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

We decided that the Plan does not have to pay for the resin-based composite, two surfaces, anterior (D2331) for tooth number 11 provided on January 19, 2021.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says you have exceeded the allowable frequency for this 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.

We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of this service have not been met. Specifically, the Plan contract covers one filling per calendar year. On January 19, 2021, fillings were provided for teeth number 6 and 11. The Plan paid for the filling of tooth number 6 on January 24, 2021. You have exhausted the allowable benefit for this service. Therefore, we decided that the Plan does not have to pay for the resin-based composite, two surfaces, anterior (D2331) for tooth number 11 provided on January 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the refractive state determination provided by an out-of-network provider on December 22, 2020.
You asked the Plan to pay for the refractive state determination. You say that the doctor is in-network and does not bill separately for the refraction. You say that you have coverage for the refraction and should be reimbursed. The Plan denied your request. The Plan says there is no benefit for out-of-network vision 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 refractive state determination provided by an out-of-network provider on December 22, 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 January 15, 2021.
You asked the Plan to waive the copayment for the office visit. You say that you were told the provider was in-network. You say you have been receiving bills showing that the provider is out-of-network. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $5 copayment for provider and professional services at an in-network primary care physician's (PCP) office. The enrollee has been asked to pay a $5 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" 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 January 15, 2021.
Your complaint about the Plan's poor customer service is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the arthrocentesis provided on February 8, 2021.
You asked the Plan to waive the copayment for the arthrocentesis. You say that the copayment is very high and should be lowered. The Plan denied your request. The Plan says the copayment 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 $250 copayment for Medicare-covered surgery at an outpatient hospital facility.
You have been asked to pay a $250 copayment for the arthrocentesis. The arthrocentesis falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The arthrocentesis is considered a surgical service.
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 arthrocentesis provided on February 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for pharmacogenomic testing provided on October 2, 2020.
You asked the Plan to pay for genetic testing. You say that this testing was deemed medically necessary to assist in the treatment of the enrollee. The Plan denied your request. The Plan says this testing does not meet the Medicare criteria for coverage.
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 pay for genetic testing. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the obtained testing was ordered for obsessive compulsive disorder, unspecified bipolar disorder, and unspecified autistic disorder. The enrollee had failed more than 3 medications for psychiatric illness, failed a medication for the present episode, had a hospital or emergency room visit within the past 3 years, and was a candidate for amitriptyline or nortriptyline for his conditions. Based on the documentation provided, the multiple genes tested were not all specific to the medication selection or proposed potential treatment. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for pharmacogenomic testing provided on October 2, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for sedation services (99153) provided on September 2, 2020.
You asked the Plan to pay for sedation services. You say that this was medically necessary. The Plan denied your request. The Plan says this cannot be paid as billed.
The Plan must follow Medicare rules. Medicare rules say that unconditionally packaged services are services for which separate payment is never made because the payment for the service is always packaged into the payment for other services. Unconditionally packaged services are identified in the OPPS Addendum B with status indicator of N. We looked at the file and Medicare rules. The billed code has a status indicator of N, meaning payment for this service is packaged into payment for other services. Based on this information, we decided that Medicare rules for coverage of sedation services have not been met. Therefore, we decided that the Plan does not have to pay for sedation services (99153) provided on September 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction (92015) provided on February 3, 2021.

You asked the Plan to pay for the eye refraction. You say that your copay should be $0 for this service and you had a referral. The Plan denied your request. The Plan says you did not use a provider in the specified vision network. Routine vision services will only be covered when you use the specified provider.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when they are received from the vision provider specified in the contract. 

We looked at the file and the Plan's rules. You did not use a provider in the Plan's specified vision network for this routine service. Based on this information, we decided that the Plan's rules for coverage of the eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction (92015) provided on February 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglasses provided on December 16, 2020.
You asked the Plan to pay for the eyeglasses. The Plan denied your request. The Plan says that the Plan covered progressive lens for this same date of service.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. The file shows that the Plan covered the eyewear benefit for
progressive lens on the same date as the standard lens. Therefore, we decided that the Plan does not have to pay for eyeglasses provided on December 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory tests provided by an out-of-network provider on January 19, 2021.
You asked the Plan to pay for the laboratory tests. You say that the referring physician requested these tests to be performed. You say that the services were provided in good faith and should be considered reasonable and medically necessary. The Plan denied your request. The Plan says prior authorization was required but not obtained.
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 laboratory tests provided by an out-of-network provider on January 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (G0483) provided on November 3, 2020.

You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service 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 G0483 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; 22 or more drug class(es), including metabolite(s) if performed.

We find that CPT code G0483 is not supported in the record. Specifically, the record does not indicate that 22 or more drug classes were tested. The documentation does not support the billed service. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services (G0483) provided on November 3, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel-One injections (J7326).
You asked the Plan to pre-approve the Gel-One injections. You say that Gel-One is medically necessary. The Plan denied your request. The Plan says a trial of Orthovisc and Monovisc is required before alternatives can be considered.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Gel-One injections. Our reviewer says that Gel-One is not medically necessary. Our physician reviewer found the record shows no trial of the plan preferred drugs, or any reason why the plan preferred drugs would be unsafe or ineffective for the enrollee. 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 Gel-One injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Gel-One injections (J7326).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a computed tomography (CT) of the abdomen and pelvis with contrast provided on November 4, 2020.
You asked the Plan to waive the copayment for a CT of the abdomen and pelvis with contrast. You say that you should not be responsible to pay for the CT scan services you received due to a complication after gallbladder surgery in 2019. The Plan denied your request. The Plan says the copayment you are being charged is correct.
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 $275 copayment for outpatient hospital services.
You have been asked to pay a $275 copayment for a CT of the abdomen and pelvis with contrast. The EOC is clear that $275 is the required copayment for this service. A CT of the abdomen and pelvis with contrast falls within the outpatient hospital services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a computed tomography (CT) of the abdomen and pelvis with contrast (74177) provided on November 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on September 4, 2019 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 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 September 4, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110).
You asked the Plan to pre-approve a complete upper denture. You say that you need a replacement because your current dentures do not fit well and cause pain. The Plan denied your request. The Plan says the service is a covered benefit, but you have exceeded the frequency limit of one every 5 Plan years.
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 complete upper denture have not been met. Specifically, the record shows that you had exceeded the frequency limit on February 26, 2018. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost shares for the infliximab (Remicade) injections provided from November 24, 2020, to January 6, 2021.
You asked the Plan to waive the cost shares for the services provided. You say that you should not be billed for expensive medication without your prior knowledge. The Plan denied your request. The Plan says the claims were correctly processed.
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 Medicare Part B prescription drugs.
The file shows that you received injections on November 24, 2020, December 8, 2020, and January 6, 2021. You have been asked to pay a 20% coinsurance for each date of service. The services fall within the Medicare Part B prescription drugs 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 cost shares for the infliximab (Remicade) injections provided from November 24, 2020, to January 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual wellness exam rendered on December 8, 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 services exceed the benefit limit.

The Plan must follow Medicare rules. Medicare rules say that an annual wellness exam is covered once every 12 months.

We looked at the file and Medicare rules. The file shows that you previously received an annual wellness exam on November 4, 2020 that the Plan covered. The annual wellness exam on December 8, 2020 was performed less than 12 months from your previously covered exam. Therefore, we decided that the Plan does not have to pay for the annual wellness exam rendered on December 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on October 22, 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 27487 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 27487 is revision of total knee arthroplasty, with or without allograft; femoral and entire tibial component. 

We find that CPT code 27487 is not supported in the medical record. Specifically, the operative report does not include documentation of increased procedural services of a total knee arthroplasty revision. 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 surgical services rendered on October 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for orthoses (L1851, L2385, L2397) provided to the enrollee on March 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 the documentation submitted did not include a valid physician order and the documentation submitted did not include an itemized shipping/billing invoice to indicate the specific supplies, or proof of delivery.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Medicare rules say that DME supplies must be provided with a proof of delivery.

We find that CPT code is not supported in the medical record. Specifically, the required documentation pertaining to the proof of delivery of these supplies was not provided.. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for orthoses (L1851, L2385, L2397) provided to the enrollee on March 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance provided on September 8, 2020.
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 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. Therefore, we decided that the Plan does not have to pay for the
periodontal maintenance provided on September 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two placements of intra-socket biological dressings.
You asked the Plan to pre-approve the two placements of intra-socket biological dressings. You say that you would like these services to be approved for coverage. 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 pre-approve two placements of intra-socket biological dressings.