Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered by the out-of-network
(OON) provider on July 14, 2020.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of
network provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the services at issue in this appeal.
The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay
for these services. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered
by the out-of-network (OON) provider on July 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental recementing on April 26, 2021.
You asked the Plan to pay for the service provided. You say that getting a new rebonding would have been more expensive. The Plan denied your request. The Plan says the service is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. Although the Plan offers a dental benefit in excess of Medicare coverage, the provided services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental recementing on April 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the abdomen.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee had a computed tomography (CT) scan in April of 2021 that showed a stable 2.3 centimeter myelolipoma of the adrenal gland and a one centimeter adrenal adenoma. The records do not support that MRI of the abdomen is reasonable and medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the abdomen.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided on December 8, 2020, by an OON
provider.
You asked the Plan to pay for genetic testing. You say that you would like this paid due to medical necessity.
The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care
physician. The Plan says that the referring provider is also out-of-network.
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 genetic testing provided on December 8, 2020, by
an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the target genomic sequence panel provided on March 19, 2020.

You asked the Plan to pay for the testing services. You say that the testing is no longer considered experimental or investigational. The Plan denied your request. The Plan says the testing is unlikely to impact therapeutic decision-making.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file, and Medicare rules. In this case, the records provided do not indicate the enrollee's stage of cancer or include a treatment plan. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the target genomic sequence panel provided on March 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gradient compression stockings (CPT code A6531).
You asked the Plan to pre-approve the DME. You say that you need compression stockings due to swelling
(edema). The Plan denied your request. The Plan says the Medicare rules have not been met. The Plan must
follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the DME have not been met. Review of the records show that you have
localized edema and Compression Stockings are only covered for Lymphedema with stasis ulcers. Therefore,
we decided that the Plan does not have to pre-approve gradient compression stockings (CPT code A6531).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction (92015) and waive the copayment for the
eye exam (92012) provided on April 2, 2021.
You asked the Plan to pay for the eye refraction and waive the copayment for the eye exam. You say that you
did not expect to be charged this much for these services and you were not advised that the refraction is not a
covered service. The Plan denied your request. The Plan says the copayment applied to your medical eye exam
is correct and refractions are not covered by Original Medicare. A refraction may be covered as part of a
routine eye exam, but these services must be received from a provider in the specified routine vision network.
The provider in this case is part of the Plan's medical network, but not the Plan's specified routine vision
network.
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
copayment for each visit to an ophthalmologist or optometrist for Medicare-covered vision care.
You have been asked to pay $40 for the Medicare-covered eye exam. 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 eye exam (92012) provided on April 2, 2021.
Medicare generally does not cover routine vision and eyewear services, such as eye refractions. However, the
Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's
coverage rules apply in this case. The Plan covers eye refractions when they are provided as part of a routine
vision service received from a provider within the Plan's specified routine vision network.
We looked at the file and the Plan's rules. While the provider in this case is part of the Plan's medical network,
they do not participate in the Plan's routine vision network. In addition, the documentation provided for review
includes a form signed by you acknowledging that Medicare and most insurance companies do not cover the
fee associated with the refraction exam. While the provider is happy to bill your insurance, you as the patient
will be responsible for the $50 refraction fee at the end of the examination. Based on this information, we
decided that the Plan's rules for coverage of an eye refraction have not been met. Therefore, we decided that the
Plan does not have to pay for the eye refraction (92015) and waive the copayment for the eye exam (92012)
provided on April 2, 2021.
Your complaint about potential confusion regarding covered services and a potential disagreement regarding
the billed cost of a non-covered service 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression (support) stockings to be provided by an out-of-network provider.
You asked the Plan to pre-approve the stockings. You say that the enrollee needs compression stockings with an out-of-network provider. The Plan denied your request. The Plan says they called the out-of-network provider and could not confirm if they were able to provide services to the enrollee within a reasonable amount of time or if they possess the compression stockings the enrollee needs. The Plan states they confirmed with the participating provider can provide the service, they have an appointment available within a reasonable time frame and is within the Medicare allowable distance and time therefore the Health Plan does not have a network deficiency.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve compression (support) stockings to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ophthalmological services and does not have to pay for an eye refraction provided on April 26, 2021. You asked the Plan to waive the copayment for ophthalmological services and to pay for an eye refraction. You say that you called to see if you had coverage for these services and you were told you did have coverage. The Plan denied your request. The Plan says the correct copayment was applied to the claim and there is no coverage for an eye refraction.
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 Medicare covered vision services.
Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury.
You have been asked to pay a $50 copayment for ophthalmological services. The ophthalmological services falls within the Medicare covered vision services 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. Also, Medicare does not cover refractive procedures even when done in connection with otherwise covered diagnosis or treatment of illness or injury. Therefore, we decided that the Plan does not have to waive the copayment for ophthalmological services and does not have to pay for an eye refraction provided on April 26, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the physical therapy to be provided by an out-of-network provider.
You asked the Plan to pre-approve the physical therapy. You say that you urgently need to receive water therapy and electrode in your throat because you are struggling to swallow food. The Plan denied your request. The Plan says there is not a gap issue and there are in-network providers available who can supply the requested service. 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the physical therapy to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services provided by a
participating provider on November 20, 2020.
You asked the Plan to waive the copayment for specialist services. You say that you do not agree with this
copayment. The Plan denied your request. The Plan says the correct copayment has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25
copayment for physician/practitioner services/specialist.
You have been asked to pay a $25 copayment for specialist services. Specialist services were provided;
therefore, the correct copayment has been applied. Specialist services fall within the physician/practitioner
services/specialist 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 specialist services
provided by a participating provider on November 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction provided on April 7, 2021. You asked the Plan to pay for eye refraction. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of payment for this service is correct, because eye refractions are only covered when performed by a Plan routine vision care network provider. The Plan also says that they have waived the copayment for the diabetic eye exam, so this denial is only for the eye refraction service.
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 these services when performed by a Plan routine vision care provider. We looked at the file and the Plan's rules. This service was not received from a Plan routine vision network provider. Based on this information, we decided that the Plan's rules for coverage of eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for an eye refraction provided on April 7, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 81230, 81240, 81241, and
81291 provided on April 14, 2021.
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 CPT codes 81230, 81240, 81241, and 81291 are not supported in the medical record. Specifically,
the documentation shows that the enrollee had molecular pharmacogenetic testing. When a laboratory assays
two or more genes in an enrollee in parallel, those two or more genes will be considered part of the same panel.
A panel constitutes a single procedural service, so one code must be submitted for the panel. Review of the file
shows that more than one code was billed for the services rendered.
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 81230,
81240, 81241, and 81291 provided on April 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for hereditary cardiovascular panel testing provided on November 10, 2020.
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because Medicare denies coverage for all cardiovascular risk assessment panels for patients with suspected or documented cardiovascular disease.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal, genetic testing, was requested for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for hereditary cardiovascular panel testing provided on November 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an abutment supported crown (D6058 x3) and pontic
(D6245), provided on April 27, 2021.
You asked the Plan to pay for an abutment supported crown, and pontic. You say that the services should be
covered. 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 an
abutment supported crown (D6058 x3) and pontic (D6245), provided on April 27, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health care provided October 6, 2020, to
December 29, 2020, by a licensed social worker.
You asked the Plan to pay for these services. You say that you believe these services should be covered by the
Plan. The Plan denied your request. The Plan says these services were not rendered by a Medicare eligible
provider.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for services provided by a practitioner who is not a Medicare eligible provider. Your provided was a licensed
social worker. This is not a Medicare eligible provider. Therefore, we decided that the Plan does not have to
pay for outpatient mental health care provided from October 6, 2020, to December 29, 2020, by a licensed
social worker.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a diagnostic digital breast tomosynthesis billed with code G0279.
You asked the Plan to pre-approve the diagnostic digital breast tomosynthesis. You say that the records provided support that payment should be made for the code in dispute. The Plan denied your request. The Plan says the procedure in dispute requires a modifier of 26.
The Plan must follow Medicare rules. Medicare rules say that the TC of radiology services furnished to hospital patients is made to the hospital only. We looked at the file and Medicare rules. The records show that the code was billed without a modifier, meaning that you are requesting payment of the technical component and the professional component. However, the place of service billed on this claim was an outpatient hospital. This means that the hospital is paid for the technical component of the service. If you had wished to bill for the professional component of this service, you would have needed to specify it was just for this component by using the -26 modifier.
Based on this information, we decided that Medicare rules for coverage of the diagnostic digital breast tomosynthesis have not been met. Therefore, we decided that the Plan does not have to pre-approve a diagnostic digital breast tomosynthesis billed with code G0279.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine vision services provided on December 28, 2020.
You asked the Plan to pay for the services provided. You say that the notice of denial is in conflict with the telephone call. The Plan denied your request. The Plan says the claim processed correctly.
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. We looked at the file and the Plan's rules. The file shows that you were reimbursed for the frames and exam you received. A claim for lenses was not submitted to the Plan. Based on this information, we decided that the Plan's rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the routine vision services provided on December 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the exercise equipment purchased on January 20, 2021.
You asked the Plan to pay for the services provided. You say that the benefit should still be offered since the
pandemic is ongoing. The Plan denied your request. The Plan says this is not a covered benefit.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
We looked at the file and the rules. The Plan contract did not include a benefit for exercise equipment at the
time the item was purchased. Based on this information, we decided that the Plan's rules for coverage have not
been met. Therefore, we decided that the Plan does not have to pay for the exercise equipment purchased on
January 20, 2021.