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

We decided that the Plan does not have to pay for add tooth to existing partial denture (D5650) provided on October 21, 2019.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says the service is not a covered benefit under the plan.
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. This service is not listed in your EOC as a covered benefit; therefore, it is not covered. Therefore, we decided that the Plan does not have to pay for add tooth to existing partial denture (D5650) provided on October 21, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Omnipod dash 5 pack.
You asked the Plan to pre-approve Omnipod dash 5 pack. You say that the requested medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Omnipod dash 5 pack.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for somatosensory testing (95938), needle electromyography (95870) and neuromuscular junction testing (95937) provided on November 12, 2019.
You asked the Plan to pay for the somatosensory testing, needle electromyography and neuromuscular junction testing. You say that you provide technicians and bill for the technical component of nerve monitoring while a physician provides the interpretation. The Plan denied your request. The Plan says that the professional interpretation of a diagnostic test must be separately billed with modifier 26 by the interpreting physician.
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 code 95938, 95870 and 95937 is supported in the medical record. Specifically, the record indicates that the professional and technical components of these services were not rendered by the same provider. It is appropriate for the technical component to be billed separately in this case. Based on this information, we decided that Medicare rules for coverage of the somatosensory testing, needle electromyography and neuromuscular junction testing. have been met. Therefore, we decided that the Plan has to pay for somatosensory testing (95938), needle electromyography (95870) and neuromuscular junction testing (95937) provided on November 12, 2019.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to pay for emergency department services provided on August 20, 2019 through August 22, 2019.
You asked the Plan to pay for the emergency department services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that the claim lacks information or has a submission error which is needed for adjudication.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan failed to forward sufficient information to substantiate the reason for denial of services. Therefore, we decided that the Plan has to pay for emergency department services provided on August 20, 2019 through August 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), the periapical x-ray (D0220), and the resin based composite for 4 surfaces on an anterior tooth (D2335) for teeth # 24 and 25 provided on October 24, 2019.
You asked the Plan to pay for the dental services. You say that you were never give the cost of service form from your dentist. You say that you had no record that you reached your $1,000 limit. You also say that you cannot afford to pay for the services. The Plan denied your request. The Plan says the annual maximum of $1,000 has been reached while processing the claim for the services you received.
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, annual maximum of $1,000 was reached during the processing of the claim for October 24, 2019.
Date of Service
Billed Amount
Allowed Amount
Plan Paid
2/28/2019
$880
$360
$360
3/13/2019
$704
$279
$279
3/28/2019
$704
$276
$276
10/24/2019
$836
$85
$85
TOTAL:
$1,000
Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), the periapical x-ray (D0220), and the resin based composite for 4 surfaces on an anterior tooth (D2335) for teeth # 24 and 25 provided on October 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT) for prostate cancer treatment.
You asked the Plan to pre-approve the PBRT. You say that you believe that this treatment will be superior to other radiation treatment options. The Plan denied your request. The Plan says the use of PBRT for prostate cancer is not proven in clinical trials to be superior to standard therapies.
"The Plan follows Medicare rules. Medicare rules say that PBRT may be covered for prostate cancer when certain conditions are met. 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 PBRT. Our reviewer says that the requested PBRT is not considered reasonable and necessary. Our physician reviewer found the American Society of Radiation Oncology finds that there is no clear evidence that proton beam therapy for prostate cancer offers any clinical advantage over other forms of definitive radiation therapy. Clinical trials are necessary to establish a possible advantage of this expensive therapy. The clinical benefits of proton therapy over traditional radiation are currently being studied in clinical trials. To date, there are no compelling data to suggest that proton therapy is superior to or more beneficial than IMRT/IGRT. The generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, and to not routinely offer it to patients. 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 PBRT have not been met. Therefore, we decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT) for prostate cancer treatment.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on May 10, 2019 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that these services were medically necessary. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained for these services. The plan says that there are in-network providers available.
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 has network providers available who can provide 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 May 10, 2019 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from July 22, 2019 to July 24, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the services that the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not have skilled nursing or skilled rehabilitation needs.
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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 the skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from July 22, 2019 to July 24, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from June 7, 2019 to
June 28, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee
did not have skilled nursing or skilled rehabilitation needs.
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 pay for the skilled nursing services. Our reviewer
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily
skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 the skilled nursing services have not been met. Therefore, we decided that the
Plan does not have to pay for the skilled nursing services provided from June 7, 2019 to June 28, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services and supplies (36415, 80069, 85014, 85018, 87086, 87088, 87186, 93005) provided September 24, 2019.
You asked the Plan to pay for the laboratory services and supplies. You say that the services were medically necessary. The Plan denied your request. The Plan says payment for these services is bundled with the primary procedure.
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 CPT codes at issue here are not supported in the medical record. Specifically, Medicare say supplies and services used during an outpatient procedure are included in the PPS payment and are not payable separately. Based on this information, we decided that Medicare rules for coverage of the laboratory services and supplies have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services and supplies (36415, 80069, 85014, 85018, 87086, 87088, 87186, 93005) provided September 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for vision services provided on October 16, 2019 by an out of network (OON) provider.
You asked the Plan to pay for vision services. You say that the Plan has been paying for these services all year. You say that now you are getting a letter saying your doctor is out-of-network. The Plan denied your request. The Plan says no prior authorization was obtained for these services. The Plan says that there are in-network 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 has network providers available who can provide 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 October 16, 2019 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided on December 24, 2018.
You asked the Plan to pay for the ambulance services. You say that this claim should be the enrollee's responsibility. The Plan denied your request. The Plan says you did not transport the enrollee.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on December 24, 2018. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for services provided on December 24, 2018.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-ray provided on August 22, 2019.
You asked the Plan to waive the copayment for the x-ray. You say that you went in-network to avoid additional charges. You say you have had the same service done without a charge. The Plan denied your request. The Plan says you have been charged 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 $50 copayment for x-ray services performed in an outpatient hospital setting. You have been asked to pay a $50 copayment for the x-ray. The x-ray falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows you were billed by the outpatient hospital.
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 x-ray provided on August 22, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from May 24, 2019 to May 25, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee received no skilled nursing services during these dates of service.
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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 the skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from May 24, 2019 to May 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the detailed and extensive oral evaluation (D0160), the panoramic x-ray (D0330), and the core build up (D2950) provided on October 23, 2019.
You asked the Plan to pay for the dental services. You say that the provider's office advised that you had $1,000 of dental coverage. You say that you thought the services would be completely covered. You also say that you received a bill for $540. The Plan denied your request. The Plan says the detailed and extensive oral evaluation is not a covered service. The Plan says panoramic x-rays are not a covered service. The Plan also says core build up is not 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 dental services you received are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the detailed and extensive oral evaluation (D0160), the panoramic x-ray (D0330), and the core build up (D2950) provided on October 23, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued SNF services for the enrollee.
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says the enrollee no longer has skilled therapy or nursing service needs.
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. Continued services beyond February 24, 2020 were requested for 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 continued services. Our physician reviewer found that the enrollee is independent with activities of daily living. This enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment. He does not have a tracheostomy tube, enteral feedings, complex wound care or other SNF level skilled nursing need. His catheter does not require a SNF admission. The enrollee is at a high functional level that does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment. He does not require these skilled nursing or skilled therapy services (or a combination of these services) on a daily basis. As a practical matter this enrollee does not require the necessary services on 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 continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a fine needle aspiration biopsy, including ultrasound guidance (10005) provided on September 20, 2019.
You asked the Plan to waive the copayment for a fine needle aspiration biopsy, including ultrasound guidance. You say that you had a follow up procedure where the same test was run for the second time due to failure to get enough tissue. You state you should not be held responsible for the co-pay for this procedure twice. The Plan denied your request. The Plan says outpatient hospital services have a $285 copay for each surgical or observation room service you get in an outpatient hospital.
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 $285 copayment for outpatient hospital services. You have been asked to pay a $285 copayment for a fine needle aspiration biopsy, including ultrasound guidance. This service falls within the outpatient hospital 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. Therefore, we decided that the Plan does not have to waive the copayment for a fine needle aspiration biopsy, including ultrasound guidance (10005) provided on September 20, 2019.