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

We decided that the Plan does not have to pay forthe two resin-based composites, problem focused limited oral evaluation, and amalgam provided .You asked the Plan to pay forthe resin-based composites, problem focused limitedoral evaluation, and amalgam. You say that you would like these services to be covered.The Plan denied your request. The Plan says the treating provider opted out of the Medicare Program. The Plan also says that you were advised that this provider did not accept Medicare, and had opted out several years ago.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan'scoverage 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 a provider who has opted out of Medicare.Therefore, we decided that the Plan does not have to pay forthe two resin-based composites, problem focused limited oral evaluation, and amalgam provided
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician's services for a medical eye exam provided .You asked the Plan to pay forthe physician's services for a medical eye exam.The Plan denied your request. The Plan says you must receive your care from a network provider. In most cases, care you receive from an out-of-network provider will not be covered. If you need medical care that Medicare requires our Plan to cover and the providers in our network cannot provide this care, you can get this care from an out-of-networkprovider. You, or your PCP, must obtain authorization from the Plan prior to seeking care.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 servicesat 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 forphysician's services for a medical eye exam provided
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forthe end-stage renal disease (ESRD) services provided .You asked the Plan to pay forthe ESRD services. You say that the services should be covered.The Plan denied your request. The Plan says the enrollee's claim would becovered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the member's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. Theenrollee ended Medicare Hospice benefits. The services in question were providedbefore the end of that month. Additionally, the record shows that the enrollee was re-enrolled inthe Medicare hospice benefit .Therefore, we decided that the Plan does not have to pay forthe end-stage renal disease (ESRD) services provided .
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services provided .You asked the Plan to pay forthe laboratory services. You say that the provider has no knowledge of the enrollee's coverage prior to the specimen's arrival at the laboratory. You also say that the provider should not be penalized for being out of network as they continue to do their part in providing timely testing and results to the Covid-19 pandemic.The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the member's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay forthe laboratory services provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe complete upper denture (D5110) and complete lower denture (D5120) provided.You asked the Plan to pay forthe dentures. You say that Medicaid paid for the dentures you received , so your Medicare plan should cover the set you got .The Plan denied your request. The Plan says they paid for the dentures . Medicaid billed the Medicare portion of your Plan as Medicare is the primary benefit and Medicaid provides secondary coverage. Dentures can only be covered by your Plan once every 5 years.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 dentures were provided in a frequency greater than that allowed under this benefit. Documentation was provided that shows your Plan paid for a set of complete upper and lower dentures in 2019. Therefore, we decided that the Plan does not have to pay forthe complete upper denture (D5110) and complete lower denture (D5120) provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forintraoperative electroencephalography (EEG) provided .You asked the Plan to pay forintraoperative EEG. You say that this is approved by the American Medical Association as being a useful and necessary part of spinal surgery.The Plan denied your request. The Plan says the denial of payment for this service is correct, because the clinical value and effectiveness of intraoperative EEG in the setting of spinal surgery has not been demonstrated in peer-reviewed literature.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 intraoperative EEG. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found intraoperative EEG is not medically necessary during routine lumbar spinal surgery. Based upon a review of the literature, the intraoperative EEG in the setting of routine lumbar spinal surgery is unproven. Its clinical value has not been established.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of intraoperative EEG have not been met.Therefore, we decided that the Plan does not have to pay forintraoperative electroencephalography (EEG) provided
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided .You asked the Plan to pay forthe ambulance services. You say that the enrollee was treated in place then triaged to BLS.The Plan denied your request. The Plan says these services are not a coveredbenefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services . The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services provided.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay fortissue transfer (14301) provided .You asked the Plan to pay fortissue transfer. You say that this is supported in the records.The Plan denied your request. The Plan says this was not billed with the correct 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.In this case, the CPT Code Manual definition of code 14301 is adjacent tissue transfer or rearrangement,any area; defect 30.1 sq cm to 60.0 sq cm.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 tissue transfer. Our reviewer says that code 14301 is not supported. Our physician reviewer found the operative note describes an advancement of undermined tissue rather than a transfer.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of tissue transfer have not been met.Therefore, we decided that the Plan does not have to pay fortissue transfer (14301) provided .
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF).You asked the Planto pre-approveIRF care. You say that this is medically necessary.The Plandenied your request. The Plansaysthe services can be safely received in other settings.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for non surgical management of a pelvic fracture after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forTTE w/Doppler, complete provided .You askedthe Plan to pay forthe TTE w/Doppler, complete. The Plan denied your request. The Plan says the services required 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 servicesat 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 forTTE w/Doppler, complete provided
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe domiciliary or rest home visits provided  by an OON provider.You asked the Plan to pay forthe domiciliary or rest home visits. You say that the enrollee was not aware, and had no knowledge that the provider was OON.The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that there is no authorization on file for the provided services.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 forthe domiciliary or rest home visits provided  by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forperiodontal maintenance (D4910) provided.You asked the Plan to pay forthe periodontal maintenance. You say that you need coverage of this periodontal cleaning. Your last Plan covered this service.The Plan denied your request. The Plan says this service is not covered by Medicare or by the Plan's supplemental dental 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 forperiodontal maintenance (D4910) provided .
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran inpatient hospital stay.You asked the Plan to waive the copayment foran inpatient hospital stay. You say that you cannot afford 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 $370 copayment for days 1-5 for inpatient hospital care. You had an inpatient hospital stay . Therefore, you are responsible to pay a $370 copayment for days 1-4 . $370 (copayment) x 4 (inpatient days) = $1,480. You have been asked to pay the total copayment amount of $1,480 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital care benefit category. This means that you have been asked to pay the correct amount basedon 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 foran inpatient hospital stay
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay forthe extremity study provided .You asked the Plan to pay forcomplete bilateral noninvasive physiologic studies of upper or lower extremity arteries (93923). You say that the Plan should pay this claim.The Plan denied your request. The Plan says the procedure code did not meet the associated diagnosis code relationship criteria.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate diagnosis code.We find that the diagnosis codes submitted are not valid for this procedure.Based on this information, we decided that Medicare rules for coverage of complete bilateral noninvasive physiologic studies of upper or lower extremity arteries (93923) have not been met.Therefore, we decided that the Plan does not have to pay forthe extremity study provided .
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approvehome health services.You asked the Plan to pre-approvehome health services. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.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 home health services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs.As such, home health nursing services are not shown to be medically necessary or reasonable.We looked at this physician's review, the file, and Medicare rules. Basedon this information, we decided that Medicare rules for coverage of home health services have not been met.Therefore, we decided that the Plan does not have to pre-approvehome health services
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay fora pair of glasses (V2020, V2103) purchased.You asked the Plan to pay forthe glasses. You say that you needed either new lenses or a new eye surgery, and a new pair of glasses is more cost effective than the surgery.The Plan denied your request. The Plan says they paid for a pair of glasses. The Plan can only cover one set of eyewear every two years.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 one pair of eyewear every two years.We looked at the file and the Plan's rules. Documentation shows that the Plan paid for a pair of glasses. Based on this information, we decided that thePlan's rules for coverage of the glasses have not been met.Therefore, we decided that the Plan does not have to pay fora pair of glasses (V2020, V2103) purchased .
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe filling (D2335) for tooth # 9 provided.You asked the Plan to pay forthe dental service. You say that you do not understand why thisdenied. You say that you already pad your $98 copayment on the date of service. You also say that this should be covered.The Plan denied your request. The Plan says 1 filling per tooth is covered every 36 months. The Plan says that the frequency limit has been exceeded. The Plan says that a filling for tooth # 9 that you received was paid.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 fillings are listed as covered, the frequency limit has been exceeded.Therefore, we decided that the Plan does not have to pay forthe filling (D2335) for tooth # 9 provided
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forCxBladder testing (0012M) provided .You asked the Plan to pay forCxBladder testing. You say that this was medically necessary.The Plan denied your request. The Plan says this is not covered.The Plan must follow Medicare rules. Medicare rules say that non-coverage has been reaffirmed for CPT codes 0012M and 0013M for CxBladder.We looked at the file and Medicare rules. The testing at issue is not covered. Based on this information, we decided that Medicare rules for coverage of CxBladder testing have not been met.Therefore, we decided that the Plan does not have to pay forCxBladder testing (0012M) provided .
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran eye exam provided .You asked the Plan to pay forthe eye exam.The Plan denied your request. The Plan says you must receive your care from a network provider. In most cases, care you receive from an out-of-network provider will not be covered. If you need medical care that Medicare requires our Plan to cover and the providers in our network cannot provide this care, you can get this care from an out-of-network provider. You, or your PCP, must obtain authorization from the Plan prior to seeking care.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 Plandid not pre-approve the servicesat 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 foran eye exam provided
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forambulance services provided to the enrollee .You asked the Plan to pay forthe services. You say that this should be paid for.The Plan denied your request. The Plan says payment is not allowed for this service because it is not appropriate for the diagnosis billed.Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 services. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found the review indicates that the documentation did not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for the enrollee. Per the reviewed documentation the enrollee was hemodynamically stable. The documentation did not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport . The documentation did not support that the ambulance transport  was medically reasonable and necessary for the enrollee.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 services have not been met.Therefore, we decided that the Plan does not have to pay forambulance services providedto the enrollee .