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

We decided that the Plan does not have to pay for the laboratory services provided on October 1, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
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 was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on October 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on November 25, 2019.
You asked the Plan to pay for the periodontal maintenance. You say that you believe this service should be covered. The Plan denied your request. The Plan says this service is not covered under your contract.
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 periodontal maintenance (D4910) provided on November 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pontics (D6240) for teeth #'s 23, 24, 25, and 26 and retainer crowns (D6750) for teeth #'s 22 and 27.
You asked the Plan to pre-approve the pontics and retainer crowns. The Plan denied your request. The Plan says these services are not medically necessary.
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 pontics and retainer crowns 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 pontics and retainer crowns. Our reviewer says that the documentation presented does not meet the criteria for coverage for a mandibular anterior fixed bridge replacing missing teeth #'s 23 to 26. Our physician reviewer found the plan considers coverage for two adjacent missing mandibular anterior teeth with a fixed bridge. This involves four missing mandibular anterior teeth. Also, there must be no missing posterior teeth for consideration of a fixed anterior bridge. Our reviewer also found that there are multiple missing mandibular posterior teeth in this case.
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 pontics and retainer crowns have not been met. Therefore, we decided that the Plan does not have to pre-approve pontics (D6240) for teeth #'s 23, 24, 25, and 26 and retainer crowns (D6750) for teeth #'s 22 and 27.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on July 7, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on July 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on December 9, 2020.
You asked the Plan to waive the copayment for the office visit. You say that you feel the enrollee should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says the enrollee received medical services beyond the scope of an annual wellness visit per Medicare guidelines. The Plan says that the correct copayment has applied per the enrollee's contract with the Plan.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $20 copayment for Physician/Practitioner services. We looked at the file, the Plan's contract and Medicare rules. The file shows that the enrollee received physician services beyond the scope of an annual wellness visit on December 9, 2020. The enrollee has been asked to pay a $20 copayment for the office visit. The office visit falls within the Physician/Practitioner services benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the office visit provided on December 9, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on December 4, 2020.
You asked the Plan to pay for the physician's services. 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 member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on December 2, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for physician's services provided on December 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy provided on November 25, 2020.
You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that this should be covered in full as a routine screening. The Plan denied your request. The Plan says you have been asked to pay 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 $150 copayment for a diagnostic colonoscopy at an in-network ambulatory surgical center. You have been asked to pay a $150 copayment for the diagnostic colonoscopy. The diagnostic colonoscopy falls within the "Outpatient hospital services" benefit category. The medical record shows that colonoscopy was performed due to prior colonic neoplasia which makes the colonoscopy diagnostic in nature. 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 diagnostic colonoscopy provided by the on November 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the walking boot (L4361) provided March 29, 2019.

You asked the Plan to pay for the walking boot. You say that you would like this claim reprocessed and approved for medical necessity. The Plan denied your request. The Plan says no medical records were received.

The Plan follows Medicare rules. The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Specifically, there were no medical records provided in this case. Without the medical records, we cannot review to see if the services were urgent/emergent or medically necessary. Therefore, we decided that the Plan does not have to pay for the walking boot (L4361) provided March 29, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services described by code A0429-QL provided on December 24, 2020.

You asked the Plan to pay for code A0429-QL. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.

The Plan must follow Medicare rules. The rules say that in the case where the beneficiary was pronounced dead after the ambulance is called but before the ambulance arrives at the scene: Payment may be made for a BLS service if a ground vehicle is dispatched. 

We looked at the file and Medicare rules. In this case, the enrollee was pronounced dead after the ambulance was called. Per Medicare guidelines, providers must report A0428 (BLS) and not A0429 in this case. Therefore, we decided that the Plan does not have to pay for the ambulance services described by code A0429-QL provided on December 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on November 20, 2020, by
an OON provider.
You asked the Plan to pay for the physician services provided by an OON provider. You say that you would
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services
provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network
care.
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 physician services provided on November 20,
2020, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the crown provided on February 2, 2021.
You asked the Plan to pay more for the crown. You say that you cannot afford to pay the remaining amount of $230. The Plan denied your request. The Plan says this claim was paid up to your annual allowed amount of $2,000. The Plan also says that the remaining amount of $230 is your responsibility.
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 Plan offers a $2,000 combined allowance for supplemental preventive and comprehensive dental services every year. The contract says that you are responsible for any amount over and above the allowance amount. The record shows that you met the annual maximum benefit while processing this claim for the February 2, 2021 date of service and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay more for the crown provided on February 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the outpatient observation services rendered on November 19, 2020.

You asked the Plan to waive the coinsurance for these services. You say that the services were performed in an office visit by your doctor. The Plan denied your request. The Plan says the coinsurance 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 in-network outpatient observation services.

Review of the file shows that you received outpatient hospital services on November 19, 2020. You have been asked to pay a 20% coinsurance for these services, for a total of $137.22. These services fall within the in-network outpatient observation 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 coinsurance for the outpatient observation services rendered on November 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pontics (D6241) for teeth #'s 13 & 14, and retainer
crowns (D6751) for teeth #'s 12 & 15.

You asked the Plan to pre-approve the pontics and retainer crowns. You say that you would like to appeal these
services. The Plan denied your request. The Plan says these services are not medically necessary for you.

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 pontics
and retainer crowns 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 pontics and retainer crowns. Our
reviewer says that the criteria for a fixed bridge has not been met for this policy. Our physician reviewer found
there is a presently missing tooth #14 and a soon to be removed tooth #13, both posterior teeth. Our reviewer
also found that the Plan specifically will not consider fixed bridges where there are missing teeth in the arch,
and therefore in this case would not find the bridge from teeth #'s 12 to 15 to be necessary.

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 pontics and retainer crowns have not been met. Therefore, we decided that
the Plan does not have to pre-approve pontics (D6241) for teeth #'s 13 & 14, and retainer crowns (D6751) for
teeth #'s 12 & 15.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for laboratory services (CPT 88341) provided to the enrollee on July 30, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says that an unbundled relationship exists between billed codes 88341 and 88342 and an appropriate NCCI modifier was not 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 88341 is "Immunohistochemistry or immunocytochemistry, per specimen."

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 services. Our reviewer says that the services at issue in this case were supported by the medical records. Our physician reviewer found CPT 88341 is defined as Immunohistochemistry or immunocytochemistry, per specimen and is reported as an add on to CPT code 88342. In this case, the submitted claim form in the case file indicates that CPT 88342 was submitted. The elements of the CPT code are satisfied.

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 services have been met. Therefore, we decided that the Plan has to pay for laboratory services (CPT 88341) provided to the enrollee on July 30, 2020.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health services (90834) provided on September 17, 2020.

You asked the Plan to pay for the outpatient mental health services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were non-emergent. There were 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 had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service 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 outpatient mental health services (90834) provided on September 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on September 22, 2020.
You asked the Plan to pay for the prophylaxis. You say that you are entitled to 3 cleanings per year. The Plan denied your request. The Plan says this service exceeds the frequency limitation in your benefit 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, prophylaxis (D1110) is limited to two procedures per plan year. The record shows that you received prophylaxes on January 6, 2020, and May 20, 2020 and your prophylaxis (D1110) benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110) provided on September 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional reimbursement for the crown - porcelain/ceramic (D2740), and inhalation of nitrous oxide/analgesia, anxiolysis (D9230) received December 1, 2020 from the out-of-network provider.

You asked the Plan to provide additional reimbursement for the crown and the nitrous oxide/analgesia. You say that your new provider's office said they would check into whether they were in the Plan's network, but never heard back from them. The Plan denied your request. The Plan says the correct cost share amount has applied to the claim.

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 payment is in excess of that covered under this benefit. The Plan agreed to pay 100% of the allowable charge for the nitrous oxide/analgesia. You are responsible for the difference between what the out-of-network provider charged and the plan's allowable charge for this service ($40). The Plan requires 50% coinsurance for crowns. You have been asked to pay 50% coinsurance ($262.50), plus the difference between what the out-of-network provider charged and the plan's allowable charge ($425) for a total of $687.50 for the crown. Therefore, we decided that the Plan does not have to provide additional reimbursement for the crown - porcelain/ceramic (D2740), and inhalation of nitrous oxide/analgesia, anxiolysis (D9230) received December 1, 2020 from the out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda every 21 days.
You asked the Plan to pre-approve Keytruda. The Plan denied your request. The Plan says there is no
indication to add Keytruda because the enrollee's tumor has no features that would suggest activity of
checkpoint inhibition.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer
drugs if they are medically accepted as safe and effective or appropriate for the particular use.
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 Keytruda. Our reviewer says that
Keytruda is not medically reasonable and necessary for the enrollee. Our physician reviewer found the
requested use of Pembrolizumab (Keytruda) is not FDA-approved for the enrollee's diagnosis. The enrollee is
not triple negative or other molecular indication. Our reviewer found that the use of Pembrolizumab (Keytruda)
is not supported by one of the major drug compendia or by clinical research that appears in a Centers for
Medicare & Medicaid Services (CMS) approved medical journal. Our physician reviewer also found that the
use is not listed as not indicated, not supported or not recommended in any of the compendia.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have
to pre-approve Keytruda every 21 days.