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

We decided that the Plan does not have to pay for the consultation provided on November 16, 2020.
You asked the Plan to pay for the consultation. You say that you were not aware that this service would not be covered. The Plan denied your request. The Plan says this service is not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the consultation provided on November 16, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visits and psychotherapy services provided from January 28, 2020 to February 25, 2020.
You asked the Plan to pay for the office visits and psychotherapy 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. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the office visits and psychotherapy services provided from January 28, 2020 to February 25, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on September 22, 2020 by an out of network (OON) provider.

You asked the Plan to pay for laboratory services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for laboratory services provided on September 22, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve interspinous process decompression (22869).

You asked the Plan to pre-approve interspinous process decompression. You say that the requested services are a medical necessity for you. The Plan denied your request. The Plan says rules for interspinous process decompression have not been met.

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 interspinous process decompression. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that interspinous process devices remain experimental in spinal surgery. More research is needed to show the safety and efficacy of the devices.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of interspinous process decompression have not been met. Therefore, we decided that the Plan does not have to pre-approve interspinous process decompression (22869).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0482 provided on May 20, 2020.
You asked the Plan to pay for the drug 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. In this case, the CPT Code Manual definition of code G0482 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed. We find that CPT code G0482 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0482 provided on May 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on January 5, 2021 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for physician services provided on January 5, 2021 by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the physical therapy (PT) visits (97110) provided January 5, 2021 to January 12, 2021.
You asked the Plan to waive the copayment for the PT visits. You say that no one was clear with you about a copay and you feel that this should not fall back on you. The Plan denied your request. The Plan says the 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 $15 copayment for physical therapy at an outpatient hospital setting. You have been asked to pay $25 for the PT visits. The PT visits falls within the Outpatient rehabilitation 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 the physical therapy (PT) visits (97110) provided January 5, 2021 to January 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on October 5, 2020 by an out of network (OON) provider.
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 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 requested provider in this case is not a network provider with the Plan. The referring provider 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 laboratory services provided on October 5, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate for the comprehensive oral evaluation (D0150) the panoramic x-ray (D0330), the unspecified preventive service (D1999), and the drugs or medicaments (D9630) provided from January 13, 2021, to January 14, 2021.
You asked the Plan to pay the in network rate for the unspecified preventive service and drugs or medicaments. You say that you were advised by a plan representative that the provider in this case was in network. You also say that these services should be covered. The Plan denied your request. The Plan says unspecified preventive service is not listed as a covered service. The Plan says that drugs or medicament is not listed as a covered service either.
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 the in network rate for the comprehensive oral evaluation (D0150) the panoramic x-ray (D0330), the unspecified preventive service (D1999), and the drugs or medicaments (D9630) provided from January 13, 2021, to January 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and testing services provided on November 28, 2020 by an out of network (OON) provider.
You asked the Plan to pay for these services. You say that you were not aware that authorization was needed. 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 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 office visit and testing services provided on November 28, 2020 by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for an emergency room visit (99283) provided on January 1, 2021.
You asked the Plan to pay for an emergency room visit. You say that the enrollee had two visits on this date. The Plan denied your request. The Plan says this cannot be paid separately.
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, we have confirmed that code 99283 has a bundled relationship with code 99285 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for an emergency room visit (99283) provided on January 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the complete upper denture (D5110), the complete lower denture (D5120), and the unspecified removable prosthodontic procedure (D5899x 2) provided on December 31, 2020.
You asked the Plan to pay more for the dental services. You say that your previous dentures had lasted 40 years. You say that they wore out to the point that they broke in half. You say that you had to get new dentures. You say that you cannot eat without them. You also say that you are on a fixed income and are unable to pay the full price. The Plan denied your request. The Plan says dentures have a 70% coinsurance when performed in network. The Plan says that unspecified removable prosthodontic procedure is not listed as a covered service. The Plan also says that the claim was processed correctly.
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, there is a 70% coinsurance when you receive these services in network.
CPT Code
Billed Amount
Allowed Amount
Coinsurance
Plan Paid
Your Responsibility
D5110
$1,050
$960
$672
$288
$672
D5120
$1,050
$843
$590.10
$252.90
$590.10
D5899
$530
$0
$0
$0
$530
D5899
$530
$0
$0
$0
$530
TOTAL:
$2,332.10
Additionally, unspecified removable prosthodontic procedures are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay more for the complete upper denture (D5110), the complete lower denture (D5120), and the unspecified removable prosthodontic procedure (D5899x 2) provided on December 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the observation care services provided on June 25, 2019.
You asked the Plan to pay for the services provided. You say that the code was adjusted and resubmitted. The Plan denied your request. The Plan says the claim was received past the allowed time frame.
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 services at issue was not filed until December 18, 2020. 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 the observation care services provided on June 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit provided on September 8, 2020.
You asked the Plan to pre-approve the office visit. You say that you cannot afford this treatment. The Plan denied your request. The Plan says Medicare does not cover non-manipulative services provided by chiropractors.
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 office visit at issue is not manual manipulation of the spine. Office visits, when provided by a chiropractor are not covered. Therefore, we decided that the Plan does not have to pre-approve the office visit provided on September 8, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 11, 2020.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the code does not meet the requirements for approval.

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 99053 is service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service. We find that CPT code 99053 is a bundled code. Payment for covered services is always bundled into payment for other services. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the medical services provided on November 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140), deep sedation/general anesthesia - first 15 minutes (D9222), deep sedation/general anesthesia - each subsequent 15-minute increment (D9223), and therapeutic parenteral drugs, two or more administrations, different medications (D9612) provided December 21, 2020.

You asked the Plan to pay for the tooth extractions, deep sedation/general anesthesia, and therapeutic parenteral drugs. You say that you thought the services were covered and need help with the cost. The Plan denied your request. The Plan says the services on this date of service were covered up to your $2,000 annual maximum therefore you are responsible for the remaining costs. Additionally, therapeutic parenteral drugs are not listed as a covered service under your dental benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the tooth extractions, deep sedation/general anesthesia and therapeutic parenteral drugs when the services are medically necessary and reasonable. 

We looked at the file and Medicare rules. The Plan provided documentation that at the time of the services you had $1,830 remaining in your dental annual maximum. The Plan provided coverage on this date of service for your tooth extractions up to your $2,000 annual maximum. Therefore, the Plan has provided coverage in accordance with the Plan contract. Based on this information, we decided that the Plan does not have to pay for the remaining extractions, erupted tooth or exposed root (elevation and/or forceps removal) (D7140), deep sedation/general anesthesia - first 15 minutes (D9222), deep sedation/general anesthesia - each subsequent 15-minute increment (D9223), and therapeutic parenteral drugs, two or more administrations, different medications (D9612) provided December 21, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services rendered from October 26, 2020 to October 28, 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 not billed with an appropriate PDPM code.

The Plan must follow Medicare rules. The rules say that SNFs billing on Type of Bill (TOB) 21X and rural hospital (non-CAH) swing-bed providers billing on TOB 18X (subject to SNF PPS) claims must be billed with a Patient Driven Payment Model (PDPM) revenue code.

We looked at the file and Medicare rules. The file shows that the claim was not billed with a PDPM revenue code. 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 pay for the skilled nursing services rendered from October 26, 2020 to October 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the personal protective equipment (D1999 x 2) provided from October 2, 2020, to October 9, 2020.
You asked the Plan to reimburse you for the personal protective equipment. You say that you were not made aware that this provider was out of network. You say that you have seen this dentist twice and was still not notified until you received a bill for $405. You also say that you would like these claims paid in full. The Plan denied your request. The Plan says personal protective equipment is not listed and therefore 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 personal protective equipment is not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the personal protective equipment (D1999 x 2) provided from October 2, 2020, to October 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the chemotherapy administration rendered on December 1, 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 procedure code 96413 is not supported.
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 96413 is chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug. We find that CPT code 96413 is not supported in the medical record. Specifically, the documentation shows the enrollee received intravenous infusion services and there is a more appropriate code for these services. 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 pay for the chemotherapy administration rendered on December 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation of the sacroiliac joint.
You asked the Plan to pre-approve the requested services. You say that the enrollee's pain is still bad even with conservative treatments. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. Radiofrequency ablation used for sacroiliac joint pain is considered not medically necessary Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation of the sacroiliac joint.