Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional skilled nursing home health visits.
You asked the Plan to pre-approve the additional skilled nursing home health visits. The Plan denied your request. The Plan says no recent records were provided from the skilled nursing visits regarding the treatment care plan for the enrollee's wound and the medical reason for the skilled nursing visit.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.
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 additional skilled nursing home
health visits. Our reviewer says that the frequency of requested home health nursing visits is not shown to be
medically necessary or reasonable. Our physician reviewer found there are no interim home health records
showing care is needed or provided.
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 additional skilled nursing home health visits have not been met. Therefore,
we decided that the Plan does not have to pre-approve additional skilled nursing home health visits.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic activities provided on May 21, 2020.
You asked the Plan to pay for therapeutic activities (97530). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the records indicate that the service was performed by an occupational therapist assistant in a home health setting.
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 97530 is therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes We find that CPT code 97530 is not supported in the medical record. Specifically, this service was performed in the enrollee's home. Procedures should be reported with the most comprehensive CPT code that describes
the services performed. There is a more appropriate code for the service. Based on this information, we decided that Medicare rules for coverage of therapeutic activities have not been met. Therefore, we decided that the Plan does not have to pay for therapeutic activities provided on May 21, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided from February 22, 2021, through March 2, 2021.
You asked the Plan to pay for the physical therapy services. The Plan denied your request. The Plan says the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the physical therapy services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physical therapy services provided from
February 22, 2021, through March 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids (V5261, V5299) provided January 7, 2021.
You asked the Plan to pay for the hearing aids. You say that you would like the hearing aids covered. The Plan denied your request. The Plan says the hearing aids were not purchased through the Plan's specified hearing aid vendor and therefore are not covered.
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 only when provided by the Plan's specified hearing provider. We looked at the file and the Plan's rules. In this case the hearing aids were not purchased through the Plan's hearing aid vendor. 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. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids (V5261, V5299) provided January 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two fixed bridges comprised of pontics (D6240) for
teeth #2, #3, #4, #29, #30 and #31, and retainer crowns (D6751) for teeth #1, #5, #28 and #32.
You asked the Plan to pre-approve the bridges. You say that the bridges are necessary. The Plan denied your
request. The Plan says the bridge requests are beyond the scope of the policy benefit coverage. Only a single
upper front tooth or two adjacent lower front teeth can be considered for replacement with a fixed bridge.
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. Provisions for a fixed
prosthesis may be considered when there is one missing maxillary anterior tooth, or two missing mandibular
anterior teeth and the enrollee's overall status would justify consideration. Fixed prosthetic appliances are not a
benefit when there is one or more missing posterior teeth in the same arch.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested bridges are each intended
to replace three adjacent teeth, which is beyond the scope of the Plan's policy coverage. Therefore, we decided
that the Plan does not have to pre-approve two fixed bridges comprised of pontics (D6240) for teeth #2, #3, #4,
#29, #30 and #31, and retainer crowns (D6751) for teeth #1, #5, #28 and #32.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the abutment supported porcelain/ceramic crown (D6058)
and extraction (D7210) provided on February 15, 2021 by an OON provider.
You asked the Plan to pay for the abutment supported crown and extraction. You say that you were advised
that these services were covered, and that you could go to any provider. You also say that the agent never
specified you had to receive services in-network. The Plan denied your request. The Plan says services
performed by an OON provider are not covered because your healthcare plan does not have OON 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, you are responsible for 100% of the
cost for dental services received OON. Therefore, we decided that the Plan does not have to pay for the
abutment supported porcelain/ceramic crown (D6058) and extraction (D7210) provided on February 15, 2021
by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a targeted genomic laboratory panel (0239U) provided on
February 4, 2021, by an OON provider.
You asked the Plan to pay for a laboratory test. You say that you are an independent lab that does not have
direct access or interaction with patients prior to the time of service and is therefore not responsible for
obtaining prior authorization. The Plan denied your request. The Plan says services were provided by an out-ofnetwork
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. The records provided for review do not show that the services at issue were urgent or
emergent. 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 a targeted genomic laboratory panel (0239U) provided on
February 4, 2021, by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgery services provided by an out-of-network provider on October 23, 2020.
You asked the Plan to pay for the surgery services. You say that the services are medically necessary and the codes should be considered for payment. The Plan denied your request. The Plan says the non-urgent services are not authorized because the provider is a non-network provider with the Plan.
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 surgery services provided by an out-of-network provider on October 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal scaling and root planing (D4341 x2) provided on
March 1, 2021.
You asked the Plan to pay for periodontal scaling and root planing. You say that the service at issue should be
covered. The Plan denied your request. The Plan says the service at issue 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 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 scaling and root planing (D4341 x2) provided on March 1, 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.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets LTACH admission criteria under CMS guidelines. You say that the enrollee is stable and suitable for transfer. You say that the enrollee's physicians believe the enrollee cannot be adequately cared for in his current condition at a skilled nursing facility, as he requires direct daily physician assessment, which cannot be performed remotely. The Plan denied your request. The Plan says the guidelines for coverage of LTACH care have not been met. The Plan says that the care needed can be provided in the current inpatient hospital.
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. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being
offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis 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.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI provided on February 17, 2021.
You asked the Plan to waive the copayment for an MRI. You say that you thought that services would be fully covered. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $300 copayment for MRI's. You have been asked to pay the allowed amount of $273.14, which is less than the $300 copayment for an MRI. An 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 an MRI provided on February 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for hereditary cardiovascular screening testing provided on September 9, 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 - except the basic lipid panel - for symptomatic 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 above, 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 screening testing provided on September 9, 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 March 4, 2021.
You asked the Plan to pay for a limited oral evaluation. You say that you could not wait to see your in-network provider and you want the Plan to pay for the service. The Plan denied your request. The Plan says the service at issue 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 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, services were provided by an out-of-network provider without prior authorization. The Plan has contracted providers available to provide these services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on March 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on July 10, 2020.
You asked the Plan to pay for lab tests. 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 denied
coverage for all cardiovascular risk assessment panels - except the basic lipid panel - for symptomatic patients
with suspected or documented cardiovascular/respiratory disease.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific
lab services is required for covered lab services.
We looked at the file and Medicare rules. The documentation submitted does not include a physician order or
clear intent to order these specific lab services for covered purposes. Based on this information, we decided that
Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have
to pay for laboratory testing provided on July 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy, anterior tooth (D3310) received May 27, 2020.
You asked the Plan to pay for the endodontic therapy. You say that the Plan covers root canals, therefore this service should be covered. The Plan denied your request. The Plan says the requested service was not covered under your 2020 supplemental 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. 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 endodontic therapy, anterior tooth (D3310) received May 27, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic mammogram and breast tomosynthesis you received at an outpatient hospital facility on February 2, 2021.
You asked the Plan to waive the copayment for the diagnostic mammogram and breast tomosynthesis. You say that you have never had to pay for a mammogram before. The Plan denied your request. The Plan says you were charged this copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for x-rays in an outpatient hospital facility. You have been asked to pay a $50 copayment for the diagnostic mammogram and breast tomosynthesis. According to your Evidence of Coverage, only screening mammograms have no copayment. The mammogram
you received was not a screening mammogram- it was ordered and performed as a diagnostic mammogram. That is why the copayment applies. The diagnostic mammogram and breast tomosynthesis fall within the x-rays in an outpatient hospital facility 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 diagnostic mammogram and breast tomosynthesis you received at an outpatient hospital facility on February 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling and root planing of four or more teeth per quadrant (D4341) for the upper left and upper right quadrants.
You asked the Plan to pre-approve the scaling and root planing services. You say that these services are medically necessary. The Plan denied your request. The Plan says there are less than four teeth in the requested quadrants, which means that periodontal scaling and root planing of four or more teeth per quadrant cannot be considered. Another procedure code may be more appropriate for consideration.
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 scaling and root planing services when the services are medically necessary and reasonable. 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 scaling and root planing services. Our reviewer says that the documentation does not support the need for coverage of scaling and root planing for four or more teeth for the requested quadrants. Our physician reviewer found the enrollee's dental record indicates the presence of two implants in the upper right quadrant and two implants in the upper left quadrant. No other natural teeth appear to be present. There appears to be a fixed complete denture. Being that there are
less than four teeth in each of the upper quadrants (including the implants), the criteria for scaling and root planing of four or more teeth per quadrant (D4341) have not been met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the scaling and root planing services have not been met. Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planing of four or more teeth per quadrant (D4341) for the upper left and upper right quadrants.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on
February 23, 2021.
You asked the Plan to pay for the office visit. You say that the letter supports the service billed and the claim
should be reprocessed for payment. The Plan denied your request. The Plan says this provider is not a network
provider with the Plan and the service was not approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
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 provided by an out-of-network
provider on February 23, 2021.