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

We decided that the Plan does not have to pay for the periodic oral evaluation, bitewing x-rays, and prophylaxis provided on January 7, 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 would like to appeal these services. The Plan denied your request. The Plan says the maximum allowed for these services have been met.
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 limited to 1 oral exam every 6 months, and 1 cleaning every 6 months. The contract says that you are limited to 1, 2 or 4 dental x-rays every 1 or 3 years depending on the type of x-ray. The record shows that you received a periodic oral evaluation, bitewing x-rays, and prophylaxis on July 23, 2020 which is less than 6 months from the January 7, 2021 date of service at appeal, and your periodic oral evaluation, bitewing x-rays, and prophylaxis benefits had been exhausted for the time periods. These services were also rendered by an OON provider. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, bitewing x-rays, and prophylaxis provided on January 7, 2021 by an OON provider
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve services performed by a qualified physical therapist in the home health setting (G0151).
You asked the Plan to pre-approve the services performed by a qualified physical therapist. You say that these services are needed for the enrollee to recover from his condition and the procedures the enrollee has had. The Plan denied your request. The Plan says the medical necessity for further physical therapy is not established.
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 services performed by a qualified physical therapist. Our reviewer says that ongoing home health physical therapy services are not shown to be medically necessary or reasonable. Our physician reviewer found the enrollee does not have documented skilled therapy needs. Our reviewer also found that the enrollee appears to have reached a plateau in function. 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 performed by a qualified physical therapist have not been met. Therefore, we decided that the Plan does not have to pre-approve services performed by a qualified physical therapist in the home health setting (G0151).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the screening mammography performed December 15, 2020.
You asked the Plan to pay for the screening mammography. You say that you do not believe you previously had this service done in 2020. The Plan denied your request. The Plan says this is a covered service, but you have exhausted the benefit limit.
The Plan must follow Medicare rules. Medicare rules say that payment can be made for a screening mammography performed after at least 11 months have passed following the month in which the last screening mammography was performed. We looked at the file and Medicare rules. The case file indicates that you last had a screening mammography in March 2020 that the Plan paid in full. Based on this information, we decided that Medicare rules for coverage of the screening mammography have not been met. Therefore, we decided that the Plan does not have to pay for the screening mammography performed December 15, 2020.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for the complete series of intraoral x-rays (D0210). We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150).
You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral x-rays. You say that you have never had any other dental full mouth series x-rays. The Plan says that the benefit maximum for this time period has been reached for the full mouth x-rays. The Plan also says that only one oral exam is covered every six months.
We decided that the Plan has to pay for the complete series of intraoral x-rays (D0210).
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 record shows that you received a complete series of intraoral x-rays (D0210). Your 2021 EOC says that you are limited to 1, 2, or 4 x-rays every 1 or 3 years depending on the type of x-ray. The contract does not clearly state that the complete series, panoramic x-rays, and vertical bitewing x-rays share a benefit limit of 1 of these three procedures every 3 years. You reasonably believed this service would be covered because complete series x-rays are listed as a covered service, with no specific frequency limitation. Therefore, we decided that the Plan has to pay for the complete series of intraoral x-rays (D0210) provided on March 23, 2021.
We also decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150).
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 limited to 1 oral exam every 6 months. The record shows that you received a comprehensive oral evaluation (D0150) on March 15, 2021, and your oral exams benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on March 23, 2021.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for moderate sedation services provided on June 15, 2020.
You asked the Plan to pay for the moderate sedation services (99152). You say that the interventional pain procedure requires the enrollee to remain still for a long period of time or in a painful position. The Plan denied your request. The Plan says it is not clear why the enrollee needed this medicine to help feel relaxed and calm for the injection.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The records do not show a medical condition significant enough to need MAC. Based on this information, we decided that Medicare rules for coverage of the moderate sedation services (99152) have not been met. Therefore, we decided that the Plan does not have to pay for moderate sedation services provided on June 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the duplex scan provided on March 22, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the duplex scan. You say that the service was medically necessary The Plan denied your request. The Plan says no prior authorization was 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 the duplex scan provided on March 22, 2021 by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ground mileage (A0425) and non-emergent ambulance transport (A0428) provided on February 14, 2021.
You asked the Plan to pay for the ground mileage and non-emergent ambulance transport. You say that you would either like this bill reduced or to only be responsible for the copay. The Plan denied your request. The Plan says the services received do not meet medical necessity criteria as alternative transportation vehicles could have been utilized without endangering your health.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 ground mileage and non-emergent ambulance transport. Our reviewer says that the documentation does not support that ambulance services were medically necessary for you. Our physician reviewer found other means of transport were not contraindicated such as stretcher or wheelchair van. Our reviewer found that you did not require expertise or special equipment during your transport back from the hospital. Our physician reviewer also found that you were stable. 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 ground mileage and non-emergent ambulance transport have not been met. Therefore, we decided that the Plan does not have to pay for the ground mileage (A0425) and non-emergent ambulance transport (A0428) provided on February 14, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to hold you harmless for an eye refraction (92015) provided on March 30, 2021.
You asked the Plan to hold you harmless for an eye refraction. You say that your refractive service should be considered because you were experiencing vision loss. The Plan denied your request. The Plan says that the service is not a covered benefit under your vision Plan.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. The eye refraction at issue was rendered by a Plan contracted provider. The file does not show that the Plan provided notice that the eye refraction would not be covered. An eye refraction is an example of a service that is normally not covered but could be covered under some conditions. This means that the EOC is not adequate notice of non-coverage in this case. Under Medicare rules, this means an eye refraction is considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for an eye refraction (92015) provided on March 30, 2021.
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: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve endodontic therapy (D3320).
You asked the Plan to pre-approve endodontic therapy. You say that you want the Plan to pre-approve the service. The Plan denied your request. The Plan says that the service at issue is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, we are unable to verify the medical necessity of the requested services without medical records. We requested medical records from the Plan, and none were received. It is the burden of the Health Plan to substantiate their denial with evidence. This denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pre-approve endodontic therapy (D3320).
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory services (36415, 80053, 86300, 85025) provided on February 1, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the services provided.
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 $40 copayment for laboratory services provided at each outpatient hospital visit. You have been asked to pay a $40 copayment for the laboratory services provided at an outpatient hospital. 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 laboratory services (36415, 80053, 86300, 85025) provided on February 1, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayments for the urgent care visits provided on January 3, 2021, and January 6, 2021.
You asked the Plan to waive the copayments for the urgent care visits. You say that you received two Corona virus tests at the urgent care visits, and they should be paid at 100%. The Plan denied your request. The Plan says that you have been charged the correct case sharing amount.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not submit the correct Evidence of Coverage. This means that we cannot confirm if the copayment amounts you are being asked to pay are correct. Therefore, we decided that the Plan has to waive the copayments for the urgent care visits provided on January 3, 2021, and January 6, 2021.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic mammography (77065) and diagnostic digital breast tomosynthesis (G0279) provided on March 10, 2021.
You asked the Plan to pay for codes 77065 and G0279. 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 must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must confirm that Medicare coverage criteria have been met.
We looked at the file and Medicare rules. In this case, there were no medical records provided confirming that
two separate diagnostic mammography (77065) and diagnostic digital breast tomosynthesis (G0279) were
provided on March 10, 2021. The file shows that the Plan paid for one set of the diagnostic mammography
(77065) and diagnostic digital breast tomosynthesis (G0279) (1 unit of 77065 and 1 unit of G0279) provided on
March 10, 2021. Therefore, we decided that the Plan does not have to pay for the diagnostic mammography
(77065) and diagnostic digital breast tomosynthesis (G0279) provided on March 10, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on August 24, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.
The laboratory testing 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 August 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that this enrollee needs inpatient rehabilitation services. The Plan denied your request. The Plan says criteria for an IRF have not been met, and the enrollee's care needs can be met in another setting.
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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does require physical and occupational therapy, but there is no documented need for an intensive rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically necessary services can be provided in a different level of care. 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular radiofrequency ablation services.
You asked the Plan to pre-approve genicular radiofrequency ablation services. You say that this request is
medically necessary for the enrollee's condition. The Plan denied your request. The Plan says there is not
enough proof that the requested procedure is as good or better than the standard treatment for knee pain from
osteoarthritis.
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 genicular radiofrequency ablation
services. Our reviewer says that the requested items/services are not considered medically reasonable and
necessary in this case. Our physician reviewer found this is considered an experimental/ investigational
procedure that is the subject of ongoing clinical trials to determine its role in the management of knee
osteoarthritis. Therefore, the request is considered not medically reasonable or necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of genicular radiofrequency ablation services have not been met. Therefore, we
decided that the Plan does not have to pre-approve genicular radiofrequency ablation services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refractions (92015) received March 15, 2021.
You asked the Plan to pay for the eye refractions. You say that the requested service was necessary and recommended by your provider. The Plan denied your request. The Plan says the provider does not participate in the vision provider network.
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 received from a vision network provider. We looked at the file and the Plan's rules. Though this provider is in-network with the plan, this provider does not participate in the vision network. This means that this provider is out-of-network when rendering supplemental (non-Medicare covered) vision services. Based on this information, we decided that the Plan's rules for coverage of the eye refractions have not been met. Therefore, we decided that the Plan does not have to pay for the eye refractions (92015) received March 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyewear purchased on November 5, 2019.
You asked the Plan to pay for the eyewear. You say that because you didn't receive good care from a network provider you shouldn't have to use them. The Plan denied your request. The Plan says that you didn't use a network 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 received from a plan Provider. We looked at the file and the Plan's rules. The file indicates you did not receive these services from a plan Provider. Based on this information, we decided that the Plan's rules for coverage of the eyewear have not been met. Therefore, we decided that the Plan does not have to pay for the eyewear purchased on November 5, 2019.