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

We decided that the Plan does not have to pay more for the implant maintenance (D6080), the bitewing x-rays
(D0274), and the unspecified preventive service (D1999) provided on September 30, 2020.

You asked the Plan to pay more for the implant maintenance. You say that this dentist is in network. You say
that you were never advised that this dentist was no longer in network. You say that you do not agree with the
implant maintenance fee as you went for a cleaning. You also say that you have a different provider taking care
of your implant related services. The Plan denied your request. The Plan says implant maintenance is not listed
as a covered service. The Plan also says that you did not contact the Plan prior to receiving the service to verify
benefits or provider eligibility.

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, implant maintenance is not among
those covered under this benefit. Therefore, we decided that the Plan does not have to pay more for the implant
maintenance (D6080), the bitewing x-rays (D0274), and the unspecified preventive service (D1999) provided
on September 30, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment from $50 to $20 for the cataract surgery
(66984) provided on December 1, 2020.

You asked the Plan to adjust the copayment. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to
the service provided.

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 $50
copayment for each specialist visit for Medicare-covered services.

You have been asked to pay a $50 copayment for the specialist visit for Medicare-covered services provided.
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 adjust the copayment from $50 to $20 for the cataract surgery (66984) provided on
December 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an orthosis (L0650) provided September 15, 2020.

You asked the Plan to pay for the orthosis. You say that the orthosis was medically necessary. The Plan denied
your request. The Plan says coverage rules have not been met.

The Plan must follow Medicare rules. Medicare rules say that a supplier of a covered item of durable medical
equipment (DME) may not contact an individual by telephone regarding the furnishing of a covered item
except in certain circumstances.

We looked at the file and Medicare rules. The plan has attested in the documentation that the enrollee stated
this orthosis was provided following an unsolicited telephone call. The record shows there are no claims on file
with the ordering physician for this enrollee. Based on this information, we decided that Medicare rules for
coverage of the orthosis have not been met. Therefore, we decided that the Plan does not have to pay for an
orthosis (L0650) provided September 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation provided on December 8,
2020, by an OON provider.

You asked the Plan to pay for the comprehensive oral evaluation. You say that you would like this service to be
covered. The Plan denied your request. The Plan says there is no coverage for when services are rendered by an
OON provider. The Plan also says that you did not contact the Plan prior to the date of service to verify
benefits and provider eligibility.

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 OON. Therefore, we decided that the Plan does not have to pay for the
comprehensive oral evaluation provided on December 8, 2020, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient facility services provided on November 4, 2020.

You asked the Plan to pay for the outpatient facility services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. 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 outpatient facility services provided on November 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the unspecified preventive procedure, by report (D1999) provided May 28, 2020.

You asked the Plan to pay for the personal protective equipment (PPE). You say that the PPE is necessary and should be covered. The Plan denied your request. The Plan says the PPE is 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 pay for the unspecified preventive procedure, by report (D1999) provided May 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Electric Stimulation therapy and the nutria pharmaceutical
blend injections (J3411, 96372, J3415, J1955) provided October 22, 2020.

You asked the Plan to pay for the Electric Stimulation therapy and the nutria pharmaceutical blend injections.
You say that the services were medically necessary. The Plan denied your request. The Plan says the services
were investigational and non-covered.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are 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 Electric Stimulation therapy and the
nutria pharmaceutical blend injections. Our reviewer says that the requested services are not considered
medically reasonable and necessary in this case. Our physician reviewer found these injections and electric
stimulation therapy is not sufficiently supported by current evidence over more conservative and proven
methods of treatment.

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 Electric Stimulation therapy and the nutria pharmaceutical blend injections
have not been met. Therefore, we decided that the Plan does not have to pay for Electric Stimulation therapy
and the nutria pharmaceutical blend injections (J3411, 96372, J3415, J1955) provided October 22, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab work provided by a participating provider on November 12, 2020.

You asked the Plan to waive the copayment for lab work. You say that you were never told that your lab work would have a copayment. The Plan denied your request. The Plan says the correct copayment has been 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 $6 copayment for outpatient diagnostic tests/lab tests. 

You have been asked to pay a $6 copayment for lab work. When additional services are provided during an office visit, additional copayments can be applied; therefore, the correct copayment has been applied. Lab work falls within the outpatient diagnostic tests/lab tests 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 lab work provided by a participating provider on November 12, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided by a participating provider on December 13, 2019.

You asked the Plan to waive the copayment for an emergency room visit. You say that you would like this copayment paid. The Plan denied your request. The Plan says the correct copayment has been 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 $90 copayment for emergency care/in-network.

You have been asked to pay a $90 copayment for an emergency room visit. The correct copayment has been applied to the services that were provided. An emergency room visit falls within the emergency care/in-network 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 an emergency room visit provided by a participating provider on December 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for medical nutrition therapy (97802) provided on November 16, 2020.

You asked the Plan to pay for medical nutrition therapy. You say that this should not require an authorization. The Plan denied your request. The Plan says this code 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 97802 has a bundled relationship with code 99350 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for medical nutrition therapy (97802) provided on November 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on November 24, 2020 by an out of network (OON) provider.

You asked the Plan to pay for lab tests. You say that you are appealing with supporting documents. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this provider is out-of-network with the Plan and the ordering provider is also out-of-network with the Plan.

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 testing provided on November 24, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care services coded 99232 provided from August 24, 2020 to August 26, 2020.

You asked the Plan to pay for the subsequent hospital care 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 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.

We find that CPT code 99232 is not supported in the medical record. Specifically, these services were billed with diagnosis code N18.30 (Chronic kidney disease, stage 3 unspecified). This diagnosis code did not become effective until October 1, 2020. This means that these services were billed with an invalid diagnosis code. Based on this information, we decided that Medicare rules for coverage of the subsequent hospital care services have not been met. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care services coded 99232 provided from August 24, 2020 to August 26, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on January 20, 2020.

You asked the Plan to pay for the ambulance services. You say that the claim was timely. The Plan denied your request. The Plan says the claim was untimely.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.

The record shows that a claim for the ambulance services was not filed until January 25, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on January 20, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the psychotherapy services provided on November 6, 2020.
You asked the Plan to pay for the psychotherapy services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. In this case, the Plan denied psychotherapy services provided to the enrollee in a skilled nursing facility (SNF) due to either an incorrect or invalid place of service. The file shows that the enrollee is in a facility considered to be a SNF. The Plan has failed to provide any information to confirm what kind of facility the enrollee received the services in or if the enrollee was receiving inpatient SNF care when the psychotherapy services took place. The Plan has not provided documentation showing that the psychotherapy services provided were not payable with a place of service of 31. Therefore, we decided that the Plan has to pay for the psychotherapy services provided on November 6, 2020.
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 pay for an eye refraction (92015) provided on November 5, 2020 after an incident.

You asked the Plan to pay for the eye refraction. You say that all of the services provided should be covered because they were part of the care provided after an incident. The Plan denied your request. The Plan says eye refractions are not covered by Medicare, and are only covered by the Plan's supplemental benefit when they are provided in relation to a routine eye exam received from the Plan's supplemental vision provider. The provider in question is not part of the Plan's network for supplemental vision services, and because the refraction was given in relation to an incident, the service was not routine.

Medicare generally does not cover eye refractions. 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 eye refractions when they are provided as part of a routine vision exam received from the Plan's supplemental vision provider.

We looked at the file and the Plan's rules. The eye refraction was provided following an incident and was therefore not considered routine. Based on this information, we decided that the Plan's rules for coverage of the eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for an eye refraction (92015) provided on November 5, 2020 after an incident.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve computed tomographic angiography, upper extremity, with
contrast material(s), including non-contrast images, if performed, and image postprocessing (73206).

You asked the Plan to pre-approve computed tomographic angiography. You say that the medical records
should support medical necessity of the requested service. The Plan denied your request. The Plan says that the
documentation does not support that the enrollee meets the medically necessary criteria for the requested CT
angiogram.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are
medically 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 computed tomographic angiography.
Our reviewer says that the requested items/services are considered medically reasonable and necessary in this
case. Our physician reviewer found in this case, the enrollee has had failed upper extremity access procedures
that required revision and subsequent removal. Now that the lower extremity has failed, the provider seeks to
determine salvage options in the upper extremity. The documentation is sufficient to establish that the upper
extremity CTA is medically reasonable and necessary. The elements of the coverage rule are satisfied.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of computed tomographic angiography have been met. Therefore, we decided that
the Plan has to pre-approve computed tomographic angiography, upper extremity, with contrast material(s),
including non-contrast images, if performed, and image postprocessing (73206).

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 pay for the drugs and medicaments (D9630), and the unspecified
adjunctive procedure (D9999 x 6) provided on November 23, 2020.
You asked the Plan to pay for the dental services. You say that the amount should be covered under your dental
policy because the medication was used by the provider to treat your dental condition, periodontal disease. The
Plan denied your request. The Plan says there is an annual maximum of $1,000 for covered preventive and
comprehensive dental services. The Plan also says that the annual maximum has 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.
Though the Plan offers a dental benefit in excess of Medicare coverage, the annual maximum has been
exhausted. The record shows that the Plan paid $87 for dental services performed on July 13, 2020, and $912
for dental services performed on November 23, 2020. Therefore, we decided that the Plan does not have to pay
for the drugs and medicaments (D9630), and the unspecified adjunctive procedure (D9999 x 6) provided on
November 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on February 18, 2020.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the laboratory services. 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 laboratory services provided on February 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee.

You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that these services are medically necessary.The Plan denied your request. The Plan says that the enrollee has no acute symptoms that require 24-hour inpatient care.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 

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 inpatient psychiatric hospital services. Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary for the enrollee. It is not expected that the enrollee would improve in a reasonable period of time as she does not have suicidal or homicidal ideation noted and no auditory or visual hallucinations. The patient does not show any abnormal behaviors or any symptoms which would require acute treatment. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for inpatient psychiatric hospital services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric hospital services have not been met.Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee.