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

We decided that the Plan does not have to pay for the fillings provided on October 5, 2020.

You asked the Plan to pay for the dental services. You say that you asked for the dental plan to be added. You say that you had a dental plan with the dentist but canceled it because you were told that the enhanced dental plan was better. You say that had you know that the enhanced dental plan was not active that you would have waited to get your fillings done until the following month. You also say that you would like the effective date for the enhanced dental plan to be backdated to October 1, 2020. The Plan denied your request. The Plan says fillings are not listed as a covered service. The Plan says that you did not enroll in the enhanced dental plan in August 2020. The Plan says that you enrolled in the enhanced dental plan on October 19, 2020. The Plan also says that your coverage was not effective until November 1, 2020.

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 fillings are not among those covered under this benefit. The record shows that you opted to not enroll in the enhance dental plan at the time you signed up for the plan. Additionally, the records show that you did not call the Plan to enroll in the enhanced dental plan until October 19, 2020, after you received the services. Therefore, we decided that the Plan does not have to pay for the fillings provided on October 5, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve kyphoplasty (22514).

You asked the Plan to pre-approve kyphoplasty. You say that the services are necessary. The Plan denied your request. The Plan says criteria for kyphoplasty not met. There is no evidence that the fracture is less than 6 weeks old on imaging studies.

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 pre-approve kyphoplasty. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found criteria for kyphoplasty not met. There is no evidence that the fracture is less than 6 weeks old on imaging studies. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of kyphoplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve kyphoplasty (22514).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the F1Heme testing.

You asked the Plan to pay for the F1Heme testing. You say that you would like reconsideration because this testing is medically necessary. The Plan denied your request. The Plan says this service was not billed correctly.

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 F1Heme testing. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found NCCN guidelines for chronic lymphocytic leukemia say that IGHV and Tp53 are useful for prognosis but not a part of this testing.

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 F1Heme testing have not been met. Therefore, we decided that the Plan does not have to pay for the F1Heme testing.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on September 3, 2020.

You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or
emergent, nor were they 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
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 September 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute setting.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for medical supplies provided by a participating provider on July 15, 2020.

You asked the Plan to waive the coinsurance for medical supplies. You say that this should be covered 100%. 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 copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a 20% coinsurance for durable medical equipment/in-network. 

The enrollee has been asked to pay a 20% coinsurance of the allowed amount for medical supplies The total allowed amount is $2,074.80. The total amount you are being asked to pay is $414.96 ($2,074.80 x 20% = $313.96). Medical supplies fall within the durable medical equipment/in-network benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for medical supplies provided by a participating provider on July 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (88280).

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.

The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. 

We looked at the file and Medicare rules. Insufficient medical records were provided to support the service at issue. The plan made multiple requests for additional records and none were received. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (88280).
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the interdental fixation device (21110).

You asked the Plan to pay for this item. You say that this device is medically necessary. The Plan denied your request. The Plan says that the device is not a covered benefit by Medicare.

The Plan must follow Medicare rules. The rules say that Medicare covers treatment for TMJ syndrome only when the condition or symptom is medical in nature. The treatment must also be medically 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 pay for this item. Our reviewer says that this device is medically necessary. Our physician reviewer found that the diagnosis of osteo-arthritis is a medical condition and the treatment of the oral appliance was not related to the care, treatment, filling, replacement or removal of teeth.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this item have been met. Therefore, we decided that the Plan has to pay for the interdental fixation device (21110).

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 surgical services (43610).

You asked the Plan to pay for surgical services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services 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.

In this case, the CPT Code Manual definition of code 43610 is Excision, local; ulcer or benign tumor of stomach.

We find that CPT code 43610 is not supported in the medical record. Specifically, the documentation does not support more than 1 unit of this service being billed. Based on this information, we decided that Medicare rules for coverage of surgical services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (43610).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a primary care provider office visit (99213)
on October 7, 2020.

You asked the Plan to waive the copayment for a primary care provider office visit. You say that the requested
services were part of an annual wellness visit and you should not be billed a copayment. The Plan denied your
request. The Plan says the correct copayment was applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10
copayment for each primary care provider office visit.

A representative of the primary care provider stated that the visit in question was for a hypertension issue.
Diagnostic visits are separate and distinct from a fully covered annual wellness visit. You have therefore been
asked to pay a $10 copayment for a primary care provider office visit. A primary care provider office visit falls
within the "Physician/Practitioner services, including doctor's office visits" 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 primary care provider office visit (99213) on October 7, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. 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 Medicare pays for care in a SNF when the four factors listed above 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on October 27, 2020.

You asked the Plan to pay for the dental service. You say that you asked for a list of in network providers from the plan. You say that this provider was included on the list. You also say that this dentist was nearby. The Plan denied your request. The Plan says the provider in this case was no longer in network on this date of service. The Plan says that the provider's network status does not change the reason for denial in this case. The Plan says that 1 comprehensive oral evaluation is covered every 3 plan years. The Plan also says that the frequency limit for this service has been exceeded.

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 frequency limit of 1 comprehensive oral evaluation every 3 plan years has been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation that you received April 29, 2019. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on October 27, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Extracranial Bilateral Study (93880) provided June 22, 2020.

You asked the Plan to waive the coinsurance for the Extracranial Bilateral Study. You say that you should not be charged the coinsurance. The Plan denied your request. The Plan says the correct cost sharing was applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 40% coinsurance for each Medicare-covered radiological diagnostic service, not including Xrays, performed in a physician's office or at a free-standing facility. 

You have been asked to pay a total of $78.16 ($195.41 allowed amount x 40% coinsurance) for the Extracranial Bilateral Study. An Extracranial Bilateral Study falls within the Other outpatient diagnostic tests - Radiological diagnostic services, not including x-rays. 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 the Extracranial Bilateral Study (93880) provided June 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computerized ophthalmic diagnostic imaging.

You asked the Plan to waive the copayment for the computerized ophthalmic diagnostic imaging. You say that you paid your specialist copayment and you should not have another copayment. The Plan denied your request. The Plan says you were charged the copayment correctly.

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 Outpatient Diagnostic Tests.

You have been asked to pay a $47.69 copayment for the computerized ophthalmic diagnostic imaging. The computerized ophthalmic diagnostic imaging falls within the Outpatient Diagnostic Tests benefit category. The allowed amount for this test is $47.69, which is less than your copayment. 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 the computerized ophthalmic diagnostic imaging.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory testing provided on August 20, 2020.

You asked the Plan to pay for the laboratory testing. 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 the laboratory testing is not supported in the medical record. Specifically, all diagnostic laboratory
testing must be ordered by the physician who is treating the enrollee, that is, the physician who furnishes a
consultation or treats an enrollee for a specific medical problem and who uses the results in the management of
the enrollee's specific medical problem. Review of the file does not support that the testing provided was
ordered/approved by the enrollee's ordering provider. Based on this information, we decided that Medicare
rules for coverage of the laboratory testing have not been met. Therefore, we decided that the Plan does not
have to pay for the laboratory testing provided on August 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee on August 10, 2020, by a non-participating provider.

You asked the Plan to pay for the medical services. You say that you depend upon the hospital staff to verify eligibility, as well as obtaining authorization from the enrollee's insurance. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider and the services were not urgent or emergent, nor were they 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 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 the medical services provided to the enrollee on August 10, 2020, by a non-participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic office visit provided to the enrollee on August 27, 2020.

You asked the Plan to pay for the visit. The Plan denied your request. The Plan says this is not a covered service.

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. 

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the chiropractic office visit provided to the enrollee on August 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Contour Next test strips (A4253).

You asked the Plan to pre-approve Contour Next test strips. You say that the items 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. Medicare rules say that therapeutic continuous glucose monitor (CGM) devices replace a standard home blood glucose monitor and related supplies. Claims for a BGM and related supplies, billed in addition to an approved CGM device (code K0554) and associated supply allowance (code K0553), will be denied. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Contour Next test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve Contour Next test strips (A4253).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the lower partial denture (D5214) provided on August 31,
2020.

You asked the Plan to pay for the dental item. You say that the office manager advised that you had copayment
coverage for a lower partial denture in the sum of $432 less the $50 deductible. You say that you received a
denial for the denture. You say that you were advised by a plan representative that you were previously told the
incorrect information. You also say that you believe that you believe that the Plan should step up and absorb
the copayment that your representative indicated initially. The Plan denied your request. The Plan says the
lower partial denture is not listed as a covered service.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

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. Additionally, there is no record that the provider's office contacted the
Plan in regards to your benefit for a partial denture. Therefore, we decided that the Plan does not have to pay
for the lower partial denture (D5214) provided on August 31, 2020.