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

We decided that the Plan does not have to pay for the core buildup procedures (D2950) provided for tooth #12 and #15 on December 17, 2020.
You asked the Plan to pay for the core buildup procedures. You say that you do not understand why one of these services was partially paid and the other was outright denied. You feel you should be reimbursed for both services. The Plan denied your request. The Plan says you met your annual maximum allowance on the date in question. The Plan paid for some of the services up until the allowed $1,500 was met, but you are responsible for charges that exceed this limit.
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 will cover up to a maximum of $1,500 per year for routine dental services. Though the Plan offers a dental benefit in excess of Medicare coverage, items or services in excess of the $1,500 annual maximum allowance are not covered under this benefit. The Plan provided documentation showing that they have covered $1,500 for dental services for you in 2020, up to and on the date in question.
Therefore, we decided that the Plan does not have to pay for the core buildup procedures (D2950) provided for tooth #12 and #15 on December 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on January 5, 2021.
You asked the Plan to waive the copayment for the specialist office visit. You say that the claim is for a hearing test and you say there is a $0 copayment for a routine hearing exam. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing 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 $45 copayment for services obtained from an in-network specialist, or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's office (as permitted by Medicare rules). You have been asked to pay a $45 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner Services, Including Doctor's Office Visits" benefit category. The record shows you were billed for the office visit and that there was no charge for the hearing test.
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 specialist office visit provided on January 5, 2021.
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 there is no advantage in moving the member from the current acute care hospital to an LTACH.

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 was admitted for hypoxic respiratory failure due to aspiration pneumonia. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal maintenance (D4910), and intraoral periapical radiographic images (D0220, D0230 x3) provided on December 1, 2020.
You asked the Plan to pay for periodontal maintenance, and intraoral periapical radiographic images. You say that you do not agree with the denial and you want the Plan to pay for the services. The Plan denied your request. The Plan says the services at issue are not covered 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
periodontal maintenance (D4910), and intraoral periapical radiographic images (D0220, D0230 x3) provided on December 1, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on December 9, 2020 by an out of network (OON) provider.

You asked the Plan to pay for lab work. 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 lab work provided on December 9, 2020 by an out of network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for a COVID-19 test provided on August 31, 2020.
You asked the Plan to pay for the COVID-19 test. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
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 dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for a COVID-19 test provided on August 31, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) brain, including brain stem (70553) provided February 9, 2021.

You asked the Plan to waive the copayment for the MRI. You say that this MRI brain scan was ordered to diagnose COVID-19 complications and you feel this should be waived. The Plan denied your request. The Plan says this claim was processed and the correct copayment was applied per the Evidence of Coverage.

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 $295 copay for diagnostic radiology other than CT scans. 

You have been asked to pay $295 copay for the MRI. The MRI 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 the magnetic resonance imaging (MRI) brain, including brain stem (70553) provided February 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on May 15, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the claim was received past the allowed 12-month timeframe.
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 physician's services was not filed until January 14, 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 physician's services provided on May 15, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on February 6, 2021, to February 9, 2021
by an OON provider.
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan
denied your request. The Plan says the referring provider is out-of-network. The Plan says that there are innetwork
providers available 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 lab work provided on February 6, 2021, to
February 9, 2021 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2740), prefabricated post and core (D2954) and the root canal (D3320) provided on January 27, 2021.

You asked the Plan to pay for the dental services. You say that you feel you are being charged too much for the dental services and one tooth is not worth $1,000. The Plan denied your request. The Plan says there is a maximum annual allowance of $1,000 for dental services. You have met this limit and are responsible for any additional costs.

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 will pay up to a maximum annual allowance of $1,000 for routine dental services.

Though the Plan offers a dental benefit in excess of Medicare coverage, items or services in excess of the $1,000 annual limit are not covered under this benefit. The Plan provided documentation that this limit has been met for the year. Therefore, we decided that the Plan does not have to pay for the crown (D2740), prefabricated post and core (D2954) and the root canal (D3320) provided on January 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an extremity vein scan (93971) provided on October 10, 2020.
You asked the Plan to pay for an extremity vein scan. You say that this was performed on the right and left sides. The Plan denied your request. The Plan says this should have been billed with one unit for a bilateral service.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied.
In this case, the MUE for CPT code 93971 is 1. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of an extremity vein scan have not been met. Therefore, we decided that the Plan does not have to pay for an extremity vein scan (93971) provided on October 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) provided on January 28, 2021.
You asked the Plan to pay for the services provided. You say that the show was on your wellness plan. The Plan denied your request. The Plan says the vaccine is not covered by your Part B plan.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the services provided. The Plan follows the same rules. The file does not show that you were injured or directly exposed to any illness related to the services provided. Therefore, we decided that the Plan does not have to pay for the Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) provided on January 28, 2021.
Benefits for the services provided may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aid (V5299) received July 6, 2020.
You asked the Plan to pay for the hearing aid (V5299). You say that the hearing provider did not tell you that the purchased hearing aid was not on the copay formulary. The Plan denied your request. The Plan says the devices that were purchased were not on the copay formulary.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids that are on the Plan's copay formulary. We looked at the file, and the Plan's rules. The purchased hearing aid was not on the Plan's copay formulary. Based on this information, we decided that the Plan's rules for coverage of the hearing aid (V5299) have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aid (V5299) received July 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you need this because you are unable to walk. The Plan denied your request. The Plan says you can be treated at a lower level of care.
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 you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program.
While you do require physical and occupational therapy, there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. 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 Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete upper denture (D5110), and the complete lower
denture (D5120) provided on January 28, 2021.

You asked the Plan to pay for the dental services. You say that you made multiple visits to get your dentures
fixed. You say that you called the Plan. You say that the plan representative recommended that you go to a
different supplier and made an appointment for you at the new office. You say that due to the original dentures'
deficiencies, you were under the impression that you had been approved for another prosthesis. The Plan
denied your request. The Plan says dentures are covered once every 5 years. The Plan also says that the
frequency limit 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 and dentures are listed as covered, the
frequency limit has been exceeded. The record shows that the Plan paid for dentures that you received on
November 6, 2019. Therefore, we decided that the Plan does not have to pay for the complete upper denture
(D5110), and the complete lower denture (D5120) provided on January 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on June 18, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an outpatient rehabilitation setting and should have been billed with POS code 57. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on June 18, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 81225, 81240, 81241, 81335 provided on October 20, 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 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 codes 81225, 81240, 81241, 81335 are not supported in the medical record. Specifically, Medicare denies coverage 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 coded 81225, 81240, 81241, 81335 provided on October 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on January 13, 2021.
You asked the Plan to pay for a limited oral evaluation. You say that the service was medically necessary. The Plan denied your request. The Plan says the service is a covered benefit, but you have exceeded the frequency limit of one every Plan year.
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. Based on this information, we decided that the Plan's rules for coverage of a limited oral evaluation have not been met. Specifically, the record shows that you had exceeded the frequency limit prior to this service on January 6, 2021. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on January 13, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the neurology visit provided on October 7, 2020 by an out of
network (OON) provider.

You asked the Plan to pay for the neurology visit. 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 neurology visit provided on October 7, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the continuous passive motility device provided on December 3, 2020.
You asked the Plan to waive the copayment for the continuous passive motility device. You say that you were told the equipment would be 100% covered. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing 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 20% coinsurance for in-network Medicare-covered benefits.
You have been asked to pay $49.42 which is 20% of the allowed amount for the continuous passive motility device. The allowed amount is $247.12. ($274.12 x 20% = $49.42). The continuous passive motility device falls within the "Durable medical equipment (DME) and related 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 the continuous passive motility device provided on December 3, 2020.