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

We decided that the Plan does not have to pay for the prophylaxis (D1110), the periodic oral evaluation
(D0210) and the intraoral - complete series (D0120) received April 9, 2021, from the out-of-network provider.
You asked the Plan to pay for the dental services. You say that you have been to this dentist in the past and
they have been in-network. The Plan denied your request. The Plan says this provider does not participate with
the Plan's Dental National Medicare Advantage 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. The provider in this case does not participate in the Plan's dental
network. The Plan contract states that if you receive services from a dentist who does not participate in the
Plan's Dental's Medicare Advantage Network then you will be responsible for the full cost of those services and
no payment will be made by the Plan. Therefore, we decided that the Plan does not have to pay for the
prophylaxis (D1110), the periodic oral evaluation (D0210) and the intraoral - complete series (D0120) received
April 9, 2021, from the out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the computed tomography (CT) scan of the body and saline infusion provided February 2, 2021.
You asked the Plan to waive the cost share for the CT scan of the body and saline infusion. You say that you would like this claim reprocessed as you have never had to pay a cost share before. The Plan denied your request. The Plan says the cost share for these claims have processed 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 $100 copayment for diagnostic radiology and. You have been asked to pay a total cost share of $107.63 for the CT scan of the body and saline infusion ($100 copayment + $7.63 coinsurance). These services fall within the diagnostic radiology and Medicare Part B
prescription drugs benefit categories. 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 cost share for the computed tomography (CT) scan of the body and saline infusion provided February 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Continuous positive airway pressure
(CPAP) device (E0601), provided on February 12, 2021.
You asked the Plan to waive the coinsurance for CPAP device. You say that the item should be covered. The
Plan denied your request. The Plan says the cost share was applied 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 20%
coinsurance for Durable medical equipment (DME) and related supplies.
You have been asked to pay a 20% coinsurance for CPAP device. This item falls within the Durable medical
equipment (DME) and related supplies benefit category. This means that you have been asked to pay the
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance
for Continuous positive airway pressure (CPAP) device (E0601), provided on February 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on November 30, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 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 services provided by an out-of-network provider on November 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), bitewing x-rays (D0274), prophylaxis (D1110), and preventive procedure (D1999) provided on December 3, 2020 by an OON provider.
You asked the Plan to pay for the periodic oral evaluation, bitewing x-rays, prophylaxis, and preventive procedure. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that non-emergency services provided by an OON provider are not available with your dental 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 covered when they are received OON. The record shows that you received a prior authorization for these services that was denied, but you continued with the treatment. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120), bitewing x-rays (D0274), prophylaxis (D1110), and preventive procedure (D1999) provided on December 3, 2020 by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on January 29, 2020.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the billed code cannot be verified.
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 looked at the file and the rules. The claim shows a place of service as an independent lab. The records do not show that the enrollee's specimen was taken at an independent lab. 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 drug testing services provided on January 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a telehealth office visit (99214) provided on January 21,
2021.
You asked the Plan to pay for a telehealth office visit. You say that this was billed correctly per Medicaid
guidelines. The Plan denied your request. The Plan says the billed place of service is not correct.
The Plan must follow Medicare rules. Medicare rules say that providers should submit telehealth services
claims using Place of Service (POS) 02-Telehealth to indicate they furnished the billed service as a
professional telehealth service from a distant site.
We looked at the file and Medicare rules. The telehealth service at issue was not billed with POS 02. Based on
this information, we decided that Medicare rules for coverage of a telehealth office visit have not been met.
Therefore, we decided that the Plan does not have to pay for a telehealth office visit (99214) provided on
January 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a powered pressure-reducing air mattress (E0277).
You asked the Plan to pre-approve the mattress. You say that the enrollee has cerebral palsy and is prone to getting pressure ulcers due to very limited movement of her torso. She would benefit from a mattress that helps prevent pressure ulcers. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for a special mattress.
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 the mattress. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation indicates that the enrollee has a history of quadriplegia secondary to cerebral palsy. The available documentation in progress notes does not document multiple stage II pressure ulcers, or multiple stage III or IV pressure ulcers or a mucocutaneous flap or skin graft for pressure ulcer on the trunk or pelvis within the past 60 days. The review indicates that the enrollee does not meet the established criteria for coverage. 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 mattress have not been met. Therefore, we decided that the Plan does not have to pre-approve a powered pressure-reducing air mattress (E0277).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal scaling and root planing (D4341 x 4) provided on December 15, 2020.

You asked the Plan to pay for the dental service. You say that before you signed up for the plan, you called the plan to determine if the dental office that you had been using was in network. You say that you were advised that the providers were in network. You say that you were expecting the provider to be in network. You also say that you were never advised of the provider's network status change. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that dental services performed out of network are not covered. The Plan says there are in network dentists available. The Plan also says that you did not call prior to the date of service to verify the provider's network status.

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, dental services performed out of
network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periodontal scaling and root planing (D4341 x 4) provided on December 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), bitewing x-rays (D0274), and prophylaxis (D1110) provided on March 3, 2021 by an OON provider.
You asked the Plan to pay for the periodic oral evaluation, bitewing x-rays, and prophylaxis. You say that you received services from this OON provider two times in 2020, and the services were covered due to COVID. You also say that you assumed services with this provider would still be covered. The Plan denied your request. The Plan says these services are not covered. The Plan also says that between March 1, 2020, and September 31, 2020 the Plan waived the requirement to see in-network providers and obtain authorizations to assist you during the COVID-19 pandemic.
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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120), bitewing x-rays (D0274), and prophylaxis (D1110) provided on March 3, 2021 by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says you do not need supervision by a provider who specializes in rehabilitation.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for dizziness, altered mental status and a urinary tract infection. Medical problems are stable. There are no
complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an eye exam provided by a participating
provider on January 8, 2021.
You asked the Plan to waive the copayment for an eye exam. 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 $20
copayment for routine vision care/in-network.
You have been asked to pay a $20 copayment for an eye exam. An eye exam falls within the routine vision
care/in-network 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 eye exam
provided by a participating provider on January 8, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid for COVID-19
provided on January 6, 2021.
You asked the Plan to pay for the infectious agent detection by nucleic acid for COVID-19. You say that this
claim is not hospice related. The Plan denied your request. The Plan says Original Medicare would be
responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal
condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the infectious agent detection by nucleic acid for COVID-19 provided on January 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on December 30, 2020 by a non-participating 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 a non-participating 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 provided on December 30, 2020 by a non-participating provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided March 10, 2021 to March 12, 2021.
You asked the Plan to waive the copayment for the inpatient services. You say that most of your inpatient stays are 5 to 7 days and you were never billed this much. It is your understanding you are only to pay $150 per day of inpatient hospital stays. The Plan denied your request. The Plan says the claim was processed with the correct copayment 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 $390 copayment per day, days 1-5 for Inpatient hospital care. You have been asked to pay $780 ($390 + $390) for the inpatient services. The inpatient services fall within the
Inpatient hospital care 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 inpatient hospital services provided March 10, 2021 to March 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive cardiovascular genetic testing (81404, 81406) provided on December 16, 2020.
You asked the Plan to pay for comprehensive cardiovascular genetic testing. You say that these services are supported in the records. The Plan denied your request. The Plan says these services are not covered.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular (CV) risk assessment panels, except the basic lipid panel, for symptomatic (with signs and symptoms) patients with suspected or documented CV disease because panel testing is not specific to a given patient's lipid abnormality or disease. We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not covered. Based on this information, we decided that Medicare rules for coverage of comprehensive cardiovascular genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for comprehensive cardiovascular genetic testing (81404, 81406) provided on December 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies rendered on
January 10, 2021.
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 there is no valid physician order.
The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating
physician before dispensing any DMEPOS item to a beneficiary.
We looked at the file and Medicare rules. There is no valid physician order for the DME. 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 continuous glucose monitor (CGM) supplies rendered on
January 10, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (DNA or RNA) services coded 87631 provided on July 21, 2020.
You asked the Plan to pay for the infectious agent detection by nucleic acid (DNA or RNA) 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. In this case, the CPT Code Manual definition of code 87631 is infectious agent detection by nucleic acid (DNA or RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza virus, respiratory syncytial virus, rhinovirus), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 3-5 targets.
We find that CPT code 87631 is not supported in the medical record. Specifically, the services rendered are not a COVID-19 test. Multiplex PCR respiratory viral panels of 6 or more pathogens are non-covered. The pathogen targets that compose the panels are determined by the manufacturers that make them, and do not represent specific pathogens that cause a common syndrome, or the organisms that commonly are found in a specific sample type or enrollee population or reflect seasonal variations. The fixed nature of these multiplex panels includes pathogens that cause infections different enough that simultaneous testing for these pathogens should be rare. Based on this information, we decided that Medicare rules for coverage of the infectious agent detection by nucleic acid (DNA or RNA) services have not been met. Therefore, we decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (DNA or RNA) services coded 87631 provided on July 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for addiction treatment provided from November 2, 2020, to December 2, 2020.
You asked the Plan to pay for addiction treatment. You say that you have resubmitted this claim with the correct diagnosis information. The Plan denied your request. The Plan says the service at issue was provided by a provider that is not Medicare-certified.
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 addiction treatment provided from November 2, 2020, to December 2, 2020.