplasties not in conjunction with extractions (D7320 x2).  You asked the Plan to pre-approve the alveoloplasties. The Plan denied your request. The Plan says this service is not covered under your benefit plan.  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 two alveoloplasties not in conjunction with extractions (D7320 x2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the eyeglasses (V2020, V2203, V2745) provided on June 2, 2021.  

You asked the Plan to pay for the eyeglasses. You say that this claim should be covered in full. The Plan denied your request. The Plan says there is a $100 annual allowance toward the purchase of routine eyeglasses. There is a $0 copayment up to this allowance, but you are responsible for all costs over and above the allowance amount. The total cost of the eyeglasses was $200.60. The Plan has paid $100, and you are responsible for the remaining $100.60.  

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers up to $100 for routine eyewear each year. You are responsible for all costs over and above this allowance amount.  

We looked at the file and the Plan's rules. The total cost of the eyeglasses purchased on the date in question was $200.60. Documentation shows that the Plan has paid the full $100 allowance for the eyewear, and you are being asked to pay the difference between the billed amount and the full allowance. Based on this information, we decided that the Plan does not have to pay any additional amount for the eyeglasses (V2020, V2203, V2745) provided on June 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the debridement and nail trimming services rendered on February 9, 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 payment is included in the global surgical package.  The Plan must follow Medicare rules. The rules say that follow-up visits and services related to the original procedure are included in the global surgical package.  We looked at the file and Medicare rules. Billed procedure codes 11042 (debridement, subcutaneous tissue [includes epidermis and dermis, if performed]; first 20 sq cm or less), 11719 (trimming of nondystrophic nails, any number), and 97597 (debridement of open wound including topical applications, wound assessment and instructions for ongoing care, per session, first 20.0 sq cm or less of total wound surface area) were billed within the 10-day global surgical period for minor procedure code 10140 (incision and drainage of hematoma, seroma or fluid collection) on February 4, 2021 and were related to the procedure. Payment for these services is included in the global surgical package. Therefore, we decided that the Plan does not have to pay for the debridement and nail trimming services rendered on February 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for an oxygen concentrator (E1390) purchased on May 12, 2021.  

You asked the Plan to pay for an oxygen concentrator. You say that the item you needed was not available in-network. The Plan denied your request. The Plan says this cannot be covered as a purchase.  

The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.  

Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for an oxygen concentrator (E1390) purchased on May 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of bladder lesion rendered on March 29, 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 services are not separately payable.
The rules say that if the modifier indicator is 0, the Column 2 code cannot be paid regardless of whether a modifier is used. The provider submitted a claim for procedure codes 51050 (removal of bladder stone) and 51525 (removal of bladder lesion). Code 51525 is a column II code with a modifier indicator of 0 when billed with column I code 51050. Code 51525 is not separately payable. Therefore, we decided that the Plan does not have to pay for the removal of bladder lesion rendered on March 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chemotherapy administration coded as 96401 provided on June 30, 2021.
You asked the Plan to pay for chemotherapy administration. You say that this code can be used for certain injections other than chemotherapy. The Plan denied your request. The Plan says this code is incorrect for the services the enrollee received.
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 96401 is chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic. We find that CPT code 96401 is not supported in the medical record. Specifically, the billed drug Prolia is not a chemotherapy medication. In this case, there is a more appropriate code that can be used to bill the injected drug Prolia based on Medicare coding guidelines. Based on this information, we decided that Medicare rules for coverage of chemotherapy administration have not been met. Therefore, we decided that the Plan does not have to pay for chemotherapy administration coded as 96401 provided on June 30, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided on May 13, 2021.
You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you disagree with the discrepancy in charges and feel that you should only owe $28.33. 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 received Medicare Part B drugs on May 13, 2021. The total allowed amount is $566.56 and 20% of that is $113.31. You have been asked to pay the total coinsurance amount of $113.31 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 May 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) provided August 17, 2021.

You asked the Plan to pay for the comprehensive oral exam. You say that you switched to an in-network dentist and would like the service covered. The Plan denied your request. The Plan says you have exceeded the frequency limit for this 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. The Plan covers the comprehensive oral exam once every three plan years. 

We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive oral exam was previously covered on July 30, 2020. Based on this information, we decided that the Plan's frequency limit for coverage of the comprehensive oral exam has been exceeded. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) provided August 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services (87086) provided June 25, 2021.  

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim was not billed with a valid diagnosis code.  

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  

We find that CPT code 87086 is not supported in the medical record. Specifically, Z87.440 is not listed as a valid diagnosis code for this service. 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 (87086) provided June 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for DME provided on July 11, 2021.  You asked the Plan to waive the coinsurance for DME. You say that you received the package at the post office but the device was stolen and you have not received a replacement yet. 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 on July 11, 2021. The total allowed amount is $58.49 and 20% of that is $11.70.   You have been asked to pay the total coinsurance amount of $11.70 for DME. DME falls 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 provided on July 11, 2021.   We note your complaint that the device was stolen and you have not received a replacement yet. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on March 8, 2021.

You asked the Plan to waive the copayment for emergency care. You say that you went to the emergency room due to the coronavirus vaccine. 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 received emergency care on March 8, 2021. This visit does not qualify for the coronavirus waiver. Therefore, you are responsible to pay the $90 copayment. 

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 March 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing rendered on January 18, 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 services are not billed correctly.  

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.  

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on January 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve crowns (D2740) for tooth #'s 8 and 12.  You asked the Plan to pre-approve the crowns. You say that you would like for the crowns to be approved for both teeth. The Plan denied your request. The Plan says the completed root canal treatment on tooth 8 does not meet clinically acceptable standards for root canal therapy. The Plan also says that the x-rays provided of tooth #12 does not show that there is a lot of tooth missing from a cavity or has a lot of damage from being broken.  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 crowns when the services are medically necessary and reasonable.   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 crowns. Our reviewer says that the documentation provided does not meet the criteria for coverage for crowns (D2740) for tooth #'s 8 and 12. Our physician reviewer found your dental record and x-rays indicate the presence of crowns on tooth #'s 8 and 12 which appear functionally adequate  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crowns have not been met. Therefore, we decided that the Plan does not have to pre-approve crowns (D2740) for tooth #'s 8 and 12.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for radiation therapy services provided on June 21, 2021.  

You asked the Plan to waive the coinsurance for the radiation therapy services. You say that you were not aware that the provider was not in-network. The Plan denied your request. The Plan says the correct coinsurance was applied.  

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% coinsurance for therapeutic radiology services.    

Procedure Allowed Amount 20% Coinsurance 
Targeted Radiation Treatment $167.28 $33.46 
Radiation Treatment Simulation $276.45 $55.29 Total:  $88.75   

You have been asked to pay $88.75, which is 20% of the allowed amount for radiation therapy services. Radiation therapy services fall 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 coinsurance for radiation therapy services provided on June 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a resin-based composite (D2332) provided by an out-of-network provider on September 2, 2021.
You asked the Plan to pay for a resin-based composite. You say that your filling fell out and you needed it fixed. The Plan denied your request. The Plan says the dental work that was provided 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 a resin-based composite (D2332) provided by an out-of-network provider on September 2, 2021.