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

We decided that the Plan does not have to pay for periodontal scaling and root-planing, per quadrant (D4341) porcelain crown, tooth (D2750) provided January 29, 2021.
You asked the Plan to pay for the dental services. You say that your application for the dental treatment was approved on December 30, 2020. After you received the approval letter you were able to make an appointment. The Plan denied your request. The Plan says the benefit 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. The plan covers up to $225 allowance for comprehensive dental services every quarter. The records show the benefit was provided on January 11, 2021.
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 periodontal scaling and root-planing, per quadrant (D4341) porcelain crown, tooth (D2750) provided January 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical tooth extraction (D7210) provided on November 30, 2020.

You asked the Plan to pay for the extraction. You say that removal of this tooth was medically necessary and should be covered. The Plan denied your request. The Plan says this service is not covered by your 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 for the surgical tooth extraction (D7210) provided on November 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of radiographic images (D0210), 2D oral/facial photographic image obtained intraorally or extraorally (D0350), and oral hygiene instructions (D1330) provided February 15, 2021.
You asked the Plan to pay for the full mouth x-ray, 2D images and oral hygiene instructions. You say that the services should be covered because you don't feel that Plan representatives gave complete information about coverage. The Plan denied your request. The Plan says the full mouth x-ray has been covered previously and is not eligible for coverage. Additionally, the Plan says that 2D images and oral hygiene instructions are not covered under your benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and Medicare rules. In this case the Plan provided documentation showing that full mouth x-rays were previously covered on September 9, 2020. Therefore, you were not eligible for coverage of additional full mouth x-rays at the time of service. Though the Plan offers a dental benefit in excess of Medicare coverage, the remaining 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 complete series of radiographic images (D0210), 2D oral/facial photographic image obtained intraorally or extraorally (D0350), and oral hygiene instructions (D1330) provided February 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on January 9, 2020 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.
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 physician services provided on January 9, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for fundus photography provided on February 8, 2021.

You asked the Plan to waive the copayment for fundus photography. You say that you feel you should not be responsible to pay the charges for fundus photography because you were not aware the doctor was going to do it and you would have denied the service if you had known. 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 $25 copayment for outpatient diagnostic procedures and tests. 

You have been asked to pay a $25 copayment for fundus photography. Fundus photography falls 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 copayment for fundus photography provided on February 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided on November 5, 2020.
You asked the Plan to pay for a lumbar-sacral orthosis. You say that the item at issue is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met because the item at issue is not medically necessary.
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 a lumbar-sacral orthosis. Our reviewer says
that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found that the available documentation in the case file does not support that the requested lumbar-sacral orthosis was medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by Medicare. An appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for a lumbar-sacral orthosis have been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is insufficient documentation of an appropriate evaluation of the enrollee and insufficient documentation of a credible physical examination of the back. 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 lumbar-sacral orthosis have not been met. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided on November 5, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve knee replacement surgery to be provided on an inpatient basis.

You asked the Plan to pre-approve acute inpatient hospital care. You say that this is a total knee replacement and needs to be inpatient. The Plan denied your request. The Plan says that the denial of authorization for inpatient level of care is correct, because this surgery can be performed in an outpatient setting.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.

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 acute inpatient hospital care. Our reviewer says that you meet the Medicare criteria to have this surgery at the inpatient hospital level of care. Our physician reviewer found the documentation is evidence regarding significant comorbidities that would relate to increased risks for post-operative complications necessitating an inpatient stay. The combination of obesity, hypertension, asthma, and varicose veins significantly increase the overall risk of perioperative complications. These include risks related to cardio-pulmonary and potential for deep venous thrombosis/pulmonary embolus. Performing the procedure as a pre-scheduled inpatient (with enhanced monitoring and closely enforced prophylactic/active treatment protocols) should greatly diminish such risks. The records do show that the treating physician would reasonably expect your necessary hospital care to span at least 2 midnights. Therefore, the request for inpatient stay for knee replacement surgery is medically reasonable and necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pre-approve knee replacement surgery to be provided on an inpatient basis.

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on October 15, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the drug testing. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.

Therefore, we decided that the Plan does not have to pay for the drug testing provided on October 15, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for vision services provided on November 5, 2020 by an out of network (OON) provider.

You asked the Plan to pay for vision services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained for these 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 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 vision services provided on November 5, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory test provided by an out-of-network provider on February 3, 2021.

You asked the Plan to pay for the laboratory test. You say that the medical records show the necessity of the service and the claim should be considered for payment. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not approved in advance.

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 laboratory test provided by an out-of-network provider on February 3, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on January 14, 2021.

You asked the Plan to waive the copayment for inpatient hospital care. You say that you had outpatient surgery and was charged for an overnight stay. The Plan denied your request. The Plan says the copayment you are being charged is correct.

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 $325 copayment for inpatient hospital care. Your contract with the Plan also clearly says that enrollees must pay a $0 copayment per day, for additional hospital days.

You have been asked to pay a $325 copayment for inpatient hospital care. The records show that you were admitted into the hospital in the morning and discharged approximately ten (10) hours later. An inpatient is a person who has been admitted to a hospital for bed occupancy for purposes of receiving inpatient hospital services. The EOC confirms that $325 is the required copayment for this service. 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 inpatient hospital care provided on January 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that the orthotics is for the resting of your toes from a stroke. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a vision exam provided on
February 5, 2021.
You asked the Plan to waive the copayment for the vision exam. You say that you had a routine eye exam for revised eyeglasses. The Plan denied your request. The Plan says the vision exam was for addressing night vision trouble and checking for open-angle glaucoma (POAG) along with moderate cataract and narrow angles. Those services are not considered routine eye services.
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 $45 copayment for Medicare-covered outpatient visit for services to diagnose and/or treat a disease or condition of the eye.
You have been asked to pay a $45 copayment for the vision exam. the vision exam falls within the Medicare-covered outpatient visit for services to diagnose and/or treat a disease or condition of the eye benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a vision exam provided on February 5, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for paramedic insert provided to the enrollee on March 13, 2017.
You asked the Plan to pay for paramedic intercept. You say that this bill should be paid by the Plan. The Plan denied your request. The Plan says in situations where a BLS entity provides the transport of the beneficiary and an ALS entity provides a service that meets the fee schedule definition of an ALS intervention (e.g., ALS assessment, Paramedic Intercept services, etc.), the BLS supplier may bill Medicare the ALS rate provided that a written agreement between the BLS and ALS entities exists prior to submitting the Medicare claim.
Providers/suppliers must provide a copy of the agreement or other such evidence (e.g., signed attestation) as determined by their A/B MAC (A) or (B) upon request. A/B MACs (A) and (B) must refer any issues that cannot be resolved to the regional office. Medicare does not regulate the compensation between the BLS entity and the ALS entity. If there is no agreement between the BLS ambulance supplier and the ALS entity furnishing the service, then only the BLS level of payment may be made. In this situation, the ALS entity's services are not covered, and the beneficiary is liable for the expense of the ALS services to the extent that these services are beyond the scope of the BLS level of payment.
The Plan must follow Medicare rules. The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the services are furnished under a contract with a qualified basic life support (BLS), the provision of medically necessary supplies and services, with a volunteer ambulance company. In addition, State law must not allow the volunteer ambulance company to bill for the transport or BLS services. The Plan has confirmed that the provider does not have a contract with the company that provided the transport services. Therefore, we decided that the Plan does not have to pay for paramedic insert provided to the enrollee on March 13, 2017.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical placement of implant body: endosteal implant (D6010) provided February 1, 2021.
You asked the Plan to pay for the endosteal implant. You say that you required an implant due to the Plan's previous denial of crown and the Plan should cover the service. The Plan denied your request. The Plan says this service 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 surgical placement of implant body: endosteal implant (D6010) provided February 1, 2021.
Your complaint about concerns about previous dental coverage, how that coverage has affected your teeth and the high cost of the dental services is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more than the benefit allowance for tint (V2744), spherocylindrical (V2303), progressive lens (V2781), and lens polycarbonate (V2784) provided on
March 2, 2021.
You asked the Plan to pay more than the benefit allowance for tint (V2744), spherocylindrical (V2303), progressive lens (V2781), and lens polycarbonate (V2784). The Plan denied your request. The Plan says the
Plan applied the $100 vision allowance benefit to the claim, which exhausted this benefit, and you are responsible for any non-covered items.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. The file shows the Plan applied the $100 vision allowance to the claim and you are responsible for any non-covered items. Therefore, we decided that the Plan does not have to pay more than the benefit allowance for tint (V2744), spherocylindrical (V2303), progressive lens (V2781), and lens polycarbonate (V2784) provided on March 2, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on July 11, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that the laboratory services are not supported in the medical record. Specifically, when a laboratory assays two or more genes in a patient in parallel, those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one CPT code must be submitted for the panel. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on July 11, 2020.