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

We decided that the Plan does not have to waive the deductible for laboratory services provided on February 3, 2021.
You asked the Plan to waive the deductible for the laboratory services. You say that this was a wellness visit and the Plan has always paid your doctor visits. The Plan denied your request. The Plan says the deductible applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that your deductible is $500. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost for most of your covered services.
The item or service you asked the Plan to waive the deductible for falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $500 deductible applies to out-of-network services.
This cost sharing is a contractual obligation that had not been met at the time the laboratory services were received from an out of-network provider on February 3, 2021. Therefore, we decided that the Plan does not have to waive the deductible for laboratory services provided on February 3, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from November 21, 2020 to November 30, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the claim needs to be submitted with a correct bill type.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate type of bill.

We find that the denied services are not supported in the medical record. Specifically, the type of bill used in this case is invalid. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for home health services provided to the enrollee from November 21, 2020 to November 30, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from January 15, 2021, to February 13, 2021.
You asked the Plan to pay for the SNF services. You say that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not require skilled services on the dates of service in this case.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 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 the SNF services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from January 15, 2021, to February 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), intraoral x-rays (D0220, D0230) and a panoramic x-ray (D0330) provided on February 16, 2021.

You asked the Plan to pay for the dental services. You say that you needed a new dentist, and one would not accept you as a patient without a new comprehensive exam and x-rays. You did not see a dentist in 2020 due to the pandemic and difficulty finding a new provider, and as a result needed extra care. You feel the Plan should cover these services as they were necessary. The Plan denied your request. The Plan says these services are not covered by your dental benefit. The comprehensive oral evaluation is a covered service; however, only one comprehensive or periodontal evaluation can be covered every three years. You previously had a comprehensive exam in February of 2019, and therefore your benefit for this service is exhausted and payment cannot be made.

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 or are requested in a frequency that exceeds what is covered under this
benefit. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150),
intraoral x-rays (D0220, D0230) and a panoramic x-ray (D0330) provided on February 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bite-wing x-rays (D0274) provided on October 8, 2020.

You asked the Plan to pay for the bite-wing x-rays. You say that you are on a limited income, and cannot afford to pay this bill. The Plan denied your request. The Plan says this service exceeds the maximum allowed per period.

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, bite-wing x-rays are limited to one procedure per plan year. The record shows that you received bite-wing x-rays (D0274) on March 11, 2020, and your bite-wing x-rays benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the bite-wing x-rays (D0274) provided on October 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cytopathology (FISH) testing provided on November 11, 2020.
You asked the Plan to pay for FISH testing. You say that the referring physician ordered this testing, and you do not have direct patient contact. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because molecular genetic screening testing is not a Medicare benefit for the diagnosis listed and was performed for screening purposes.
The Plan must follow Medicare rules. Medicare rules say that FISH testing code 88120 is only covered for diagnosis code R31.29 when repeat testing is believed to be medically reasonable and necessary and R31.29 is listed as secondary with the primary neoplastic diagnosis.
We looked at the file and Medicare rules. This testing was billed with diagnosis code R31.29 as the primary diagnosis, and no other diagnosis codes were billed, which does not meet Medicare's billing and coding requirements. Based on this information, we decided that Medicare rules for coverage of FISH testing have not been met. Therefore, we decided that the Plan does not have to pay for cytopathology (FISH) testing provided on November 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for durable medical equipment provided by a participating provider on March 18, 2021.

You asked the Plan to waive the coinsurance for durable medical equipment. You say that you have washed your hands clean of this situation. You say that the Plan should not have to pay for this either. The Plan denied your request. The Plan says the correct coinsurance has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for durable medical equipment.

You have been asked to pay a 20% coinsurance of the allowed amount for durable medical equipment. The total allowed amount is $404.98. The total amount you are being asked to pay is $80.96 ($404.98 x 20% =
$80.96). Durable medical equipment falls within the durable medical equipment 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 durable medical equipment provided by a participating provider on March 18, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of skilled nursing facility services from
June 24, 2021, and beyond.
You asked the Plan to pre-approve a continuation of skilled nursing facility services. You say that the enrollee
needs continuation of skilled nursing facility services. The Plan denied your request. The Plan says the enrollee
does not require daily skilled nursing and /or daily skilled rehabilitation services.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.
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 a continuation of skilled nursing facility
services. Our reviewer says the enrollee no longer qualifies for SNF coverage. Our physician reviewer found
the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled
therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent
deterioration of the enrollee's condition. The enrollee's care needs at this point are custodial and, as a practical
matter, can be provided at a lower level of care (ex. home, AL, LTC).
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a continuation of skilled nursing facility services have not been met. Therefore,
we decided that the Plan does not have to pre-approve continuation of skilled nursing facility services from
June 24, 2021, and beyond.
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), the intraoral - complete series of radiographic images (D0210) and the prophylaxis (D1110)
received April 9, 2021, from the out-of-network provider.
You asked the Plan to pay for the dental services. You say that you have been to this dentist in the past and
they have been in-network. The Plan denied your request. The Plan says this provider does not participate with
the Plan's Dental National Medicare Advantage 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. The provider in this case does not participate in the Plan's dental
network. The Plan contract states that if you receive services from a dentist who does not participate in the
Plan's Dental's Medicare Advantage Network then you will be responsible for the full cost of those services and
no payment will be made by the Plan. Therefore, we decided that the Plan does not have to pay for the
comprehensive oral evaluation - new or established patient (D0150), the intraoral - complete series of
radiographic images (D0210) and the prophylaxis (D1110) received April 9, 2021, from the out-of-network
provider.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for the palliative dental treatment. We decided that the Plan does not have
to pay for the adjunctive pre diagnostic test and the 2D oral/facial photographic imaging.

You asked the Plan to pay for the dental services. You say that you feel you should not receive bills for such
high amounts when you pay an additional premium for dental benefits. The Plan denied your request. The Plan
says adjunctive pre diagnostic testing and oral/facial photographic imaging are not services that are covered by
your dental benefits. The Plan also says that they cannot pay for palliative dental care that is provided on the
same day as a periodic oral evaluation and periodontal maintenance. These services were denied correctly.

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 decided that the Plan has to pay their share for the palliative dental treatment.

The Plan denied payment of the palliative (emergency) dental treatment on the basis that the service cannot be
paid for on the same day as periodontal maintenance and a periodic oral exam. This limitation/exclusion is not
stated clearly in the Plan's contract or in any policy documentation forwarded for review. The contract states
that the Plan can cover palliative (emergency) treatment of dental pain twice per calendar year at 50% when
received from an in-network provider. There is no evidence that this service cannot be covered in conjunction
with other specific codes or that you have already met the benefit limits for this service in 2021.

We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of palliative dental treatment have been met. Therefore, we decided that the Plan has to pay the
allowed 50% for the palliative (emergency) dental treatment (D9110) provided on February 27, 2021.

We also decided that the Plan does not have to pay for the adjunctive pre diagnostic test and the 2D
oral/facial photographic imaging.

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
adjunctive pre diagnostic test (D0431) and 2D oral/facial photographic imaging (D0350) provided on February
27, 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the prophylaxis (D1110 x 2), the application of fluoride varnish (D1206 x 2), the bitewing x-rays (D0274), the initial periapical x-ray (D0220), the additional periapical x-ray (D0230), the oral exam (D0120 x 2), and the drugs and medicaments (D9630) provided from January 19, 2020, to December 15, 2020.
You asked the Plan to reimburse you for the dental services. You say that you have been reimbursed for services from this provider in the past. You also say that you were not notified of the provider's Medicare status change. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan also says that payment cannot be made for services performed by 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, dental services performed by a provider who has opted out of Medicare are not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the prophylaxis (D1110 x 2), the application of fluoride varnish (D1206 x 2), the bitewing x-rays (D0274), the initial periapical x-ray (D0220), the additional periapical x-ray (D0230), the oral exam (D0120 x 2), and the drugs and medicaments (D9630) provided from January 19, 2020, to December 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the osseous surgery (D4260) provided on December 30, 2020.
You asked the Plan to pay for osseous surgery. You say that coverage for this service was described in the dental rider information, and this service was covered when you had it done in 2018. The Plan denied your request. The Plan says this service is not covered by your dental 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 pay for the osseous surgery (D4260) provided on December 30, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the additional dose of Prolia.

You asked the Plan to pre-approve the Prolia. You say that you would like reconsideration because the Prolia is medically necessary. The Plan denied your request. The Plan says the documentation does not support that the Prolia has been effective or that it has prevented bone fractures.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary.

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 Prolia. Our reviewer says that the documentation does not support that Prolia is medically reasonable and necessary. Our physician reviewer found the documentation does not show that Prolia has been effective or that it has prevented bone fractures.

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 Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve the additional dose of Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for trimming of dystrophic nails, any number (G0127) and debridement of nails, by any method, 1 to 5 (11720) provided February 9, 2021.
You asked the Plan to pay for the podiatry services. You say that the enrollee is a resident in a nursing home and has an authorization on file for all care at the facility including consultations. Please accept this appeal for reconsideration of the claim. The Plan denied your request. The Plan says the service exceeds the maximum number of units allowed per day. The benefit for this service is included in the payment allowance for another service/procedure that has already been adjudicated.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. The plan must follow Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the MUE for CPT code 11720 and G0127 is 1 per date of service. We have confirmed that CPT codes 11720 and G0127 were bundled as being considered components of the same procedure. Separate payment is not allowed. The records show this processing on check dated 02/23/2021. Based on this information, we decided that Medicare rules for coverage of the podiatry services have not been met. Therefore, we decided that the Plan does not have to pay for trimming of dystrophic nails, any number (G0127) and debridement of nails, by any method, 1 to 5 (11720) provided February 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2740) provided on February 22, 2021.
You asked the Plan to pay for the crown. You say that you were advised that crowns were covered at 50% every five years. The Plan denied your request. The Plan says this service is not covered under your plan. The Plan also says that you made no calls to the Plan prior to this date of service, and you were not enrolled in the dental rider in the month of February 2021.
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 crown (D2740) provided on February 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for manual therapy and massage therapy provided by an out-of-network chiropractor on January 8, 2021, January 14, 2021, and January 19, 2021.
You asked the Plan to pay for the manual therapy and massage therapy. You say that you only had manipulation of the spine done at the appointment. The Plan denied your request. The Plan says manual therapy and massage therapy are not covered services when provided by a chiropractor and in-network providers were available for covered chiropractic services.
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. Medicare rules also 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 covered chiropractic services. The Plan did not pre-approve the item/service at issue. Also, manual therapy and massage therapy are not covered services when provided by a chiropractor. 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 manual therapy and massage therapy provided by an out-of-network chiropractor on January 8, 2021, January 14, 2021, and January 19, 2021.